[Senate Hearing 110-536]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 110-536
 
    HEARING ON NOMINATION OF JAMES B. PEAKE TO BE SECRETARY OF THE 
                     DEPARTMENT OF VETERANS AFFAIRS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                            DECEMBER 5, 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 Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Larry E. Craig, Idaho
Bernard Sanders, (I) Vermont         Kay Bailey Hutchison, Texas
Sherrod Brown, Ohio                  John Ensign, Nevada
Jim Webb, Virginia                   Lindsey O. Graham, South Carolina
Jon Tester, Montana                  Johnny Isakson, Georgia
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director


















                            C O N T E N T S

                              ----------                              

                            December 5, 2007
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
    Prepared statement...........................................     3
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     4
Murray, Hon. Patty, U.S. Senator from Washington.................     5
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     7
Tester, Hon. Jon, U.S. Senator from Montana......................     9
Hutchison, Hon. Kay Bailey, U.S. Senator from Texas..............     9
Webb, Hon. Jim, U.S. Senator from Virginia.......................    11
Craig, Hon. Larry E., U.S. Senator from Idaho....................    17
Specter, Hon. Arlen, U.S. Senator from Pennsylvania..............    74

                               WITNESSES

Inouye, Hon. Daniel, U.S. Senator from Hawaii....................    13
Dole, Hon. Bob, Former U.S. Senator from Kansas..................    15
Peake, James B., Lieutenant General U.S. Army (Ret.), M.D., 
  Nominee to be Secretary, Department of Veterans Affairs........    18
    Prepared statement...........................................    21
    Response to pre-hearing questions submitted by Hon. Daniel K. 
      Akaka......................................................    22
    Response to written questions submitted by:
      Hon. Daniel K. Akaka.......................................    39
      Hon. Christopher S. Bond, U.S. Senator from Missouri.......    42
      Physicians for Human Rights................................    42
      Hon. Richard Burr..........................................    43
      Hon. John D. Rockefeller IV, U.S. Senator from West 
      Virginia...................................................    44
      Hon. Patty Murray..........................................    48
      Hon. Barak Obama, U.S. Senator from Illinois...............    50
      Hon. Jon Tester............................................    52
      Hon. Arlen Specter.........................................    53
      Hon. John Ensign, U.S. Senator from Nevada.................    54
    Response to additional written questions submitted by:
      Hon. Daniel K. Akaka.......................................    55
      Hon. Jon Tester............................................    56
    Questionnaire for Presidential nominee.......................    57

                                APPENDIX

Rodriguez, Ciro D.; Gonzalez, Charles A.; Smith, Lamar; Cuellar, 
  Henry, U.S. Members of Congress; letter to Hon. Daniel K. 
  Akaka, Chairman................................................    85
Melia, John, Executive Director, Wounded Warrior Project; letter 
  to Hon. Daniel K. Akaka, Chairman, and Hon. Richard Burr, 
  Ranking Member.................................................    86
Mitchell, Harry E., U.S. Member of Congress, 5th District, 
  Arizona; letter to Hon. Daniel K. Akaka, Chairman..............    86


    HEARING ON NOMINATION OF JAMES B. PEAKE TO BE SECRETARY OF THE 
                     DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                      WEDNESDAY, DECEMBER 5, 2007

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 9:39 a.m., in 
Room SD-G50, Dirksen Senate Office Building, Hon. Daniel K. 
Akaka, Chairman of the Committee, presiding.
    Present: Senators Akaka, Murray, Brown, Webb, Tester, Burr, 
Specter, Craig, and Hutchison.

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

    Senator Akaka. Aloha. The hearing will come to order.
    Today's hearing is to consider the nomination of James B. 
Peake to be Secretary of Veterans Affairs.
    Dr. Peake has a long and distinguished career, which our 
colleagues, Senator Inouye and Senator Dole, will describe in 
detail when they introduce the nominee.
    For now, I just note the unusual combination of combat 
service as an infantry officer in Vietnam after his graduation 
from West Point, followed by medical school and a highly 
successful career as an Army physician, culminating in his 
service as the Army Surgeon General.
    Dr. Peake, you have a tremendous challenge facing you, and 
I know you know that. Heading VA is never easy. Indeed, it may 
be one of the most daunting tasks in or out of government. 
Doing so in a time of war is dramatically more difficult. And 
taking over, as you will, assuming your confirmation, when 
there is only a little more than a year left in the current 
administration only compounds a demanding situation. Your 
ability to articulate clearly your priorities will be critical 
to your success.
    I recognize that you come to this nomination with a wealth 
of experience, even though little of that experience has come 
from working directly with VA. I am confident, however, that 
you have a strong sense of empathy for those served by VA and a 
deep commitment to VA's missions, and that these traits will 
serve you well.
    As you suggested in your answers to my pre-hearing 
questions--and I want to tell you I really appreciate your 
responses--VA has a strong and dedicated workforce. Things are 
not perfect within VA; few human endeavors are. But I am 
satisfied that VA is staffed by people who seek to do what is 
right by veterans. What the Secretary must do, with the backing 
of the Congress, is give those employees the leadership and the 
tools--especially the resources--they need to carry out their 
jobs. If confirmed, you will appear before this Committee early 
next year in connection with VA's 2009 budget. It will be vital 
that you be prepared at that time to inform us whether the 
proposed budget is truly sufficient for the coming fiscal year.
    A time of war puts tremendous strain on VA. Not only must 
the Department strive to continue to meet the needs of those 
from prior conflicts who already depend on VA, but it must 
quickly adapt so as to address the needs of those injured or 
disabled in the current conflicts. Each war brings different 
challenges, as you know--different demands, as well. In the 
current conflicts, VA is having to respond to relatively new 
challenges, such as the significant number of veterans 
suffering from Traumatic Brain Injury, alone or in combination 
with other debilitating injuries, in addition to wresting with 
conditions that followed prior wars, as well, such as Post 
Traumatic Stress Disorder.
    One area that needs special and immediate attention is the 
process by which an injured servicemember moves from DOD to VA. 
A great deal of work has been done on that front--especially 
over this year--and much is being done now. I am hopeful that, 
if you are confirmed, your long experience in the Army will 
enable you to continue to improve on those efforts. Returning 
servicemembers, especially those who are seriously injured, 
must not be made to struggle as they work with both DOD and VA. 
We must strive for, and we must achieve, a truly seamless 
transition.
    Another area that is demanding attention and a focused 
effort is the systems--both DOD's and VA's--for compensating 
servicemembers and veterans for in-service injury. It is no 
exaggeration to say that VA's current compensation system is 
broken. The frustrating lack of timeliness; the need for 
fundamental rethinking of the overall compensation system (as 
recommended by the Veterans' Disability Benefits Commission and 
others); and the challenge of coordinating DOD and VA's 
systems, are all areas that must be addressed quickly and 
effectively. This Committee, indeed, the full Congress, stand 
ready to work with the administration on this effort. If you 
are confirmed, this must be one of your highest priorities.
    In closing, I note and commend your strong commitment to 
avoiding even the appearance of any conflict of interest, not 
only with respect to your most recent employer, QTC, but also 
with those organizations where you served in an advisory 
capacity, as well as in connection with your stock portfolio. I 
personally harbored no concerns about your integrity, but I 
understand the worries of some that your brief time in the 
private sector might somehow have led you to favor corporate 
entities with which you were associated. I trust that all fair-
minded individuals will appreciate the steps you have taken to 
preclude even an appearance of any conflicts of interest.
    I look forward to your testimony today, your responses to 
questions from Committee Members, and to any post-hearing 
questions. It is vitally important that the position of 
Secretary of Veterans Affairs be filled as soon as feasible.
    Now I would like to call on our Ranking Member, Senator 
Burr.
    [The prepared statement of Hon. Daniel K. Akaka follows:]
         Prepared Statement of Hon. Daniel K. Akaka, Chairman, 
                        U.S. Senator from Hawaii
    Aloha. The hearing will come to order. Today's hearing is to 
consider the nomination of James B. Peake to be Secretary of Veterans 
Affairs.
    Dr. Peake has a long and distinguished career which our colleagues, 
Senators Inouye and Dole, will describe in detail when they introduce 
the nominee. For now, I just note the unusual combination of combat 
service as an infantry officer in Vietnam after his graduation from 
West Point followed by medical school and a highly successful career as 
an Army physician, culminating in his service as the Army Surgeon 
General.
    Dr. Peake, you have a tremendous challenge facing you. Heading VA 
is never easy. Indeed, it may be one of the most daunting tasks in or 
out of government. Doing so in a time of war is dramatically more 
difficult. And taking over as you will, assuming your confirmation, 
when there is only a little more than a year left in the current 
Administration only compounds a demanding situation. Your ability to 
articulate clearly your priorities will be critical to your success.
    I recognize that you come to this nomination with a wealth of 
experience, even though little of that experience has come from working 
directly with VA. I am confident, however, that you have a strong sense 
of empathy for those served by VA and a deep commitment to VA's 
missions and that these traits will serve you well.
    As you suggested in your answers to my pre-hearing questions, VA 
has a strong and dedicated workforce. Things are not perfect within VA; 
few human endeavors are. But I am satisfied that VA is staffed by 
people who seek to do what's right by veterans. What the Secretary must 
do, with the backing of the Congress, is give those employees the 
leadership and the tools, especially the resources, they need to carry 
out their jobs. If confirmed, you will appear before this Committee 
early next year in connection with VA's 2009 budget. It will be vital 
that you be prepared at that time to inform us whether the proposed 
budget is truly sufficient for the coming fiscal year.
    A time of war puts tremendous strain on VA. Not only must the 
department strive to continue to meet the needs of those from prior 
conflicts who already depend on VA, but it must quickly adapt so as to 
address the needs of those injured or disabled in the current 
conflicts. Each war brings different challenges, different demands. In 
the current conflicts, VA is having to respond to relatively new 
challenges, such as the significant number of veterans suffering from 
Traumatic Brain Injury--alone or in combination with other debilitating 
injuries--in addition to wresting with conditions that followed prior 
wars as well, such as Post Traumatic Stress Disorder.
    One area that needs special and immediate attention is the process 
by which an injured servicemember moves from DOD to VA. A great deal of 
work has been done on that front, especially over this year, and much 
is being done now. I am hopeful that, if you are confirmed, your long 
experience in the Army will enable you to continue and to improve on 
those efforts. Returning servicemembers, especially those who are 
seriously injured, must not be made to struggle as they work with both 
DOD and VA. We must strive for, we must achieve, a truly seamless 
transition.
    Another area that is demanding attention and focused effort is the 
systems--both DOD's and VA's--for compensating servicemembers and 
veterans for in-service injury. It is no exaggeration to say that VA's 
current compensation system is broken. The frustrating lack of 
timeliness, the need for fundamental rethinking of the overall 
compensation system as recommended by the Veterans' Disability Benefits 
Commission and others, and the challenge of coordinating DOD and VA's 
systems are all areas that must be addressed, quickly and effectively. 
This Committee, indeed, the full Congress, stand ready to work with the 
Administration on this effort. If you are confirmed, this must be one 
of your highest priorities.
    In closing, I note and commend your strong commitment to avoiding 
even the appearance of any conflict of interest, not only with respect 
to your most recent employer, QTC, but also with those organizations 
where you served in an advisory capacity as well as in connection with 
your stock portfolio. I personally harbored no concerns about your 
integrity, but I understand the worries of some that your brief time in 
the private sector might somehow have led you to favor corporate 
entities with which you were associated. I trust that all fair-minded 
individuals will appreciate the steps you have taken to preclude even 
an appearance of any conflicts of interest.
    I look forward to your testimony today, your responses to questions 
from Committee Members, and to any post-hearing questions. It is 
vitally important that the position of Secretary of Veterans Affairs be 
filled as soon as feasible.

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

    Senator Burr. Good morning, Mr. Chairman, my colleagues. I 
thank you for scheduling this hearing in a very timely manner 
to consider the nomination of General James Peake to be 
Secretary of Veterans Affairs. A number of my colleagues on 
this panel have said that it is important, especially now, to 
have a permanent leader at the helm of the Department of 
Veterans Affairs. With that in mind, I hope this Committee can 
schedule a markup as soon as possible after this hearing. I 
think we can move this nomination to the floor and, hopefully, 
quickly have a confirmed leader at the helm of VA.
    General Peake, I have examined your application. I have 
examined carefully the Committee papers. I am convinced that 
you have really prepared for this job for a lifetime. In fact, 
I do not think you could have been better prepared for this job 
if you had actually planned it for a number of years. Your 
dedication to service to this Nation in uniform goes back to 
1962, when you entered the military at West Point. After 
graduating from West Point, you led troops in combat in 
Vietnam. There you were wounded not once, but twice.
    Your bravery, your valor have been recognized with military 
medals and commendations too numerous to mention. But, I will 
highlight just a few: two Distinguished Service Medals, the 
Silver Star, the Bronze Star for Valor, and two Purple Hearts.
    Of course, as if your attendance at West Point and your 
dedicated combat service were not enough, you decided not only 
to stay in uniform but to go to medical school and to serve an 
additional 32 years in the military as a physician. Today, you 
are a board-certified thoracic surgeon, and a Fellow of both 
the American College of Surgeons and the American College of 
Cardiology.
    Your dedication to duty and medical skills were obviously 
no secret to your fellow medical colleagues or senior military 
leaders. In 2000, you were selected to be the Army's 40th 
Surgeon General. Those experiences alone, in my mind, qualify 
you for this job.
    You understand life as a soldier on the ground. You have 
experienced the challenges of recovery from wounds suffered 
during war. And you have led the next generation of men and 
women who followed you into service.
    Mr. Chairman, VA is an agency dedicated to ``care for him 
who shall have borne the battle and for his widow and his 
orphan.'' I believe we have found the man to lead the VA who 
not only understands combat service, the needs of our injured 
military personnel, and America's veterans; but a man who has 
spent the better part of his life taking care of those men and 
women and, more importantly, their families.
    Dr. Peake, I fully intend to support your nomination to be 
the next Secretary of Veterans Affairs, and it is my deep hope 
today that every one of my colleagues on this panel will, in 
fact, show their support and we will act very quickly.
    Senator Dole, I welcome you today and thank you for the 
introductions, and I know Senator Inouye will be here.
    Mr. Chairman, I thank you for this hearing and for an 
expeditious consideration of General Peake's nomination.
    Senator Akaka. Thank you very much, Senator Burr.
    Senator Murray?

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

    Senator Murray. Well, thank you, Chairman Akaka, for 
holding this hearing. General Peake, welcome. Senator Dole, it 
is good to see you again.
    Mr. Chairman, I think we all know that this is a very 
critical and serious time in VA's history. Our troops are 
fighting overseas, and we see more veterans coming home and 
entering our system every day. We know we are facing 
unprecedented challenges as we try to provide the level of care 
that all of our heroes have earned.
    I think it is no secret that you all know I think too many 
leaders at the VA have done the agency and our veterans a 
disservice over the last years and that we have seen too many 
apologists for the administration's policy rather than being 
strong advocates for our veterans. Our veterans have earned the 
benefits the VA is supposed to provide them, but we have seen 
them come home to long waiting lines to see a doctor, 
bureaucratic ineptitude, VA claims backlogs of months, and many 
other serious challenges that we have all witnessed over the 
past several years.
    I do not think we should dwell on the mistakes of the past, 
but I really think we have to learn from them, and I think we 
have an opportunity to do that as we decide who will be the 
next Secretary of the VA. In fact, I think whether to confirm 
General James Peake may be the most important decision we make 
on how our veterans issues are dealt with over the next year.
    I often say, that no matter how Americans feel about this 
war today in Iraq, they uniformly believe that we have an 
obligation to take care of our men and women when they come 
home; and they are ready and willing to stand up and do that 
today. And I want you to know that I stand ready and willing to 
work with any Secretary who is committed to truly fighting for 
the best interests of our veterans.
    So, Mr. Chairman, I very much look forward to this hearing 
today and to hearing from General Peake. General Peake has had 
a very distinguished career and an impressive history of 
service to his country. For most of his nearly 40 years in the 
military, he has been devoted to improving medical care for our 
wounded servicemen and -women, including a stint as Army 
Surgeon General. He has held numerous positions within the 
Army, including Commanding General of the Madigan Army Medical 
Center in my home State of Washington. But, we all know a 
strong resume is not enough. We have to have a leader at the VA 
today who has the fortitude, the backbone, and the courage to 
stand up to the administration, to all of us; to be honest, and 
up front about our veterans' current and future needs; and to 
get us on the right course to caring for these heroes who risk 
their lives for our country. I hope today we will find that 
General Peake is the VA Secretary that our veterans deserve.
    Mr. Chairman, our VA system is uniquely positioned to 
recognize and treat the specialized injuries, medical 
conditions, and mental health challenges that are caused by 
combat and military missions. Our local VA doctors and nurses 
are some of the most caring and compassionate people I know, 
and I know they are dedicated to giving our veterans the best 
care possible. I was, in fact, out in Yakima, Washington, last 
week at a VA clinic. It was packed to the gills with veterans 
who had come to tell us about the serious challenges that they 
were facing. And I was most impressed by our VA officials on 
the ground--Sharon Helman from Walla Walla, Max Lewis who 
headed our VISN--who came to that hearing with a button on that 
sent a message to every veteran in the room, and it is the 
first time I have seen that happen. I shared with General Peake 
right before this hearing the button, and, General, when you 
put it on, I will know you have gotten the message. It says 
``Business As Usual'' and has a slash through it. And I think 
the message sent to the veterans at that meeting is that people 
were going to sit up and take notice and make sure that their 
needs were met. And, General, when you put the button on, I 
will know you are the right man. So, I am glad you have it.
    But I think, seriously, that our servicemembers really 
deserve better than what they have been getting from 
Washington, DC, and I hope that with a new VA Secretary we can 
change that attitude and really get back, on a bipartisan 
level, to making sure that the men and women who serve us are 
served well.
    Mr. Chairman, we know that Congress has together worked to 
solve some of these problems. We have a lot of huge challenges 
ahead of us. Thanks to recent advances in battlefield medicine, 
our troops, as we know, are surviving incredible injuries that 
would have been fatal in earlier conflicts. And I know some of 
those advances were overseen by General Peake. However, many 
more of our servicemembers are coming home with devastating and 
debilitating wounds that are creating a lot of new challenges 
for our VA.
    One of our biggest challenges is to ensure that our 
veterans are not waiting months or even years for compensation. 
As of earlier this year, the VA had as many as 600,000 
disability compensation claims waiting to be answered. I heard 
at that Yakima hearing last week from a number of veterans who 
say they are at the end of their patience fighting for their 
own disability claims. We know the claims system is old and 
antiquated and needs to be fixed. Both the Dole-Shalala 
Commission and the Veterans' Disability Benefits Commission 
have studied this issue and brought us recommendations, and in 
many ways their suggestions are similar. But, there are some 
key differences, and, General Peake, if you are confirmed, you 
will have to work with us to address those differences and help 
us move forward to reform this system aggressively.
    Mr. Chairman, I am also particularly concerned about the 
challenges we face as we try to meet the mental health needs of 
our returning servicemembers. According to the VA, a third of 
all of our Iraq veterans who are enrolled in the system have 
sought treatment for a mental health problem. That is an 
astounding statistic. But we also know it is probably too low, 
because many of the veterans are not asking for care, because 
today, we still have a stigma surrounding treatment, or because 
they fear that a mental health diagnosis is going to hurt their 
military or their civilian careers.
    We know that as our troops are deployed overseas for the 
third, fourth, and now even fifth tour of duty, the risk of 
suffering from PTSD and other mental health conditions is 
increasing. Just a few weeks ago, as I shared with the VA 
Committee, CBS News reported on a tragic result of not treating 
mental health conditions. CBS found that veterans are twice as 
likely to commit suicide as other Americans. And perhaps, I 
think, the most disturbing to me in that report was that the 
risk is highest among 20- to 24-year- olds, as high as 4 times 
that of non-veterans.
    Now, the VA has taken steps to address that tragic 
situation. Congress has taken steps as well. A lot more needs 
to be done. The VA and the Defense Department have to focus 
their efforts on fighting the stigma of mental health treatment 
and improve screening, improve outreach, and improve care.
    Finally, thousands of our servicemembers are suffering from 
Traumatic Brain Injury, which we know is the signature injury 
of this war. That means many of our soldiers are going to fight 
subtle injuries that are going to hurt their ability to work 
and communicate with their families and friends. There is still 
a lot we do not know, so, it is very critical that we continue 
to do research, to identify, prevent, and treat TBI so we can 
better care for our veterans suffering from this devastating 
injury.
    Mr. Chairman, General Peake has already answered, as we 
know, a number of questions from us. I look forward to hearing 
his testimony today. I believe absolutely we have got to have a 
Secretary who is willing to roll up his sleeves and get to work 
because we cannot wait another year to start to deal with these 
many challenges in front of us.
    So, General Peake, thank you for your willingness to take 
this on. I look forward to the hearing today and to your 
answers and responses to our questions.
    Thank you very much.
    Senator Akaka. Thank you very much, Senator Murray.
    Senator Brown?

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

    Senator Brown. Thank you, Mr. Chairman. General Peake, 
thank you for appearing here. I look forward to working with 
you. And, Senator Dole, nice to see you. And, Dan, good to see 
you, too.
    I, of course, echo what Senator Murray just said about the 
importance of this agency. It is one of the largest in our 
Government. We clearly are not prepared for the next 20, 30, 
40, 50 years with these injuries that Senator Inouye was 
talking about on the Senate floor one day--who survived and who 
did not survive these wars--and what all three of you have 
given to this country; and how so many of these young men and 
women will be with us for many, many, many years and will 
demand and deserve such a high level of care.
    Senator Murray also talked about the backlog. My State, 
with a veteran population of a million veterans, has a backlog 
of over 14,000 claims--and as General Peake and I were talking 
on the street one day in front of the Russell Building--some 
5,000 of those claims have been pending for over 180 days. And 
I know of his interest in dealing with this backlog. The 
President's request underfunded the VA, and we are fighting to 
get the funding with, so far, pretty good success.
    Two other concerns. I am concerned about the culture of 
privatization that has in some cases led to bad contracts, 
misused taxpayers' funds, of which there has been a lack of 
accountability. The GAO found that not only did the VA not save 
jobs, it did not save money in its efforts at privatization in 
many cases. Four-fifths of the blue-collar jobs targeted for 
outsourcing to private contractors are held by veterans. So, 
for this agency to outsource jobs to private contractors, and 
cut the number of positions that veterans are now holding 
working for the VA, simply does not make sense. A large share 
of them are minorities. A large share of them are disabled vets 
with service-connected injuries that are using these jobs to 
return to gainful employment and financial independence.
    I offered successfully an amendment on the Senate floor on 
the VA military construction bill which reaffirmed existing 
laws, ensuring the VA must conduct public-private competition 
before transferring Government functions performed by more than 
10 employees. And you will hear more about that, and I think 
that is a very important part of your responsibility.
    Last, I have done a series of roundtables with 15 to 20 
veterans at each around my State--probably a dozen of them 
since I took office in January--and one was particularly 
troubling. In Cleveland, at the VA hospital, about 15 young men 
and women who recently had left--mostly Guard and Reserve 
soldiers, but some were regular Army, regular Air Force--had 
recently left active duty, and were back home trying to 
reintegrate into the community; going to school, going to work. 
Almost every single one of them said that when they left the 
military they were not told--this is not your responsibility, 
except we have talked about the transfer from DOD to VA--many 
of them were told very little about education benefits, and 
health benefits, especially; that once they said they weren't 
going to re-up, the military--their commanding officers seemed, 
frankly, to lose interest in them--they were told to turn in 
their equipment. They came home, and then they struggled.
    There is a program at Cleveland State, one of the best, one 
of the only in the country, that really works to get veterans 
in the classroom and have special classes for them as they 
integrate into society. But there is not enough information 
coming from their commanding officers, coming from DOD, helping 
them integrate back into society and giving them knowledge of 
the access to veterans' services. I hope that that will be one 
of your top priorities as people struggle after serving their 
country to get back on their feet, disabled vets and non-
disabled vets alike. It is something we absolutely owe them, 
especially education and health benefits.
    Again, thank you, General Peake, for being here, and thank 
you, Mr. Chairman.
    Senator Akaka. Thank you, Senator Brown.
    Senator Tester?

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

    Senator Tester. Thank you, Mr. Chairman. I appreciate you 
holding this hearing. I want to thank the two Senators, Senator 
Dole and Senator Inouye, for being here today. I especially 
want to thank Jim Peake for being here, and thank you for your 
service to this country, and thank you for wanting to do this 
job. You have a distinguished military career. That goes 
without saying. You seem to be a man of good moral character. 
That is very, very important.
    If you get confirmed to this job, you have an incredible 
opportunity to impact the VA in a very, very positive way. 
Challenges for the VA are great, and they will continue to 
grow. It still takes too long for veterans to get an 
appointment with a VA doctor. That needs to change. It still 
takes an average of six months for a disability claim to get 
resolved. That absolutely needs to change. Too many PTSD claims 
are denied or given an unacceptably low rating, and the claims 
that are appealed by our veterans take, on average, two years 
to resolve. We all know that these are unacceptable.
    Fixing these problems will be an enormously complicated 
process, and they will require substantial time and attention 
and sometimes money. I look forward to hearing much about 
General Peake's strategies for handling these issues. I hope 
that despite his extensive background in the private sector he 
agrees to address many of these issues without relying too much 
on privatization of the VA. The private sector needs to be 
involved in some of the areas in this country, particularly in 
the rural areas and the specialty care areas; however, as the 
American Legion has said, I believe the VA system is a system 
worth saving.
    Finally, Mr. Chairman, I hope to hear more from General 
Peake about the particular needs of rural veterans. Montana 
being a rural State, and the fact that many of the veterans 
that live in rural areas do not live as long as veterans that 
live in urban areas, it is critically important. I look forward 
to hearing him expand upon the questions that he answered, the 
pre-hearing questions about rural medicine for vets, 
telemedicine, and how we can improve rural health care. 
Clearly, the needs of vets in Montana and in all areas of this 
country go well beyond just telemedicine.
    As I have said, Mr. Chairman, General Peake seems to be a 
very good man. He has a solid military record. Really, the 
question is whether he can deliver the urgent leadership 
necessary to implement the solutions that will make the VA work 
better for the men and women who have put their lives on the 
line for this country.
    I want to thank you very much once again for being here. 
Thank you, Mr. Chairman, for holding this hearing. I look 
forward to your comments and the questions that follow.
    Senator Akaka. Thank you, Senator Tester.
    Senator Hutchison?

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

    Senator Hutchison. Well, thank you, Mr. Chairman, very 
much.
    First, I want to say that the two people who are sitting on 
either side of you have more credibility with the veterans 
community and for this country as the greatest patriots I know, 
and that they are here with you means a lot to me.
    Secondly, I think at a time when we know that the biggest 
problem we have is making sure that our veterans get the health 
care they need, having a physician for the first time to be the 
head of Veterans Affairs I think was a very wise choice by the 
President. So, I, of course, have visited with you; and with 
your distinguished record, which Senator Burr has enumerated, I 
certainly intend to support your nomination because I believe 
you can make things happen.
    I want to talk about the three issues that are of greatest 
concern to me. As you know, I am also Chairman of the Military 
Construction and Veterans Affairs Subcommittee of 
Appropriations. The claims processing, as has been mentioned 
here before--a wait of 177 days for a disability claim to be 
processed is unacceptable. This Congress, in a very bipartisan 
way, has passed appropriations through my Committee that would 
specifically target hiring more claims processors. In fact, we 
specified this year in our appropriations bill, which I hope 
honestly, Mr. Chairman, that we can pass free-standing, because 
it has been agreed to, but has not yet moved to the President, 
we specified $124 million to hire an additional 1,800 claims 
processors. If we can get that bill through, I will be looking 
to you to expedite the hiring of those claims processors and 
trying to change the system.
    Senator Dole and Secretary Shalala, who headed the 
Commission that we all know was so vital for the 
recommendations that it made for improvement in veterans health 
care, both said that the entire system needs to be 
restructured. So, that is something that I think should be 
first on your agenda, and we would certainly want to hear from 
you on that subject.
    Secondly, I want to say something good about the VA because 
our veterans do deserve the very best care. But I hear 
complaints, complaints, complaints, and yet the good things 
that the VA does are largely unnoticed, and they never seem to 
be remarked on by Members of Congress or the groups that could 
talk about it, and that is the electronic records system. The 
VA is state-of-the-art. It is the very best. After the Katrina 
disaster in Louisiana, not one veteran missed a medical 
treatment or a medicine because the electronic transfer 
happened, and wherever the veteran was, that veteran went to a 
veterans' facility anywhere in the country, and they could be 
treated. That is remarkable. And I want to give many of those 
sitting on the front row here who have been with the Veterans 
Administration and previous administrators and Secretaries 
credit for that because it is phenomenal.
    However, the Department of Defense is not up to speed in 
making sure that the people who are leaving active duty because 
of injuries are having the smooth, seamless transfer that we 
all expect to go into the veterans system. It could not be too 
complicated for the Department of Defense and Veterans Affairs 
to have the same system for electronic transfer of records. So, 
I think that is an area where you can take the accomplishments 
of past Secretaries and the Department and transfer that into a 
success by working with the Department of Defense and having 
that seamless transition.
    The third area that is very important to me and has been on 
my Appropriations Subcommittee, as well, is the research. We 
all know that the wounds of today's veterans are different from 
those suffered by the two wonderful, valiant men sitting at the 
table with you, and you, yourself, from Vietnam, theirs from 
World War II. The injuries are different today. We have more 
brain injuries, more traumatic impact injuries because of these 
IEDs. We have more Post Traumatic Stress Syndrome, or at least 
we are treating it. It could be that we had it before and we 
did not do enough. I think that is probably likely. But today 
we do know about it, and General Patton's word is wrong on this 
subject--as we all agree, I think--and that is, we have got to 
treat the injuries of today.
    Research is doing so much more in that regard. The 
prostheses and the use of arms and legs that are missing or 
partly missing has taken phenomenal step in the right 
direction. But we need to continue that to make sure that we 
are doing the very best for these veterans, to have the most 
normal lives possible.
    The Post Traumatic Stress Syndrome--we have mental health 
centers now that have been designated as centers-of-excellence 
for mental health for our veterans' treatment. We now have the 
traumatic injury centers in different areas of our country. 
This is all very good. Gulf War illness research, which is very 
important to me and I think is something that has been 
overlooked in the past, though not in the recent past; because 
the Veterans Administration has gone forward to see what the 
effects on the brain from coming in contact with chemicals 
does. And they are finding that maybe there is a connection 
between these debilitating sort of Lou Gehrig's disease 
symptoms that are connected with some contact with chemical 
weapons.
    So, I hope that these three areas, which are major 
priorities certainly for me and many Members of Congress, will 
be addressed by you. And I think you can take some very good 
successes in the Veterans Affairs Department, and add to those 
with the help of the Dole-Shalala Commission recommendations 
and with veterans like Senator Inouye, who are in this 
Congress, and all of those on this Committee who have really 
focused on this and made sure that we did improve the service 
and increase the appropriations for this very important need.
    So, with that, I look forward to hearing your remarks and 
supporting your nomination. And hopefully, Mr. Chairman, we can 
do this, so that we can have not an Acting Secretary but a 
Secretary who is going to hit the ground running and make 
things happen in the next year for our veterans.
    Thank you.
    Senator Akaka. Thank you very much, Senator Hutchison.
    Senator Webb?

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

    Senator Webb. Thank you, Mr. Chairman, and, General, 
welcome. I would like first to express my appreciation to you 
for your service, and particularly your service as a young Army 
officer. The West Point class of 1966 has really been 
memorialized, I think, as having taken the most casualties of 
any of the West Point classes in Vietnam. As high as 10 percent 
of that class was killed in Vietnam, as I recall, a very 
difficult period during the war when you and others served. I 
have a great deal of appreciation for that.
    I, as you know, am going to want to hear from you about 
your views and your ability to affect the views of the 
administration when it comes to a proper GI bill for the people 
who have been serving since 9/11. And, it is rather fortuitous 
that Senator Dole and Senator Inouye are sitting with you this 
morning, because when I have been speaking about the need for a 
GI bill that properly recognized the service of people since 9/
11 and assists those who are readjusting, I continually come 
back to the World War II GI bill, which was an amazing piece of 
social legislation, as well as a piece recognizing properly the 
service of people. It gave people a true chance at a first-
class future in a way that very few other programs in this 
country have.
    I have three quotes I would like you to think about before 
you and I have a dialogue. This is, as I say, very fortuitous. 
I did not know that Senator Dole was going to be here, but this 
is what he said before this Committee in October: ``I think the 
World War II GI bill was the single most important piece of 
legislation when it comes to education, how it changed America 
more than anything I can think of, and we ought to take the 
same care of veterans today.''
    And then I asked my staff--when I was trying to be able to 
explain why this is important and why this Montgomery GI Bill 
is not addressing the ability of these people who have been 
serving since 9/11 to have a first-class future. I asked my 
staff to take a look at the advantages our colleagues in the 
Senate who were World War II veterans were able to obtain 
through their use of the World War II GI bill. This is a chart 
that was put together, and Senator Inouye, who is a cosponsor 
of our GI bill, S. 22 that I introduced, is one of the people 
on here. But, if you take a look at this, you can see the 
institutions that those who served in World War II were able to 
attend on the World War II GI bill and what that would cost 
today and what percentage of that would be able to be paid for 
by this present Montgomery GI Bill, and you see the problem.
    Senator Lautenberg, who also is a cosponsor of the bill, 
was able to go to Columbia on a full ride. Today it would cost 
$46,874 to go to Columbia. The present GI bill, the average 
participation rate of $6,000, would take care of not even 13 
percent of that. This is what we are looking at.
    The U.S. military is doing a very good job in terms of 
managing its career force. What it is not doing is 
understanding the difficulties in transition of the people who 
are leaving. Not everybody who comes in the military, as you 
and I well know, even under a volunteer system, comes in 
because they want to make it a career. They come in because 
they love their country; they want to serve for a while; maybe 
they want a soldier, they got a family tradition; these sorts 
of things. And, we are not taking care of these people.
    And just out of fairness, I put myself on here. I would not 
be sitting here today, or it would have been a much more 
difficult journey for me to be sitting here today, without the 
help of Uncle Sam. You know, this country put me through 
undergrad at the Naval Academy. I do not know what the number 
is that we can put on that. In fact, they get a little shaky 
when you ask them how much it really costs to put each 
individual through. And then, because I had been wounded and 
was on a voc rehab program, I was able to go to Georgetown Law 
School. And that is the same benefit that the World War II 
veterans had. They paid my tuition, they bought my books, and 
they paid a monthly stipend. Today that would cost $51,000 a 
year, and this Montgomery GI Bill would pay for 11.6 percent of 
that.
    If we put the other chart up, this is you and me, General. 
Our country put you through school--put you through medical 
school; put me through school--put me through law school. We 
have got some really tremendous young men and women out there 
who have stepped forward at a time when a lot of other people 
have dealt with this situation intellectually, and we owe them 
absolutely the best transition that they can get into civilian 
life. It will reduce things like Post Traumatic Stress. It will 
give them something affirmative to bring back to the community. 
And I hear from DOD that they think this will affect retention. 
I do not think they are being creative enough. I think this 
will broaden recruitment. I spent a lot of time doing manpower 
issues in the Pentagon. I have got 5 years in the Pentagon, as 
you know--one as a Marine and the other 4 as a defense 
executive. And the word, the signal word when I was in the 
Pentagon was that the best recruitment tool you have is a proud 
veteran back in the community, someone who believes they have 
been treated right and is proud of their service. And this is 
the kind of thing that would help that.
    So, I am looking forward to hearing your thoughts on this 
during your testimony. This is a time in the administration, 
toward the end of an administration, where I do not know how 
many minds you would be able to change. But at the same time, I 
hope we can have an honest broker in there; and from your own 
background I am really strongly hoping that you can help us 
make this happen.
    Thank you, Mr. Chairman.
    Senator Akaka. Thank you very much, Senator Webb.
    And now I would like to ask for the statements of our two 
Senators who have honored us by being present here today. I 
want to begin by saying they have so much in common. Both of 
them served in World War II. Both of them were badly injured. 
Both of them were in the same hospital. Both of them were 
distinguished Senators in the U.S. Senate. And they are here 
today to speak and introduce Dr. Peake. And being here long 
enough, I am struggling as to who to ask to speak first. If we 
go by age, I know who should speak first. And so, what I will 
do is I will ask Senator Inouye and Senator Dole to decide who 
will speak first.
    [Laughter].

               STATEMENT OF HON. DANIEL INOUYE, 
                    U.S. SENATOR FROM HAWAII

    Senator Inouye. Thank you very much, Mr. Chairman. I am 
honored to join my dear friend Bob Dole, Senator Bob Dole, in 
presenting to the Committee the President's nominee for the 
position of Secretary of the Department of Veterans Affairs. I 
would like to thank General Peake for agreeing to serve. Our 
country needs the General, and I am certain no one is more 
proud of you than your wife, Janice, and your children, 
Kimberly and Thomas.
    This Committee carries the tremendous responsibility of 
ensuring that we live up to our enduring obligations to our 
veterans. The President's nomination of Dr. Peake sends a 
strong message that this administration is serious about 
transforming the care of wounded warriors to ensure that our 
veterans get the world-class care they deserve.
    I am confident that there is no one more qualified to 
accomplish this task than Dr. James Peake. As the son of an 
Army nurse and a career Medical Service Corps officer, he grew 
up in a home where service to country was paramount and where 
respect for soldiers and their families was expected. He 
graduated from the United States Military Academy, as noted, in 
1966. After completing airborne, ranger, and pathfinder 
training, he served as an infantry officer in the 101st 
Airborne Division in Vietnam. He was decorated three times for 
valor and earned a Silver Star. And many of you know that he 
was wounded in action and received two Purple Hearts. Dr. Peake 
attended Cornell University Medical College and later 
specialized in cardiothoracic surgery. He dedicated the rest of 
his 38-year career to caring for soldiers and their families.
    In the year 2000, he assumed the highest position within 
the Army Medical Department when he became Surgeon General of 
the U.S. Army, and I have had the honor and privilege of 
knowing Dr. Peake since 1980, when he was assigned to Tripler 
Army Medical Center in Hawaii. He was then the Chief of Surgery 
and later became Deputy Commander.
    As Army Surgeon General, Dr. Peake led the Army medicine 
transformation. He had a vision, a foxhole-to-hospital view of 
the entire medical system, with the goal that nine out of ten 
soldiers wounded on the battlefield would survive. That was a 
very ambitious role when considered that during the time of Bob 
Dole and myself, we were lucky if you had more than 75 percent.
    Training every combat medic to be an emergency medical 
technician was critical to realizing his vision and was his 
emphasis on joint medical evacuations, establishing forward 
surgical teams, and placing mental health, nursing, and 
physical therapy at the brigade level.
    In December of 2001, projecting the potential for a large 
number of amputee patients from the global war on terror, Dr. 
Peake directed the development of the Amputee Patient Care 
Program. Today, the VA and the Department of Defense work very 
closely in this program to meet the needs of our patients. The 
VA social workers, benefits counselors, vocational educational 
rehab counselors, and researchers have been detailed to Walter 
Reed in support of the care of our patients. The success of 
this program is due in large part to Dr. Peake's ability to 
anticipate the need for change and to lead people towards a 
common vision.
    The time is right for change in the Veterans Affairs 
Department, and what we need at the VA is someone who cares, 
someone with a mission focus, someone who has managed large 
organizations, and someone who can build bridges with the 
Department of Defense, someone who can work with the bipartisan 
nature of the Committee to do the right things for those great 
men and women who are taking their places in history as our new 
combat veterans.
    Dr. Peake is uniquely qualified to meet these challenges. 
Dr. Peake has the distinction of being the first physician and 
the first general to be nominated as Secretary of the 
Department of Veterans Affairs. His time as an infantry officer 
gives him a warrior's perspective on how we should care for our 
wounded. As importantly, his 40 years of distinguished military 
service gives him the wisdom and credibility of a proven 
leader.
    Very shortly, I will be returning to Hawaii to participate 
in the events commemorating the December 7th attack on Pearl 
Harbor, the Day of Infamy that led to the largest generation of 
veterans this country has seen and a generation that is aging. 
This generation reminds us of the importance of the VA and the 
vital services the Department of Veterans Affairs provides.
    I am confident that with this appointment the VA will meet 
the considerable challenges ahead, not just for our aging 
veterans but for all veterans. And so, Mr. Chairman and Members 
of the Committee, I thank you again for the opportunity to join 
my dear friend, Senator Dole, in presenting this great 
American, Dr. James Peake.
    Senator Akaka. Thank you very much, Senator Inouye.
    Senator Bob Dole.

              STATEMENT OF HON. BOB DOLE, FORMER 
                    U.S. SENATOR FROM KANSAS

    Senator Dole. Well, Senator Inouye, we did not know many 
generals. We were lieutenants. But, it is nice to be seated 
next to these big shots. It is probably a first for both of us.
    We are very proud of General Peake, and what really 
impressed me was the fact that his mother was a nurse, because 
our mothers are wonderful and we forget about that from time to 
time, until you end up in a hospital somewhere. And if you go 
to Walter Reed or a VA hospital and there is a young man or a 
young lady injured there, either there is going to be the 
spouse there or the mother, just as they were back in our days 
in World War II.
    You all know his background: he is dedicated to service--a 
must for somebody to take on a 1-year job. I have often thought 
the VA Secretary ought to be like the FBI. It ought to be 
somebody we find out there, regardless of politics, who can 
serve for 10, 15 years uninterrupted. You know, maybe a lot of 
these problems would be cleared up in the process.
    I remember being a service officer after World War II for 
the American Legion and the VFW and the DAV in my little home 
town. So, you know, we have had problems. There are always 
problems. We have got 25 million plus veterans, and there are 
problems. And veterans have rights to appeal, which extends the 
time they get their benefits, and they certainly should 
exercise that right. Sometimes we talk about how many days or 
months or how many cases. A lot of them are because the veteran 
does not think he got a fair shake the first round and he 
appeals the case, as he should.
    You know, I think there is a great positive story to be 
told about the VA. It must be the largest medical organization 
in the world. When you stop to think about it. How many 
hospitals--107?
    Dr. Peake. 153.
    Senator Dole. 153. And I do not know how many amputations a 
year, how many different cases they have. As Senator Hutchison 
pointed out, they have certainly got the best IT system, I 
think, in this country, and probably everywhere. But, you know, 
when I see a piece called ``Waging War Against the VA,'' and 
you find some outstanding people like Tammy Duckworth, who is a 
friend of mine, and others--Tammy said she owed her life to 
Walter Reed. So, you know, they do a lot of good things, and 
they take care of a lot of good people. I know it is easy to 
focus on the negative, and it is going to happen. Let's face 
it. We are all normal Americans. We like to complain from time 
to time, and sometimes we are not treated fairly. If you are 
veteran and not treated fairly, you know, that should not be 
tolerated, as Senator Murray pointed out.
    There are mistakes being made. I do not know what percent 
of the personnel in the VA system are veterans. A lot of these 
people who are taking care of you have been there, and they are 
certainly doing their best to make certain the veteran gets the 
care. And that is another plus as far as General Peake is 
concerned. I hope he does take a look at the GI bill. I would 
not be around and I do not think Senator Inouye would be 
around--there are 8.5 million of us that took advantage of it 
in World War II out of 16 million. It does not have to be 4 
years. It could be whatever. And it did become, for me, the 
most important thing that ever happened; because once you get a 
college education, you want your children and everybody else in 
your family to have the same opportunity.
    One thing that has occurred to me--this is a little off the 
point--I think the universities and the colleges ought to 
participate, too. There ought to be a little discount on the 
tuition or some way they can participate. They are not going to 
be overwhelmed with veterans from Iraq and Afghanistan, but 
certainly they can make a little contribution, which would 
lower the tuition cost in some cases. But, anyway, I would be 
happy to work with Senator Webb trying to figure out a good 
bipartisan approach to this.
    I did a little checking around to see how other people 
described General Peake, and the words and phrases used to 
describe General Peake have been: tough, smart, hard-working, 
focused, fair, compassionate, pragmatic, thoughtful, measured. 
He is someone who listens, he has a vision, and he demands and 
expects results. That is what we are looking for, somebody who 
is demanding; somebody who expects results; and somebody who is 
going to respond to this Committee and the Members on this 
Committee and the veterans groups that are working with 
veterans and others around the country.
    I think the fact that you are willing to do this for one 
year--it is a short time--there are many things you can do. I 
do not know of anybody in the Congress that I have ever known 
the 35\1/2\ years I hung around in the House and Senate that 
did not want to help veterans. We all want to help veterans. We 
just need the guidance and the facts to make certain that the 
deserving veterans, you know, are getting whatever they need. 
Whatever you think of President Bush and whatever you think of 
the administration or the war--I remember the President telling 
me and Secretary Shalala to do ``whatever it takes.'' And that 
is where we are, and that is the responsibility. Whatever it 
takes--whether it is dollars, whether it is education, or 
whether it is whatever other concerns the Committee may have.
    The general is going to have a tough, tough assignment. We 
are talking about, as you know, not just the Afghan and Iraqi 
veterans but, the Vietnam veterans--they are getting a little 
older--and the Gulf War veterans. People forget about the 
sacrifices made by the Korean veterans--that we lost 37,000-
plus young men and women. And then there are still a lot of us 
around from World War II. I think we are down to about 5 
million out of 16 million.
    I want to thank Senator Brown for his participation in the 
Honor Flight program where they bring these old guys back here, 
and women--the women are not old; the guys are old. They 
charter airplanes, and they put them on a plane from Ohio. You 
have had many. They fly them back here without any cost to the 
veteran. They tour all the memorials, and they end up at the 
World War II Memorial. It is a very emotional, important time 
in their life. You can see the tears rolling down their cheeks. 
It is the greatest thing. I have had letters from some of these 
men who just said that nothing like this has ever happened. 
They thought they were forgotten. And just that little visit--
and Ohio I think is the leading State; North Dakota is right 
behind. North Dakota is running out of veterans, they have had 
so many trips. And it does not cost them one dime; it is all 
raised locally. Like Spokane would raise money--they could not 
make it in one day, though, Spokane and back. But it is 
something you get on your website--Honor Flight. It is a great 
program.
    But, anyway, General Peake is going to look after all of us 
older veterans, as well as all the others, and I want to thank 
him for taking on this responsibility. I sort of got involved 
in the process of--I am not that close to the White House--but 
in this case I wanted to have some input. I recommended some 
people. And I know that they have really worked at it. I talk 
sometimes two or three times a week with people who were doing 
whatever you would call it at the White House, looking at 
different candidates--and General Peake just rose to the top. 
They had other well-qualified men and women, but General Peake 
was the choice, and I think the right choice. So, Senator 
Inouye and I are honored to be here today, and I hope we do not 
hurt you too much.
    Senator Akaka. I want to thank you both very much for your 
statements today in support of Dr. Peake.
    Senator Craig?

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

    Senator Craig. Mr. Chairman, thank you very much, and I 
will be brief.
    I have had the great opportunity to visit with the general.
    Let me speak in as precise a way as I can so we can hear 
from our new Secretary. I have worked over the years and have 
spoken out about seamless transition. I now see an opportunity 
with a leader who understands this--with a foot having just 
stepped out of DOD and into VA. I believe, after having visited 
with him, the vision to make that transition in a way that 
brings medical records and personnel records fluently and 
consistently through the process so that we get into the 21st 
century with our men and women in uniform as they transition 
out of defense, out of active service, into a veteran's status, 
in a way that can be called seamless. If this Secretary can 
accomplish that, I believe he will accomplish a great deal.
    Lastly, Senator Dole, you spoke of a relationship in 
education and a responsibility this country has in working with 
veterans. Let me recommend you look at--and I will send it to 
you--a program that I helped the University of Idaho initiate 
over 2 years ago called ``Operation Education.'' They have 
since programmed it and sent it out to colleges and 
universities across the country. And it is simply this: an 
Iraqi or an Afghan vet who wants to come to the University of 
Idaho, with all of their veterans benefits, can come, and we 
will match whatever is necessary to make their stay there work. 
We have reached out to private sector folks and to foundations 
and to the university foundation.
    For example, if they are married, then we find a job for 
the spouse. We provide daycare to the children. A combination 
of things that has brought, I think, the opportunity of that 
veteran coming out of Iraq or Afghanistan and using those 
benefits, we simply add to the benefits and leverage the 
benefits into a full benefit. That is what the public and 
private sector ought to be doing in cooperation.
    I recommend it to you. I will send it to you. I think you 
would enjoy looking at it. It is working very well. It is 
called ``Operation Education.'' Thank you.
    Thank you, Mr. Chairman.
    Senator Akaka. Thank you very much, Senator Craig. At this 
time I would like to ask Dr. Peake to stand for the 
administration of the oath.
    Would you raise your right hand? Do you solemnly swear or 
affirm that the testimony you are about to give this Senate 
Committee on Veterans' Affairs will be the truth, the whole 
truth, and nothing but the truth, so help you God?
    Dr. Peake. I do.
    Senator Akaka. Thank you very much.
    Dr. Peake?

 STATEMENT OF LTG JAMES B. PEAKE, USA (RET.), M.D., NOMINEE TO 
          BE SECRETARY, DEPARTMENT OF VETERANS AFFAIRS

    Dr. Peake. Well, Chairman Akaka, Senator Burr, ladies and 
gentlemen of the Committee. Senator Akaka, thank you so much 
for scheduling this hearing expeditiously. I deeply appreciate 
the confidence of the President in this nomination, and I am 
honored and I am humbled to be before you today seeking your 
endorsement to become the next Secretary of Veterans Affairs.
    I want to thank Senator Inouye and Senator Dole for their 
wonderful words of introduction. I have held each of these 
great leaders in such high esteem over so many years, each of 
them representing service to this Nation in the military, 
wounded in battle, a full career of public service to follow. 
Their endorsement alone underscores the responsibility that I 
know comes with this job.
    As has happened so often in my Army career, my wife, 
Janice, is taking care of our family. My son, Tom, is 
graduating with his master's degree down in Texas, and she and 
my daughter are off to be with him. She has been my mainstay on 
this whole journey you have heard about, and I could not be 
more fortunate.
    With the career I have had, though, there is also an 
extended military family, and there are a number in the 
audience today. I would like to introduce one special member of 
that Army family, and that is Mr. Rick Bunger. Rick was my 
radio-telephone operator when I was a platoon leader in 
Vietnam. He is a veteran, came home, went from rodeo bullrider 
to successful businessman, and he has traveled from Arizona to 
be with me here today. I never dreamed that in front of this 
Committee that cares so much about veterans that I would have 
the opportunity, Rick, to thank you publicly for your service. 
But with your permission, Mr. Chairman, I do that now for the 
record.
    I want to thank each of you on this Committee for finding 
the time to meet with me individually. I was deeply impressed 
and appreciate your individual commitment to our veterans and 
to the mission of the Department of Veterans Affairs. I 
listened carefully to your concerns. They ranged from the very 
real challenge of the transition from DOD to VA care--the 
attendant issues of sharing information between the 
Departments, the importance of the continuity of care which 
that will help--to the very nature and the quality, of the care 
in the VA itself--and not just the quality, but access to that 
care, access that is timely and with minimal bureaucracy.
    The special challenges of rural health care as it relates 
to access for our veterans was an issue that I heard from many 
of you and of the special challenges that this poses, 
particularly for mental health. I appreciate the universal 
concern that PTSD and Traumatic Brain Injury may be less 
apparent than some of the horrendous physical wounds that we 
are seeing fresh from the battlefields; but that these injuries 
are, nonetheless, real, and are likely to become the signature 
injury of this conflict.
    The great advances in prosthetic devices that allow our 
amputees the opportunity for maximal functioning need to be 
matched with the same kind of advances in dealing with mental 
health issues of our veterans and of their families. That means 
research, developing the base of mental health providers, 
ensuring access, addressing stigma, developing practice 
guidelines, measuring the outcomes, and providing support to 
address the co-morbid conditions.
    You spoke to me about Gulf War illness. Even now, 15 years 
later, we do not have clear answers for those who returned from 
Desert Shield and Desert Storm with unexplained illnesses. I 
know and share your concern that this not be forgotten, that we 
continue to care for these men and women and continue to seek 
the answers to the questions of why; not just for them but for 
future veterans as well.
    I appreciate your concerns about the VA infrastructure, 
ensuring that VA forecasting is done well to ensure that we 
make the right investments, to have the appropriate physical 
and human infrastructure to care for the evolving demography of 
our veteran populations.
    I heard clearly the dissatisfaction with veterans waiting 
excessive periods of time to have their claims adjudicated; of 
the importance in reducing the backlog of claims, while at the 
same time ensuring consistency in our rating processes. While I 
am gratified that the VA has nearly 3,000 new claims people on 
board and in training, I look forward, if confirmed, to moving 
forward to making the system less complex, more understandable, 
and better supported with the tools of information technology. 
A veteran should not need a lawyer to figure out what his 
benefit is, and he should not need a lawyer to get it.
    Every single one of these issues that I heard from you is 
important. Each one is complex, and each needs both short-term 
and long-term approaches as we honor our commitments to those 
who have served--those who have served before and to this new 
generation of combat veterans. It is important we get it right 
for them now. And as you said, Senator, it is not business as 
usual.
    Well, the issue today I guess is why me--given the 
challenges I have outlined, the size of the organization, the 
complexity of the mission. You have seen my bio. My father and 
my mother, both buried at Arlington, were in the military. I 
was raised in the Army, chose a career, 38 years cared for 
soldiers and their families. I have spent time in medical 
centers and in troop units. I have been in combat zones and on 
disaster relief missions. I have worked in the joint and 
interagency arena, engaged with many stakeholders in military 
medicine, and appreciate the importance of working 
collaboratively with the veterans service organizations and the 
military service organizations. Fifty percent of our Army 
medical force is in the reserves. I spent a large amount of my 
time, and energy really, over multiple assignments, with and 
for these men and women who truly live up to the moniker of 
``twice the citizen.'' I know they have unique veterans issues. 
Fifty percent of Army Medical Command personnel are civilians, 
so I have dealt with a large civilian workforce.
    I have learned that one cannot micromanage large 
organizations. One needs to delegate and trust subordinate 
commanders. I do believe in accountability, in facts, in data-
driven decisions. I have learned by asking questions and by 
challenging assumptions, and I will do that if confirmed at the 
VA. I will do that to try to make a difference in those issues 
about which we spoke in your office, and which I have heard 
from you today: to make a difference for our veterans, for 
those who served in World War II and Korea, whose needs may be 
different from the needs of my generation; the Vietnam veterans 
generation, my colleagues and my friends who are now finding an 
increasing need for VA services; to make a difference for this 
next generation of combat veterans returning from Afghanistan 
and Iraq, who have immediate needs that are quite different 
from those whose last battle was 40 years ago.
    I know these young men and women, too. I have been 
responsible for training many of them; for helping build the 
system that is returning them from the battlefield despite 
serious wounds; for investing up front and providing them the 
best prostheses; for trying to understand the mental health 
issues longitudinally, from the front edge of the battlefield. 
I care about them. I appreciate the debt that we owe them. I 
believe we must look proactively to their needs today while 
shaping the system for their needs of the future.
    I thank this Committee for your unwavering commitment to 
the Nation's veterans, and if confirmed, I look forward to 
working with you with that same personal commitment.
    Mr. Chairman, I thank you so much for this speedy hearing, 
and I look forward to your questions.
    [The prepared statement of Dr. Peake follows:]
        Prepared Statement of LTG James B. Peake, (Ret.) M.D., 
              Nominee to be Secretary of Veterans Affairs
    Mr. Chairman, Senator Burr, Ladies and Gentlemen of the Committee. 
Senator Akaka, Thank you for scheduling this hearing so expeditiously.
    I deeply appreciate the confidence of the President in this 
nomination and am honored and humbled to be before you today seeking 
your endorsement to become the Secretary of Veterans Affairs. I want to 
thank Senator Inouye and Senator Bob Dole for their kind words of 
introduction. I have held each of these great leaders in such huge 
esteem for so long, each of them representing service to this nation--
in the military, wounded in battle, and a full career of public service 
to follow--their endorsement, alone, underscores the responsibility 
that I know comes with this job.
    As has happened so often in my Army Career, my wife Janice is 
taking care of our family. My son, Tom, is graduating with his Masters 
Degree down in Texas and she and my daughter are traveling to be with 
him. She has been my mainstay on this journey that brings me before you 
and I could not be more fortunate. With the career I have had, there is 
also an extended Military family. There are a number in the audience 
today, but I would like to introduce one special member of that Army 
family, and that is Mr. Rick Bunger. Rick was my Radio-Telephone 
Operator when I was a platoon leader in Vietnam. He is a Veteran who 
came home, and went from rodeo bull rider to a successful businessman. 
He has travelled from Arizona to be here with me today. I never dreamed 
that, in front of this Committee that cares so much about veterans, I 
would have the opportunity to thank him for his service, but I am 
delighted to do that now for the record!
    I want to thank each of you on the Committee for finding time to 
meet with me individually. I was deeply impressed and appreciate your 
individual commitment to our veterans and to the mission of the 
Department of Veterans Affairs. I listened carefully to your concerns.
    They ranged from: the very real challenge of the transition from 
DOD to VA care; the attendant issues of sharing information between 
these Departments; the importance of the continuity of care to the very 
nature and quality of that care across the VA system; and not just 
quality, but access to that care--access that is timely with minimum 
bureaucracy.
    The special challenges of rural health care as it relates to access 
for our veterans was an issue that I heard from many of you, and of the 
special challenges this poses for mental health in particular.
    I appreciate the universal concern that Post Traumatic Stress 
Disorder (PTSD) and Traumatic Brain Injury (TBI) may be less apparent 
than some of the horrendous physical wounds that we see fresh from the 
battlefields, but, that these injuries are nonetheless real, and are 
likely to become the signature injury of this conflict. The great 
advances in prosthetic devices that allow our amputees the opportunity 
for maximal functioning need to be matched with the same kind of 
advances in dealing with the mental health issues of our veterans and 
of their families. That means research, developing the base of mental 
health providers, insuring access, addressing stigma, developing 
practice guidelines, measuring the outcomes and providing support to 
address the co-morbid conditions.
    You spoke to me about Gulf War Illness. Even now, 15 years later, 
we do not have clear answers for those who returned from Desert Shield 
and Desert Storm with unexplained illnesses. I know and share your 
concern that this not be forgotten, that we continue to care for those 
men and women and continue to seek answers to the questions of why, not 
just for them, but for future veterans as well.
    I appreciate your concerns about the VA infrastructure, insuring 
that VA forecasting is done well to insure that we make the right 
investments to have the appropriate physical and human infrastructure 
to care for the evolving demography of our veteran populations.
    I heard, clearly the dissatisfaction with veterans waiting 
excessive periods of time to have their claims adjudicated; of the 
importance in reducing the backlog of claims, while, at the same time, 
insuring consistency in our rating process. While I am gratified that 
the VA has nearly 3,000 new claims people on board and in training, I 
look forward, if confirmed, to moving forward with making the system 
less complex, more understandable, and better supported with the tools 
of information technology. A veteran should not need a lawyer to figure 
out what benefit is due, or to get that benefit.
    Every single one of these issues that I heard from you is 
important. Each is complex and each needs both short-term and long-term 
approaches as we honor our commitment to those who have served before; 
to this most recent population of combat veterans; it is important that 
we get it right for them now.
    The issue at hand today, is ``Why me?'' Given the challenges I have 
outlined, the size of the organization, the complexity of the mission . 
. . . You have seen my bio: my father and my mother, both buried in 
Arlington, were in the military. I was raised in the Army.
    I chose a military career and for 38 years I cared for soldiers and 
their families.
    I've spent time in medical centers and in troop units; I've been 
with them in combat zones and in disaster response operations.
    50 percent of our Army Medical Force is in the reserves. I spent a 
large amount of time and energy over multiple assignments with and for 
these men and women who truly live up to the moniker, ``twice the 
citizen.'' I know that they have unique veterans issues. 50 percent of 
the Army Medical Command personnel are civilians, so I've dealt with a 
large civilian work force.
    I've learned that one cannot micromanage large organizations, one 
needs to delegate and trust subordinate commanders. I do believe in 
accountability, in facts, and data driven decisions. I have learned by 
asking questions and challenging assumptions. If confirmed, I will do 
that in the VA.
    I will do that to try and make a difference in those issues about 
which we spoke in your offices: to make a difference for our veterans; 
for those who served in World War II and Korea whose needs may be 
different from the needs of my generation of Vietnam veterans, my 
colleagues, my friends, who are now finding an increasing need for VA 
services; to make a difference for this next generation of combat 
veterans returning from Afghanistan and Iraq who have immediate needs 
quite different from those whose last battle was 40 years ago.
    I know these young men and women too. I've been responsible for 
training many of them, for helping build the system that is returning 
them from the battlefield despite serious wounds, for investing up-
front in providing the best prosthesis, for trying to understand the 
mental health issues longitudinally beginning at the front edge of the 
battle field. I care about them. I appreciate the debt that we owe 
them. I believe we must look proactively to their needs today, while 
shaping the system to meet their needs of the future.
    I thank this Committee for your unwavering commitment to our 
Nation's veterans. If confirmed I look forward to working with you with 
that same personal commitment.
    Mr. Chairman, I thank you again for this speedy hearing.
    I look forward to your questions.
                                 ______
                                 
 Response to Pre-Hearing Written Questions by Hon. Daniel K. Akaka to 
 LTG James B. Peake, (Ret.) M.D., Nominee to be Secretary of Veterans 
                                Affairs
    Question 1. What do you believe are the most important problems and 
challenges currently confronting VA? In the next year, which of these 
problems and challenges will you focus on and how do you intend to 
address them?

    Response. Problems & Challenges:
     Transition: The transition from active duty servicemember 
to veteran of our current generation of returning, combat experienced, 
men and women is an important current challenge. The challenge is 
broader than just those with severe injuries found unfit for service. 
We must be proactive for those who need support from the VA in 
readjustment to and reintegrating in civilian life. We must anticipate 
and prepare for the fact that some of these Veterans who initially did 
not recognize or claim a disability will have legitimate claims that 
require timely and accurate adjudication.
     Mental Health/Traumatic Brain Injury: Understanding, 
appreciating, and intervening appropriately for those with mental 
health issues, particularly PTSD; and understanding the relation of the 
spectrum of Traumatic Brain Injuries and levels of associated 
impairment will be both a short and long term issue for this newest 
generation of Veterans.
     Access to Care: Insuring access to care with compassion, 
timeliness, quality, and without hassle whether our Veterans live 
metropolitan areas or in the rural areas of our country.
     Backlog of Claims: Addressing the time required to execute 
the claims process to provide benefits, through reproducible, thorough 
and accurate ratings.

    Approaches to address these issues:
     Creating clear expectations within the VA as to standards, 
attitudes, and Veteran focus supported by an investment in training.
     Crossing the information and cultural gaps and barriers 
with DOD.
     Measuring the outcomes against standards and a culture of 
accountability.
     Process analysis and re-engineering supported by 
information technology/automation tools.

    Question 2. Some believe the Secretary of Veterans Affairs should 
be an independent advocate for veterans; others believe that the 
Secretary should be the executor of the Administration's policies 
relating to Veterans. What is your view of the appropriate role of the 
Secretary of Veterans Affairs?
    Response. As a member of the President's cabinet, I appreciate that 
I am a part of the administration. But, I believe I am in the 
administration with the responsibility to not only advocate for 
Veterans, but to insure that our Veterans receive the best of care; 
that they have their benefits provided in a timely fashion, and that 
the many programs that serve them produce the outcomes that make a 
positive difference in their lives. I recognize that this means 
appropriately forecasting the needs and advocating for the funds to 
meet those needs while making sure that the funds provided are well 
used.

    Question 3. What do you believe are the differences and challenges 
in heading a civilian department versus a military organization? As a 
result of any differences, do you anticipate that you will have to 
alter or modify your leadership style?
    Response. Within the departments, there are more similarities than 
differences, i.e., a highly skilled work force, men and women who care 
deeply about the mission, many of whom have had long careers in the 
department. The civilian component of the DOD is larger than some might 
realize. In fact, 50 percent of the US Army Medical Command work force 
was made up of civilians during my tenure. The span of control with the 
VA is more diffuse than the military; the locations within the VA are 
relatively fixed compared to the deployable assets and characteristics 
of the military. Another difference is in the nature of our VA 
beneficiaries, spread throughout the land where advocacy groups have 
become partners in the delivery of services as well as within the 
department and with Congress in the shaping of these services.
    I do not anticipate a fundamental difference in my leadership style 
which I would characterize as integrity based, mission focused and 
recognizing that the only way to succeed is through the men and women 
at every level who do the real work of the organization. To accomplish 
this I will make focused efforts on communication to insure clarity of 
intent; to insure that those men and women know that I value them and 
count on them; and to let them get to know me. In the Army I had the 
advantage of having been a general officer for 8 years before I became 
the Surgeon General and was known. Though many in the VA do know me, it 
is not at the same level. I will similarly need to reach out to and 
communicate with the VA's partners, the VSO's; to this Committee, and 
to those on the House side if I am to be an effective leader for the VA 
and for Veterans' issues.

    Question 4. How have your previous experiences prepared you for 
heading the second largest Federal department? What lessons did you 
learn as Army Surgeon General that you plan to apply to leading the VA?
    Response. I believe that there are several areas of my experience 
that are relevant:
    Because of the mission of the Department of Veterans Affairs--
Caring for those who have borne the battle . . . and their widows and 
orphans--I do believe my 38+ years in the Army, with service in the 
line as an infantry officer and in medicine as a physician, 38 years of 
taking care of soldiers, provides a personal background of caring, 
understanding and empathy that will keep my decisions true to the 
mission.
    My management experience includes 10 years as a colonel with 
executive responsibility in medical teaching centers, in command of the 
Army medical forces in Korea, and as the Chief Consultant to the 
Surgeon General during Desert Shield and Storm. This was followed by 12 
years as a general officer in command of progressively larger and more 
complex organizations with subordinate units geographically dispersed 
and with, particularly in my 4 years as Surgeon General, the important, 
direct interface with Congress, the joint and interagency community, 
and the Army staff. The lessons that I have learned in this journey, 
not just as the Surgeon General, are the importance of data driven 
decisions, measurement of outcomes and the notion that if something is 
measurable it can be improved; and that this approach supports a 
culture of accountability.
    Leadership of units from a platoon in combat, to a team around an 
operating room table, to a department of surgical specialists many more 
senior than I, to the combat medical units of the XVIII Airborne Corps 
with active and reserve units up and down the east coast, to leading 
more than 50,000 men and women of 11 major subordinate commands is 
valuable and relevant experience that that has emphasized the 
importance of listening, of valuing people, and of communicating while 
maintaining a clear focus on the mission. Visibility and accessibility 
are important as a leader. I believe my progression over the spectrum 
of leadership described provides a foundation to apply this experience 
to the much larger VA.

    Question 5. What is your management style? Are you a ``hands-on 
manager''? Do you rely on significant delegation? Do you seek to 
achieve consensus with those on your management team before making a 
decision or do you generally gather relevant information and input, and 
then make a decision?
    Response. The only way one can get anything accomplished in an 
organization much larger than even an infantry company, let alone an 
organization the size of the VA, is through delegation. But, with the 
delegation must come accountability supported by data. I do my homework 
on issues and ask questions to understand the issues. In that sense, I 
am a hands-on manager. As the ``intent'' of policy is communicated, my 
expectation is that those many operational decisions made at levels 
below the Secretary are made consistent with that ``intent.'' In 
decisionmaking, I welcome all input, encourage the dissenting view, and 
seek outside critical thinking. I am always impressed that a product 
can be made better. However, with that input, I will make decisions 
with or without consensus. As a corollary, when there is not full 
consensus, I recognize my increased obligation to communicate my 
rationale; engaging and seeing the decision to success (ownership); and 
in changing course if I am wrong.
     If confirmed, do you expect to visit various VA facilities 
in order to accurately capture what is occurring in the field?
    Response. I look forward to visiting the facilities, meeting with 
the men and women of the VA and finding the venues to meet with those 
we serve. My Army experience supports the importance of ``visiting the 
troops'' in the field as well as ``walking around'' one's own 
headquarters.

    Question 6. As I am sure you are aware, many veterans have raised 
concerns about your coming to VA from QTC--a private sector firm that 
has significant business relationship with the Department. Two 
Questions:

     What will you do as Secretary to ensure that you have no 
dealings whatsoever with QTC or with any efforts on QTC's part to 
continue or expand the company's dealing with VA or on any other 
matters involving QTC and VA?
    Response. If confirmed, I will terminate any connection with QTC, 
will have no ongoing or residual financial interest in QTC, and will 
recuse myself in any matters related to QTC.

     What Plans do you have with respect to QTC when you leave 
the position of Secretary? Do you expect to return to the firm?
    Response. I have no plans to return to QTC, if confirmed; and, more 
specifically, I will not do so.

    Question 7. Secretary Nicholson was accused, rightly or wrongly, of 
being out of touch with the needs of veterans. Are you satisfied that 
you are attuned to the needs of America's veterans? If not, how do you 
plan to improve your understanding of the needs of America's veterans?
    Response. My whole life has been with soldiers. My mother was an 
Army Nurse, my father a Medical Service Corps officer. Those who came 
over to our house included active duty career officers and their 
families and those who had worked for or with my father but who were 
out of the Army, sergeants, privates, officers alike. Many of those had 
served in WWII and in Korea. As a surgeon throughout the 70's and 80's 
I had the great privilege of taking care of many in that last 
``Greatest Generation'' who were dual eligible for DOD and VA care. As 
a commander myself, I know the faces of soldiers and their families and 
have dealt with their needs. As a medical commander, I've been involved 
with the medical and family needs of those injured. As the Chief 
Medical Director of QTC, I talked with veterans in our facilities or on 
the phone and dealt with their C&P examination issues.
    Though I do have what I believe is a solid understanding and 
empathy for our veterans, I know that I will gain an even better 
perspective, should I be confirmed, as I proactively engage Veterans 
Service Organizations, our own dedicated work force, and the veterans 
themselves who seek the spectrum of VA services.

    Question 8. If you were able to have a one-on-one meeting with 
every VA employee, what would you say? If confirmed as Secretary, how 
will you implement this message in terms of policies and actions?
    Response. First, I would tell them how privileged I feel to be 
joining their team; that I believe deeply in the mission; and that I 
believe in them. I would want them to know of my background both in the 
military and in regards to my rather long association with the VA 
through the Special Medical Advisory Group; through working for the 
last year with the VBA; and even with my experience with a VA Cemetery 
as the commanding general at Fort Sam Houston. I would talk about our 
opportunity to look to the future of this next generation of combat 
veterans returning from Iraq and Afghanistan, getting it right for them 
and their families while simultaneously honoring our commitment to the 
WWII and Korea generation, and addressing the men and women of the 
Vietnam era (my generation), who are now finding more need for our 
services. I will commit to each of them my dedication to the mission, 
to them, and to creating the environment for their success as, 
together, we serve the needs of veterans and their families.
    I will use the chain of command, all of the command information 
channels available and will find the personal venues to deliver this 
message. Policies and actions will be consistent with this message.

    Question 9. How many staff do you plan to bring with you to VA? Do 
you anticipate asking the White House to allow you to replace any 
political appointees, including any confirmed by the Senate?
    Response. I am impressed with the quality of the VA senior 
leadership. I have no preconceived plan to replace any political 
appointees and have not been in a position to assess the need to bring 
in additional staff. I am aware of the potential for an Assistant 
Secretary for Acquisition and look forward to the support of this 
Committee in moving forward with that position.

    Question 10. The President noted in his introduction that you are 
the first physician and first general to serve as Secretary. While he 
was certainly correct about your credentials compared with prior 
Secretaries, there have been other generals, including perhaps the most 
famous of all, Omar Bradley, who headed the VA before it became a 
cabinet department in 1989. It is correct, however, that you are the 
first physician to head either the Veterans Administration or the 
Department of Veterans Affairs, and I think that there may be at least 
one compelling reason why a physician has not previously been picked 
for the job, namely, the potential conflict between the Secretary and 
the Under Secretary for Health, relating to VA's health care mission.
    By law, the Under Secretary is a health care professional 
responsible to the Secretary for ``the operation of the Veterans Health 
Administration.'' The Secretary, on the other hand, is responsible for 
``the control, direction, and management of the Department.'' This 
difference suggests that the Under Secretary for Health, like the two 
other Under Secretaries with respect to their Administrations, is 
expected to exercise direct operation control of VHA and that the 
Secretary's role is to supervise the Under Secretary, but not to be 
directly involved in the operation of the VHA.
    If confirmed, how do you anticipate working with Dr. Kussman or 
whomever is the Under Secretary for Health to ensure that this division 
of responsibility is recognized and honored.
    Response. The VA is extremely fortunate to have Dr. Kussman as the 
Under Secretary for Health--its ``Top Doc''. He has assembled a very 
talented team of professionals. If confirmed, I will seek to complement 
Dr. Kussman's efforts and initiatives in leading his administration, 
not to compete. With my medical background, I anticipate being able to 
more quickly make the decisions that he might bring to me since I do 
not anticipate needing ``Medicine 101.'' As I execute my 
responsibilities as Secretary, I would anticipate that my guidance to 
him will be well informed because of my medical background and my 
military background. If anything, I anticipate a greater synergy 
supported by our common medical background and our long association.
    I would note also that Dr. Kussman, Under Secretary Cooper, and I 
all share the background of being flag officers. Again, common 
backgrounds offer synergy rather than competition for authority.

    Question 11. Please describe how you intend to work with the Deputy 
Secretary. Will the Deputy Secretary be VA's Chief Operating Officer?
    Response. Gordon Mansfield is one of my heroes. I am delighted that 
he will continue as the Deputy Secretary. He will continue as the VA's 
Chief Operating Officer.

    Question 12. Please describe how you intend to work with the 
General Counsel. Will the General Counsel be a key member of your 
management team?
    Response. The General Counsel will be a key member of the 
management team. Ethical and Legal behavior are the hallmarks of a 
quality organization. The General Counsel is a major compass in this 
regard as well as one who will provide the detailed advice on specific 
policies, legislation, and initiatives. The General Counsel will have 
open-door access to me to ensure the communication necessary to provide 
that advice.

    Question 13. Please describe how you intend to work with the 
Inspector General. Are you comfortable with the IG's dual 
responsibility, to the Secretary as the head of the Department, and to 
the Congress?
    Response. I understand the Inspector General function from my 
military experience, appreciate their uniquely privileged role, and am 
comfortable with that role. The IG can be a very powerful force in 
maintaining the VA as a learning organization, identifying systemic 
issues that we can fix internally or acquire the support to fix 
externally. Their work will not sit on the shelf, but will be used to 
make us better.

    Question 14. Please describe how you intend to work with the three 
Under Secretaries and with the Assistant Secretaries.
    Response. We will, on a regular basis, meet as a group; we will 
have dedicated one-on-one time. The Under Secretaries have unique 
responsibilities to exercise direct operation control of their 
respective administrations and the Secretary's role is to supervise the 
Under Secretaries. I owe them guidance, objectives, and resourcing with 
the support of all of the assistant secretaries will be dedicated to 
their success.

    Question 15. Are you satisfied with the current alignment of 
Assistant Secretaries or do you anticipate proposing any changes to the 
number of Assistant Secretaries or to their responsibilities?
    Response. The addition of a proposed Assistant Secretary for 
Acquisition is the only Assistant Secretarial position change of which 
I am currently aware. I do not have any preconceived notion of other 
changes that might be required.

    Question 16. How do you plan to work with the Veteran Service 
Organizations? Do you anticipate meeting with VSO representatives on a 
regular basis?
    Response. I appreciate the unique roles of the Veterans Service 
Organizations and the Military Service Organizations and will work 
collaboratively with them as we develop policy, as we seek insights 
from their members, as we work with them as partners in the service 
delivery. I look forward to meeting with them on a regular basis.

    Question 17. What are your views on the situation that was 
described in the media reports earlier this year about Walter Reed Army 
Medical Center and on earlier problems with the medical holdover 
detachments at Fort Stewart and Fort Knox? In hindsight, what might you 
have done as Army Surgeon General to prevent or mitigate the problems 
that surfaced at Walter Reed, Fort Stewart, and Fort Knox?
    Response. Regarding the Walter Reed issues, I do not have first 
hand knowledge of the details having retired in 2004. However, it is 
unacceptable for soldiers to be housed in inadequate barracks. What was 
reported as a lack of caring for those wounded warriors who moved to 
outpatient status was disturbing as was the failure to bring these 
issues through the chain of command. I know that the Army has responded 
with a concerted effort to reestablish appropriate chain of command and 
accountability for those soldiers remaining at Walter Reed in an 
outpatient status and keeping them focused on their individual mission 
of medical improvement and rehabilitation. I also believe a valuable 
service was done in highlighting the convoluted and complex nature of 
the DOD Physical disability system, the overlap of the VA disability 
system, and the need, as highlighted by every group who has examined 
this recently, for revision, simplification, and modernization to 
accommodate for medical and societal changes. I was gratified to read, 
though often as an add-on comment, the recognition of the very high 
quality of inpatient care, of the amazing success in bringing soldiers 
home from the battlefield when, in prior conflicts they would have 
died.
    Regarding the Fort Stewart issue of medical hold-over care, I was 
intimately engaged. The situation that the press highlighted included 
inadequate barracks, slow processing times, and medical resources that 
were not adequate to meet the demand. The majority soldiers who had 
reported to a mobilizationsite medically unfit. Others had suffered 
some condition in their train-up that made them non-deployable. The 
first group was large and a result of policy (changed as a result of 
this experience) that kept soldiers who reported unfit to 
mobilizationsites on active duty for medical board disposition. I had 
not anticipated this category of soldiers to be large and had not 
expanded capacity to meet the demand.
    My response: Within 24 hours of becoming aware of this issue I 
dispatched a general officer led team to meet individually with each of 
the 500 Soldiers at Fort Stewart. Questionnaires were used to collect 
and categorize their issues. The team also met with leaders on the 
installation; Division Commander, garrison commander, and other key 
leaders. I coordinated with the Amy staff and other Army leaders to 
have their subject matter experts available to assist this team to 
resolve those issues outside of the medical arena. In addition to Fort 
Knox, the team followed the trip to Stewart with trips to Fort Benning, 
and Fort Campbell, again meeting with Soldiers at each installation and 
their family members as well. Assessing the teams input, we immediately 
looked at policy issues that needing changing, new ones that should be 
instituted, or resource related issues of more people, equipment or 
facilities. Immediate changes reduced the normal TRICARE access to care 
standards for appointments; for MRIs and other diagnostic imaging 
procedures, and for surgical procedures. I pushed greater use of the 
community assets (purchased care) while at the same time bringing in 
VA, public health service staff and borrowed staff from other Army 
locations. I worked with Army leadership to approve mobilization of 
additional personnel in anticipation of increased numbers of injured/
wounded Soldiers returning from both Iraq and Afghanistan and justified 
additional funds for contract providers, physical disability advisors 
and other support staff. We reduced the ratio of case managers to 
patients, the ratio of soldiers to disability benefit advisors, and 
ensured that hospitals assign primary care physicians who would 
directly oversee this population of patients. I approved the 
establishment of a unique contract that would allow quick access to 
healthcare professionals to include mental health specialists.
    Strict reporting requirements were enacted for the medical 
facilities and they were held accountable to the new standards. The 
medical holdover population was modeled and forecasts allowed resource 
distribution and monitoring of our progress in resolving the needs of 
this population of Soldiers.
    Each soldier was mandated to have a case manager to stay with the 
soldier through their hand-off with the VA. I supported the development 
of the Community Based Healthcare Organization medical concept of 
operation. This initiative continues allowing soldiers to return home 
and receive their care locally but under the management of the 
community based organization with National Guard leadership.
    Prior to this and before the war, the issue of the disability 
system was on my scope. I had insisted that ``The Compassionate and 
Efficient Disposition of the Unfit Soldier'' be placed as a key 
performance process on the Balanced Score Card Strategy Map for the 
United States Army Medical Command. In hindsight I could have 
recognized that the peacetime processing standards (a problem already) 
were inadequate to support a surge that potentially would come of 
wartime. I might have anticipated the impact of the flawed policy 
regarding the retention of soldiers unfit at the time of mobilization 
and fought harder to change it prospectively. I might have worked 
harder to create the imperative to reengineer the disability system. 
Though I was one of the outspoken champions of DOD/VA sharing, I could 
have pushed harder for advances that were more aggressive than the 50 
VA caseworkers that we welcomed into Army hospitals or been more 
aggressive in staff sharing beyond the 4 cardiac surgeons that I 
detailed to the VA.

    Question 18(a). What difficulties confronting wounded, injured and 
ill servicemembers transitioning from the military to the VA health 
care systems are the result of DOD policies and practices? Of VA 
policies and practices? Of some combination?
    Response. If confirmed, I look forward to detailed briefings on the 
current status of policies and practices and the result of pilot 
programs that, I understand, are ongoing. Already addressed, as I 
understand from what I have read and in general discussion, are the 
establishment of specific standards for living quarters for wounded 
warriors, an expanded and aggressive case management approach; a 
strengthening of the chain of command for care and oversight of the 
wounded warrior; the beginning stages of the recovery coordinators as 
suggested in the Dole-Shalala report; information exchange as wounded 
warriors are moved into VA facilities for the next stages of their 
care. Each of these was an area that needed strengthening and focus. 
The VA has moved to expand the polytrauma capability with an additional 
polytrauma center planned as well as polytrauma expertise identified 
within each VISN. I am told that VA has pushed the limits of their 
authority to provide medical support to family members who are 
supporting their wounded warriors. The pilot program in the national 
capital region that began in November will provide lessons in the 
single physical and VA rating for Medical Evaluation Boarded 
servicemembers. The incentive for the servicemember to move from one 
system to the other--or rather the incentive not to move from one 
system to the other--is only partially addressed by these measures and 
is not completely within the purview of administrative change.

    Question 18(b). If confirmed, what do you believe you will be able 
to do to enable VA to change the current situation and to ensure that 
separating servicemembers are made aware of the benefits and services 
that are available to them?
    Response. I believe that the different demographics of separating 
servicemembers require targeted approaches. The wounded warrior with 
recognized combat related injuries is one group. The active duty 
servicemember with an active duty unit affiliation with its full time 
chain of command who elects to separate from service prior to 
retirement is another. The retiring servicemember who may become dual 
eligible is a third group. The reserve (to include National Guard) 
servicemember, demobilizing and returning to civilian life while 
remaining in the reserve force, subject to call-up represents yet 
another group. Coordinating access for these unique groups, crafting 
and delivering a common message with the responsible service, 
appropriate counseling, the processes to deliver those services, and 
measuring the success of the engagement are steps that I would 
champion, if confirmed. I am fully supportive of web based access to 
assistance and would explore other methods to ease communication for 
veterans/families in need of assistance.

    Question 18(c). Will your Army background be a plus or a minus in 
dealing with the relationships between VA and the Navy and the Air 
Force?
    Response. I believe my background will be a plus. My joint 
experience at senior levels dates from my time in command of Army 
medical forces in Korea while serving as the Joint Surgeon with staff 
oversight for both armistice and wartime health care planning. As the 
first lead agent for TRICARE, I worked closely and collaboratively with 
Navy and Air Force medical commanders in our region as well as with the 
VA leadership in Washington State and Oregon. As Surgeon General I 
believe my relationships with my fellow Surgeons General was positive 
and I have sustained those relationships with those who have moved into 
the senior leadership positions within the Services since my 
retirement.

    Question 19. Currently, the VA/DOD Senior Oversight Committee, co-
chaired by Deputy Secretaries Mansfield and England, meets on a weekly 
basis to deal with joint VA and DOD issues. In part, the SOC has been 
addressing those Dole-Shalala Commission recommendations that can be 
corrected administratively. If confirmed as Secretary, what would be 
your priorities for the SOC?
    Response. I am aware of the eight ``Lines of Action'' which, I 
believe, address the high level key areas. If confirmed, a first 
priority will be to gain an in-depth understanding of the level of 
progress within each of these ``Lines of Action'' and formulate my own 
assessment of progress, priorities, or potential areas for addition.

    Question 20. If implemented as set forth in the draft legislation 
presented by the White House, the disability reforms recommended by the 
Dole-Shalala Commission would create a multi-tiered disability system.

     How would you ensure that any changes to the current 
disability system are fair, equitable, and uniformly administered for 
all veterans?
    Response. With the system as it is today, I have heard concerns 
that there is unfairness, inequitable and non uniform decisions that 
occur from time to time and across different geographic areas. Working 
with Congress and the administration to revise the disability system 
offers the opportunity to simplify the process, create a way ahead for 
an equitable and uniformly administered system while meeting the needs 
of each of the tiers that might be identified.

     Do you believe that a disability system that treats 
veterans of different generations differently is desirable?
    Response. The demographics of the Veteran population in the United 
States represent a spectrum. The needs at different parts of this 
spectrum may be quite different. The geriatric medical requirements of 
the World War II generation are quite different from the acute needs of 
the recently returned young Veteran; just as the social needs of the 
older Veteran who may be leaving the active work force is different 
from the vocational and rehabilitation needs of the your Veteran who 
aggressive assistance in re-entering that work force. In between is the 
Vietnam generation who's medical and life circumstance may require yet 
a different focus. It is important that we provide the support and care 
needed that is appropriate to the Veteran.

     Do you believe that veterans of prior conflicts should be 
given a lower priority in claims processing than veterans of current 
conflicts?
    Response. I believe that the VA should strive, through, process 
improvement, automation tools, training, and the expanded claims work 
force that the Committee has supported, to do ``today's work today and 
to standard'' for all Veterans. A quality system must have the ability 
to identify and deal with uniquely urgent or emergent situations by 
exception.

     Do you believe that claims resulting from combat versus 
non-combat injuries or diseases should be prioritized differently?
    Response. I believe the first priority for the VA is to those who 
have sustained service-connected disabilities whether injury or 
disease, physical or mental, and to those veterans in need. I 
understand that the term combat injury within the Dole-Shalala 
commission context is, according to their guidance, broadly understood 
to include training for combat whether in or out of a combat zone and 
with the opportunity for Secretarial discretion to be more inclusive if 
warranted.

    Question 21. I understand that VA has solicited an outside bid to 
carry out two technical studies that are being sought as a result of 
the recommendations of the Dole-Shalala Commission. Once these studies 
are completed, do you believe that the Secretary has the authority to 
implement changes to the disability compensation schedule generally? Do 
you believe that the Secretary has the authority to distinguish between 
multiple systems of compensation and how they are to be applied to 
different groups of veterans?
    Response. The change to the disability compensation schedule 
requires congressional approval. I do believe that legislation is 
required to change the disability system itself. If confirmed, I pledge 
to work closely with Congress, the Department of Defense, and the 
Veterans Service Organizations to create and manage the change 
necessary to meet the needs, both short-term and life-term, of this 
newest generation of combat veterans while insuring that we meet our 
enduring obligation to those of the ``Greatest Generation'' and of my 
generation who have served before.

    Question 22. The Disability Benefits Commission recently released a 
report on its two-and-a-half-year 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. That report 
contains 113 recommendations. In your view, how should VA analyze, and, 
if appropriate, implement the recommendations?
    Response. Though I have not studied each of the 113 
recommendations, I appreciate the work that went into developing such a 
detailed report. VA should analyze each of the recommendations and 
consider its value and validity in the scope of the larger revision and 
changes which are being considered in the disability system. I believe 
this is an area where the Senior Oversight Committee can add value, 
urgency and leadership and I will support their efforts at the big 
picture look and in ensuring appropriate improvements are implemented 
in a timely manner. For those recommendations which VA has the current 
authority to implement, an overall implementation plan with timelines 
should be developed based on a prioritization of the recommendations.

    Question 23. The relationship between VA medical centers and 
medical schools has endured for more than 60 years and has been 
credited with improving quality of care for veterans. These 
affiliations draw the best and brightest physicians and help VA fulfill 
its research and educational missions. I am concerned, however, about 
the viability of the relationship. Please share your philosophy 
regarding the overall value of academic affiliations, including the 
role affiliates play in staffing VA facilities. What is your assessment 
of how Army medical interacts with academic medicine?
    Response. The academic affiliations are one of the enduring 
strengths of the VA. I believe that a robust teaching environment and 
high quality research affiliations are contributing factors to the 
excellence of the Veterans Health Administration. As with any 
relationship, it is healthy to continue to reexamine the outcomes of 
the relationship to ensure the basis remains sound; that our Veterans 
benefit from the care of the affiliate, that the research is of high 
quality and supporting the Veterans' needs; that our Veteran population 
is providing needed access to those in training, and that our changing 
demography of Veterans warrants the maintenance of the affiliation. The 
relationship of Army medicine with academic medicine is less 
interdigitated. Army Graduate Medical Education programs are 
individually accredited, but often work with civilian academic 
institutions for specific rotations. The Army training of ancillary 
medical specialties is, except for degree producing programs, done 
largely without affiliation with outside academic medical centers.

    Question 24. Many veterans, especially those with complicated 
health issues, rely upon the specialized services of VHA. Many of these 
services, like spinal cord injury, blind rehabilitation, and 
prosthetics, are unique to VA and are unmatched by the private sector. 
In an era of declining budgets and decentralization of funds, please 
describe your views on VA's responsibility to maintain capacity in 
these programs.
    Response. I fully support the continued excellence of VHA in these 
highly specialized areas of expertise and service.

    Question 25. Post Traumatic Stress Disorder is a major concern for 
the Committee, both in terms of compensation and health care.

     As a combat veteran, what is your experience with veterans 
and PTSD?
    Response. In combat I had members of my platoon who handled the 
same level of exposure to the horrors of war quite differently; from a 
single soldier becoming overtly combat ineffective; to another 
providing effective fire in an ambush and then continuing to fire round 
after round, even after the action was completed; to the majority of my 
soldiers who were able to perform their duties even in the face of the 
same combat stressors. Personally, I experienced some of the symptoms 
of Post Traumatic Stress, but at a level that would not be classified 
as a disorder. In fact, it is part of what I believe is a ``normal'' 
range of adaptation. As long as two years after I returned, I would 
sometimes startle at an unexpected loud noise or have an occasional 
dream about combat. I was fortunate that these faded with time for me 
and did not affect either my professional or social life.

     Do you personally know veterans who continue to suffer 
from PTSD or veterans who were diagnosed with PTSD, but who are now no 
longer suffering from the condition?
    Response. I do know Veterans who continue to suffer from PTSD. On a 
personal basis I know Veterans who have had PTSD symptoms, who now are 
coping well and are not disabled. I do not know if they had been 
formally diagnosed with PTSD meeting the DSM IV diagnostic criteria. I 
believe that this spectrum of mental health issues is treatable and we 
will learn more as we continue to do scientific inquiry.

     Under what circumstances, if any, is it possible for a 
non-combat veteran to suffer from PTSD?
    Response. The circumstance in which an individual experienced, 
witnessed, or was confronted with an event, combat or otherwise, that 
involved actual or threatened death or serious injury, or a threat to 
the physical integrity of self or others and whose response involved 
intense fear, helplessness, or horror might cause that individual to 
suffer from PTSD.

     VA has significantly decreased its in-patient programs for 
veterans with PTSD. What do you view as the role of in-patient 
treatment for PTSD, in particular for veterans with co-morbid substance 
use disorders?
    Response. I am not aware of the extent of the reduction of in-
patient programs or of a backlog in access to these in-patient 
programs. I am aware that significant advances in outpatient and 
community-based programs for mental health treatment and support have 
enjoyed success and popularity, not only in the VA, but nationwide. If 
confirmed, I will look carefully at the balance between the various 
treatment modalities for PTSD and the co-morbid substance abuse 
disorders to ensure access to the right care in the right location.

     Please describe the priority that you believe VA should 
place on providing care to veterans with PTSD, and how would you ensure 
that priority is manifested in budget requests and programmatic 
planning?
    Response. Care of our Veterans with PTSD and with related symptoms 
short of PTSD is, rightfully, a very high priority. I am aware of the 
recent increase in mental health workers recruited by the VA and, if 
confirmed, I would continue to support this initiative as well as 
exploring the issues of access in rural areas of the country. I will 
work with Congress, OMB, and the experts of the mental health community 
to identify new programs and emerging treatments and in programming the 
resources to support them.
     What are your views on the need for more research into the 
best treatments for PTSD?
    Response. I believe that PTSD will be a hallmark condition of the 
current conflict. I am proud to know that the VA has been at the 
forefront of research in this area. I believe that there is still much 
to learn and that it is the VA's obligation to remain at the forefront 
of this learning.

    Question 26. Last year VA suffered on, of the biggest losses of 
personally identifiable information in history. Fortunately, the data 
was recovered and there have been no reports of any personally 
identifiable information being compromised. Secretary Nicholson 
testified last year that he intended for the VA to become the ``gold 
standard'' for IT security within the Federal Government. If confirmed, 
what priority will you put on efforts to ensure that veterans' 
personally identifiable information is protected?
    Response. The protection of personally identifiable information 
will be a high priority for me. Though I have not been briefed on the 
details, I understand that, subsequent to the noted event, many 
specific policies, procedures, and safeguards for information integrity 
have been put in place. A major information management restructuring 
and centralization has occurred, and investments have been made in 
hardware and security applications. If confirmed, I will work to ensure 
accountability through oversight and compliance monitoring. I 
understand that a specific office with this function has been 
established.

    Question 27. The Dole-Shalala Commission recommended that a corps 
of well-trained, highly-skilled Recovery Coordinators be swiftly 
developed to ensure prompt development and execution of patient-
centered Recovery Plans for every seriously injured servicemember. The 
Commission's recommendation called for members of the Commissioned 
Public Health Service to perform this role. On October 31, VA and DOD 
announced an agreement to provide ``Federal recovery coordinators'' for 
seriously injured, ill, and wounded servicemembers and their families. 
Under the current concept the ``Federal recovery coordinator'' will be 
VA employees and the program will apply only to those injured, ill or 
wounded in combat. Two questions:

     Do you believe the care coordination role is one VA should 
be performing prior to a servicemember's separation from the military?
    Response. The complexity of the conditions and the complexity of 
the systems can be bridged by a coordinated effort from the beginning 
in laying out a recovery plan and monitoring it's execution in 
conjunction with the patient, the patient's family and with the 
agencies involved. As the care coordinator's role evolves it must 
involve the VA while the servicemember is still on active duty.

     Do you believe that this program should be focused solely 
on those seriously injured, ill, or wounded in combat, or should it 
include others who are seriously injured or ill from service elsewhere?
    Response. If confirmed, I will endeavor to insure that the broad 
inclusion of the ``combat related'' description is operative and that 
appropriate additional exceptions have a clear and easy process for 
approval.

    Question 28. VA's vocational rehabilitation and employment program 
is one of the smallest, yet most important, programs within the 
Department. It is the linchpin for helping veterans who incur service-
connected disabilities, achieve a fulfilling and gainful future. I am 
deeply committed to making sure that this program lives up to its full 
potential, especially when individuals who have sustained serious 
injuries in combat are involved. What are your thoughts on the role 
that vocational rehabilitation plays in terms of the total 
rehabilitation of an individual recovering from severe combat-related 
injuries?
    Response. I agree with the importance of vocational rehabilitation 
in support of the critical objective of making our Veterans self-
sustaining, proud, and independent financially, socially, and 
emotionally. I believe in finding the right incentives to get them into 
these programs and keeping them in these programs through the point of 
their transition to gainful employment. If confirmed, I will strongly 
support these programs for Veterans who need help in being productive 
citizens.

    Question 29. There has been significant discussion for at least the 
last decade about the need for DOD and VA to create a bi-directional/
interoperable electronic health record. In 2003, the President's Task 
Force to Improve Health Care Delivery for our Nation's Veterans 
recommended that the VA and DOD develop and deploy such a record.

     What involvement did you have with this effort while 
Surgeon General?
    Response. As the Surgeon General, I invited the President's Task 
Force and personally briefed them on Army medicine to include being a 
champion for DOD/VA sharing. I was a vocal supporter of the development 
of a longitudinal, queriable patient record that would capture a 
servicemembers care from MEPS Station to VA Cemetery.

     Based upon your experience, do you believe that, to 
achieve this goal it is necessary for DOD's and VA's electronic health 
record systems to be combined or to simply have the ability to share 
data?
    Response. I do believe this is an obtainable goal that does not 
necessarily require a single system. More important is the harmonizing 
and adoption of a common health care lexicon and standardization of 
processes.

     Do you believe the current problems in the area can be 
resolved in a timely manner so that VA doctors can have access to 
complete medical history, including military health records?
    Response. Timely is yesterday! So my answer is that we need to move 
as quickly as possible with initiatives that do share digital data and 
records as we advance to the interoperative use of computable data as 
an achievable goal, while making up any short term shortfall with 
paper, and personal communication. We must ensure, even without perfect 
electronic transfer that providers have the information needed to 
provide outstanding care appropriate to the continuum of care.

     As a former practicing physician, what medical information 
do you believe VA health care providers need from DOD?
    Response. I believe that VA physicians and the other health care 
providers within VA need the most comprehensive medical information 
that DOD can provide that is relevant to the patient's current active 
medical conditions. It would be impossible to list here the full 
spectrum of the specific data elements that might be required to do 
this. I would point out that I do not see this information flow as one-
way from the DOD, given particularly: the service to those dual 
eligible Veterans; the potential for a Veteran to return to active 
service after care in the VA; and what our rehabilitative services 
might achieve in returning someone who had been unfit back to duty.

    Question 30. VA currently uses the criteria of 170,000 unserved 
veterans within a 75-mile radius for purposes of establishing new 
national cemeteries. In the past, the Senate has supported this 
standard and has authorized new cemeteries based upon VA's 
recommendations. Do you believe this should continue to be the standard 
practice? In the absence of a VA recommendation, do you believe 
Congress should legislate location of new national cemeteries?
    Response. I understand that the stated goal is: by 2011, to have 90 
Veterans within 75 miles of a national or State veterans' cemetery. It 
is my understanding that Congress has been extremely supportive of this 
strategic direction--five new cemeteries are targeted to open in 2008 
because of your support. If confirmed, I will continue to work closely 
with our National Cemetery Administration and Congress to insure the 
resources are available for new cemeteries and to insure the standards 
are maintained that mark the lasting tribute that commemorates 
Veterans' service to our Nation.

    Question 31. What is your view of the correlation between combat 
service and homelessness?
    Response. I have read that up to one-in-four of single male 
homeless people are Veterans. It has been estimated that nearly 200,000 
Veterans may be homeless on any given night. Risks include poverty, 
lack of family support, precarious living conditions.
    I am told that, currently, there is little information to suggest 
that combat service, per se, has a direct link to homelessness. But, 
deployments with disruption of family lives, the effects of traumatic 
events of combat, may very well contribute to homelessness and is a 
correlation that truly needs investigation.

     Do you believe that VA has a particular obligation to 
aggressively address homelessness among veterans?
    Response. Yes

      Public Law 106-377 funds the Interagency Council on 
Homelessness and makes the Secretary of Veterans Affairs a rotating 
chair of the Council. What do you see as VA's role in working with 
other departments, agencies, especially HUD, to address the needs of 
homeless veterans and their families?
    Response. I believe homelessness is a multifaceted problem that 
involves individual economics, skills development, mental health and 
social well-being. If confirmed, I look forward to supporting the 
inter-agency/interdisciplinary approach to understanding and supporting 
homeless Veterans.

    Question 32. VA has a history of significant waiting times for 
care--a problem from which specialty care particularly suffers. What 
are your thoughts on the priority that should be accorded to reducing 
waiting times? In your view, how long should a veteran be expected to 
wait for a non-emergent health care appointment?
    Response. Excess waiting times result in patient dissatisfaction in 
any health system and so must be a priority in a patient-centered, and, 
in our case, veterans-centered, care environment. In some cases excess 
waiting times can have an impact on the course of an illness or in 
extended period of patient distress. In other cases the Veteran him or 
herself may choose a visit time outside of specified standards for 
their own convenience and without compromising care. The waiting time 
standards should address this spectrum. I understand that the VA 
standard for a non-urgent specialty care appointment is within 30 days. 
This is consistent with the DOD TRICARE standard for non-urgent 
specialty access and is reasonable with the caveat that the referring 
provider can decrease that time depending on the clinical assessment.

    Question 33. The active-duty military has become increasingly more 
reliant on the Reserve components to accomplish its missions. What will 
you do, if confirmed, to ensure that governmental services, including 
pre-, during, and post-deployment services, including transition 
services, are equally available to National Guard and Reserve veterans?
    Response. The ``pre-, during . . . services'' are largely within 
the purview of the Department of Defense. I believe in their recently 
instituted annual Personal Health Assessment and reserve health 
readiness initiatives. Where needed and feasible the VA should be 
supportive of these DOD efforts. Regarding the ``post-deployment 
services, including transition services,'' I will, if confirmed, work 
to make VA an integral participant from emphasis on the Benefits 
Delivery at Discharge program, to educating demobilizing Guard and 
Reserve veterans about their benefits, to encouraging their access to 
VA services in their immediate 24 months of post deployment presumptive 
period currently authorized, and to working with the reserve component 
leadership through DOD collaboration.

    Question 34. In your view, how long should a veteran have to wait 
to have his or her initial claim for compensation adjudicated?
    Response. I am aware that the VA has as its strategic goal to 
provide claims decisions in an average of 125 days. I know also that 
this goal has been very difficult to achieve for many reasons. However, 
I believe VA can and must do better. VA's compensation claims process 
is complex and the evidence gathering often involves obtaining 
information from DOD, VHA, other Federal agencies, and private 
providers. I believe the recently introduced Disability Evaluation 
System pilot, a joint VA and DOD initiative, holds great potential for 
servicemembers undergoing a Medical Evaluation Board Proceeding. I am 
committed to working with all involved parties and the Congress to 
streamline the disability compensation claims process for all Veterans.

    Question 35. VBA has come under fire for the lack of timeliness of 
its claims' processing. While VBA has made progress in improving 
timeliness and accuracy of disability claims processing, further 
improvement is needed. VBA has turned its attention to decreasing the 
amount of time it takes to process a claim, but that improvement seems 
to be at the cost of a decrease in the quality of its decisionmaking. 
Do you have any views on how a more balanced approach can be reached?
    Response. The nearly 3,000 additional personnel for the Veterans 
Benefit Administration dedicated to claims processing will help in the 
short term and as they become better trained (as I understand it, a 
major focus of Admiral Cooper) and experienced, the accuracy will 
improve in addition to the timeliness.
    However, I support the observation by multiple recent groups 
looking at this problem, that a simplified disability system with 
updating of the rating criteria on a go-forward basis offers the best 
opportunity to have clear, fair, and reproducible ratings that are 
supportable by modern rules-based information technology tools.

    Question 36. Accurate forecasting of usage of veterans benefits is 
essential in planning for resources to administer those benefits. What 
do you see as the Secretary's role in insuring that VA forecasts the 
need for additional staffing resources so that Congress could 
appropriate those resources in a timely manner?
    Response. I believe that the Secretary must use actuarially 
supported data combined with real information from practice patterns 
and collaborate with the DOD using their best data to provide accurate 
forecasting and appropriately identify the resources to support those 
forecasted needs.

    Question 37. As one who knows first-hand the value of educational 
benefits under the GI Bill, I am deeply committed to making sure that 
this important benefit is available to today's veterans. I recognize 
that this benefit is not just a readjustment benefit in today's all-
volunteer force. It also serves as a recruitment and retention tool.

     What are your thoughts about the delicate balance between 
these in aspects of the benefit? Do you believe that one outweighs the 
other?
    Response. From my years in the military I appreciate the value that 
soldiers place on their educational benefits. For many, it is a way to 
take an economic burden of education off of their parents, for others, 
the GI Bill represents the only route to additional schooling past high 
school. It is perhaps most important as a motivator for service for 
those who enlist not specifically seeking a career. For the 
servicemember returning from combat, it can be a powerful readjustment 
benefit as described in the Bradley report of 1956. Education can 
produce a better adjusted Veteran and one who is better positioned to 
resume life as a productive citizen. I absolutely share this 
Committee's belief, and appreciate your history of action, in investing 
in those who have served this Nation in uniform.

     How do you see the VA working with DOD on GI Bill issues, 
such as the size, scope, and details of benefits under the various GI 
Bills and in reaching out to eligible individuals to ensure that they 
are aware of and use their benefits?
    Response. The forum for such collaboration exists with the DOD/VA 
Joint Executive Council. If confirmed, I would support a focused look 
at this subject, and would work with Congress and DOD and our Veteran 
Service Organizations to take the results of that work into an 
effective update of our GI Bill programs.

    Question 38. There has been increasing pressure in recent years for 
VA to contract for services in local--especially rural--communities 
where VA facilities are not easily accessible. Mental health is one 
area of particular emphasis in this regard. What do you believe is VA's 
responsibility for meeting the needs, including mental health needs, of 
rural veterans? If confirmed, what emphasis would you place on this 
issue?
    Response. Rural Health is a topic that has come up on several 
occasions in my pre-hearing meetings with the Committee Members and so 
I appreciate that emphasis is needed. I believe that Veterans in rural 
areas may be well served locally, if care is available, but that the VA 
has an obligation to monitor the quality of that care. I also 
appreciate the challenges of making this care part of the continuum of 
care expected of a quality health system. If confirmed, I will ask 
early in my tenure for an update from the recently-created Department 
of Rural Health, explore the various interagency opportunities, and the 
potential for leveraging technologies such as Telemedicine/
Telepsychiatry, to better serve remote Veterans.

    Question 39. There are a number of issues about the current GI Bill 
that I find troubling.

     One aspect that especially concerns me is that there are 
individuals who are serving in combat, placing their own lives in 
harm's way, who have had to make a monetary contribution in order to 
establish eligibility for GI Bill benefits. What are your thoughts on 
this issue?
    Response. It is my understanding that the Montgomery GI Bill was 
enacted by Congress in 1984 and designed for a peacetime active duty 
service and supported a contribution that put skin-in-the-game. If 
confirmed, I will work with DOD and this Committee to re-examine this 
premise in light of the current conflict and the sacrifices of today's 
servicemembers and Veterans.

     I am also very concerned that there are individuals who 
are serving with the National Guard and Reserves and who may have 
completed multiple deployments in combat zones but who stand to lose 
eligibility to valuable educational assistance benefits if they 
separate from their unit. What are your thoughts about these 
individuals and the portability of their benefits?
    Response. I do not yet have a detailed understanding of the full 
scope of this issue. However, my sense is that once these valuable 
educational assistance benefits are earned, they ought to follow our 
servicemember. If confirmed, I will follow up on this issue to fully 
understand the issue and make appropriate corrections within my 
authority or recommendations for change.

    Question 40. All Federal agencies have certain responsibilities to 
maximize contracting opportunities for veteran-owned small business and 
especially service-disabled veteran-owned small businesses. In general, 
it appears that VA has a better record than most other Federal 
agencies. However, some have raised concerns that to meet the goal of 
increased contracting with these businesses, there has been increasing 
reliance on partnerships between large corporations and small service-
disabled veteran-owned businesses, in which the involvement of the 
SDVOB is really only on paper. In your view, does the VA have an 
obligation to ensure that contracts with small service-disabled 
veteran-owned businesses truly involve and benefit these firms in the 
actual contracted activity?
    Response. I am aware of the VA's emphasis on Veteran-owned and, 
especially, service-disabled veteran-owned small business as preferred 
contractors. Given the magnitude of some of the programs and projects 
it may be unrealistic to expect successful performance by any small 
business--veteran-owned or not--in the prime contractor role. I whole-
heartedly endorse our government providing preferential treatment to 
our own Veteran small business owners and particularly those service-
disabled small business owners. If confirmed, I will work closely with 
our contracting office to insure we have clear outcome objectives that 
include development of these veteran-owned small businesses (coaching, 
teaching, mentoring, investing and rewarding) and consider that such 
metrics may be applied to the large corporations who may be better 
positioned to function as a prime, but with a specified level of 
subcontracting to the veteran-owned concerns.

    Question 41. I have long advocated strategies for recruiting and 
retaining highly trained medical professionals within the VA health 
care system. Just a few years ago, I supported legislation to create a 
more competitive pay system for VA physicians and dentists, as well as 
other legislative initiatives targeted at nurse recruitment. Despite 
these efforts, VA continues to face a growing nursing shortage, as well 
as vacancies for specialty care physicians. In your view, what should 
VA do to improve personnel recruitment and retention at VA health care 
facilities, particularly of nurses? What more can VA realistically do 
to improve recruitment in areas where there are fewer specialty care 
physicians overall?
    Response. The recruitment of all health care personnel, including 
physicians and nurses, remains a challenge in U.S. health care. While I 
do not know all of the programs that are currently in place to support 
the recruitment and retention of VA physicians and nurses, I do believe 
that the VHA's reputation as a high-quality health care system is a 
strong recruitment incentive. Generally, VHA will have to continue to 
ask for authorities to allow it to match market pay and performance 
incentives that are offered in the community sector. Not to do so would 
jeopardize the quality of health care providers that treat Veterans. 
Additionally, I would look to ensure that the practice environment for 
our providers is supportive, collaborative, and an inducement to 
retention.

    Question 42. Many in the newest generation of veterans are 
technologically savvy. Veterans can submit claims for compensation over 
the Internet. However, such applications are treated as e-mail copies 
of the application and are not integrated into the claims process. Do 
you believe that VA has a role in improving the use of technology for 
the processing of initial applications for compensation and to aid in 
the timeliness and accuracy of claims adjudication?
    Response. Yes, I believe that the VA should quickly adapt an e-
commerce model that enables those increasingly technologically savvy 
Veterans with a positive, secure, and easy experience.

    Question 43. For some medical conditions that occur after service, 
the scientific information needed to connect the medical condition and 
the circumstances of service may be incomplete. When information is 
incomplete, Congress or the Secretary of Veterans Affairs has the 
authority to presume disabilities and diseases as service-connected for 
the purposes of compensation. If confirmed as Secretary, what would be 
your approach for evaluating whether a presumption is warranted?
    Response. I am aware that there have been recommendations made by 
the President's Commission on Veteran's Disability Benefits and by the 
Institute of Medicine on presumption. I am also aware that this is a 
critical policy decision that determines benefits for millions of 
Veterans. If confirmed, I will study these recommendations and others 
in formulating my approach.

    Question 44. As you know, women constitute an ever-growing segment 
of the Armed Forces and consequently, the overall veteran population. 
What do you see as the primary challenges to appropriately treat and 
serve women veterans in VA facilities? Are there aspects of your 
experience working with women in the military that can translate into 
innovative solutions for improving care for women veterans?
    Response. I believe the challenges include facilities, culture, and 
expertise in women's health issues that have not traditionally resided 
within the VA. Military medicine has traditionally cared for all family 
members, with delivery of babies being one of the most common 
admissions in that system. Even with that base, we had adjustments to 
the deployment culture as more women came into the force. I had a 
specific consultant on women's health issues to focus on our active 
duty women. The importance of ambience, a sense of caring, of attention 
to the privacy needs and sensitivities to security are important in 
addition to the expertise and availability of equipment and services to 
address the physical and emotional needs of women Veterans. These 
capabilities need to be planned for prospectively as the number of 
women veterans grows to the anticipated 10 percent of the veteran 
population by 2020.

    Question 45. A major issue in recent years has been the proposal 
for mandatory funding for VA health care, with many veterans' 
organizations calling for the guaranteed funding of the systems each 
year at a level set by law. What do you see as the benefits or 
drawbacks or both to such an approach to funding for health care?
    Response. I appreciate this to be a very complex issue and one for 
which I will require detailed briefing to provide a more informed 
response. I understand that VA's position has been that annual 
actuarial projections, rather than pat formulas, are the most rational 
way to project the resource needs for Veterans health care. I do have 
an open mind on the subject and intend to carefully study it before 
forming an opinion.

    Question 46. At the present time, military recruiters are actively 
recruiting servicemembers from countries in the Pacific Islands, such 
as the Federated States of Micronesia. Some veterans benefits, such as 
vocational rehabilitation services, VA home loans, and health care are 
not normally provided outside of the Untied States. In your view, what 
obligation does the government have to provide non-citizen disabled 
veterans benefits and services needed to compensate for and overcome 
the disabilities which they incurred after being recruited into United 
States military service?
    Response. I believe that all disabled veterans should receive the 
benefits earned through their service, regardless of citizenship 
status. I have been informed that VA has legal authority to furnish 
hospital care and medical services to any veteran residing outside the 
United States without regard to the Veteran's citizenship if such care 
and services are necessary for treatment of a service-connected 
disability. VA may also provide vocational rehabilitation programs 
outside the United States to assist veterans in becoming employable and 
obtaining suitable employment. The law, however, does not provide for 
independent living services outside the Untied States. I have also 
learned that VA guaranteed home loans and grants for Specially Adapted 
Housing for seriously disabled veterans cannot, by regulation, be made 
to veterans living outside of the Untied States and its territories. 
This is, in large part, because of problems in administering this type 
of benefit to veterans in foreign countries where there is no VA 
presence. If confirmed, I will ask for this area to be reviewed.

    Question 47. In 2004, a blue-ribbon panel completed an exhaustive 
review of VA's vocational rehabilitation and employment program. In its 
findings, it made more than 100 recommendations. Of those, VA reports 
that 88 recommendations have been implemented to some extent. I remain 
concerned, however, that there are far too many eligible veterans who 
do not apply, complete the evaluation process, have a rehabilitation 
plan developed, or complete their plan. No one seems to really know why 
there is such a low completion rate when measured against the number of 
veterans who apply and who are determined entitled. What priority do 
you believe VA should place on determining why the successful 
completion rate for individuals in this program is so low?
    Response. I have not had the opportunity to review the blue-ribbon 
panel review noted. However, I do believe that the VA should place 
emphasis on outcomes, not just participation, in all of our programs. 
If confirmed, I will review the panel recommendation and the results of 
our vocational rehabilitation and employment programs.

    Question 48. Restructuring and downsizing in several VA health care 
facilities have led to contracting with community providers for care. 
Also, a large number of existing VA community-based outpatient clinics 
are run by non-VA providers. What do you believe is VA's responsibility 
for monitoring care furnished by contract providers and how might that 
monitoring be carried out?
    Response. As VA works to provide access to meet the needs of 
Veterans, it is incumbent on us to maintain the same high quality 
standards that we have within the VHA.
    Appropriate monitoring of claims, appropriate contracting; 
appropriate retrieval of health records to compliment the continuity of 
care are all mechanisms that might be used to meet this obligation.

    Question 49. There is legislation currently pending in Congress 
that would provide World War II Merchant Mariners with a tax-free 
annual pension of $1,000 a month, a payment based upon neither 
disability nor financial need.

     What is your opinion about VA providing certain groups 
with entitlement to a monetary payment that is based neither on being 
disabled nor in need?
    Response. The VA administers the entitlements determined by law and 
I do understand that there are some historic precedents for such 
groups. However, I believe the priority should be given to those 
Veterans with service-connected disability or Veterans in need.

     Should VA provide such special compensation to a group 
without doing the same for similarly situated groups?
    Response. The first priority of the VA should, I believe, be to 
those with service-connected injuries or disease whether physical or 
mental, and to those Veterans in need. The VA should administer what 
other benefits are legislated by Congress to the best of our ability 
with the resources applied to insure our first priority commitment is 
fulfilled.

    Question 50. Under the Uniformed Services Employment and 
Reemployment Rights Act of 1994 (USERRA), employers--including the 
Federal Government--have certain responsibilities to re-hire 
individuals who are seeking to return to their jobs following a period 
of active service. It is particularly troublesome to me that an 
individual who has been sent into battle by the government would need 
to do battle with that same government for the right to regain a job 
and its associated benefits. However, it does happen and it happens far 
too often. Indeed, according to Department of Labor, more than 30 
claims of violations of USERRA were lodged against the Department of 
Veterans Affairs in fiscal 2006. This should be embarrassing to the 
agency. If confirmed, what steps do you believe you can take to ensure 
that VA follows USERRA?
    Response. I believe that the legal protection of employment for 
those men and women who have left their jobs to serve this country is 
yet another important contribution made by this Committee. I know that 
among our deployed reserve soldiers, it is a concern that is often on 
their minds. I also agree that the Federal Government and perhaps, most 
particularly, the Department of Veterans Affairs ought to be the 
positive example.
    If confirmed, I will look into the practices that would have the 
Department of Veterans Affairs out of compliance with the law and make 
corrections where that occurs.

    Question 51. Public Law 106-117 contains a provision mandating that 
VA provide non-institutional extended-care services to veterans who are 
enrolled in the VA health care system. While most veterans would prefer 
to stay out of nursing homes, GAOI confirmed that VA is nowhere near 
full capacity on the non-institutional side of long-term care.

     What is your view of the value of noninstitutional long-
term care?
    Response. I believe that non-institutional care can provide a high 
quality of life enhanced by societal and family interaction when so 
enabled.

     Do you have any personal or professional experience in 
this area?
    Response. My personal experience in this area was with my mother-
in-law who, because of Alzheimer's disease required progressive nursing 
home care and with my father who, until his death, eschewed a nursing 
home, but was enabled by home health and a capable caregiver to remain 
in a home setting that was much more satisfying to him. As a cardiac 
surgeon, I often worked with the social workers to find intermediate 
care for recovery and rehabilitation, but realized the quicker one 
could transition the patient back to non-institutional environment, the 
more likely it was that my patient would be productive and enjoy a 
higher quality of life.

     If confirmed, what steps will you take to promote VA's 
development of non-institutional extended care?
    Response. First, I was gratified to understand that more than 90 
percent of VA's medical centers provide home and outpatient long-term 
care programs and that about 50 percent of VA's total extended care 
patient populations receives care in non-institutional settings. I 
fully support VA's patient-focused approach and these programs, and, if 
confirmed, I will review the metrics of success and the incentives to 
support this program with our Veterans.

    Question 52. VHA has had considerable success in using electronic 
health records. What are your views on how technology might be used to 
address problems that arise from VBA's reliance on paper files?
    Response. I believe that this is a very important axis of advance. 
I understand that much work has been done toward the goal of automating 
VBA processes, but that the paper service medical records of the past 
have limitations on digitization potential. On a go-forward basis, this 
constraint should be eliminated and with a simplified disability 
schedule, decision support information technology should provide a 
valuable tool in addressing these problems.

    Question 53. In 1941, Congress passed legislation which, in 
recognition of the difficulty of using official military records to 
establish the disability of veterans who were disabled in combat areas, 
provided for a relaxed evidentiary standard in the case of claims from 
veterans who served in combat areas. It has recently come to my 
attention that VA defines ``combat'' very narrowly when applying this 
standard, requiring a veteran claimant to produce proof of direct 
combat with an enemy. I have introduced legislation which would 
recognize service in a combat zone as ``combat'' for purposes of VA 
claims. Do you see this as an appropriate response to this issue?
    Response. If confirmed, I will review the details of the 
definitions related to combat. My understanding within the Dole-Shalala 
description of ``combat-related''--a disability acquired while training 
and preparing for combat--does not have to be sustained in the Combat 
Zone to qualify.

    Question 54. Recently, it came to the Committee's attention that 
there may be thousands of Reservists who have returned from 
mobilizations longer than 20 months, including extended deployments in 
Iraq or Afghanistan, to find that while their length of service 
qualifies them for Chapter 30 benefits, due to Army procedures, their 
orders fall short of the 730-day threshold, and thus, they are 
ineligible for full educational benefits. A specific example is the 1/
34th BCT from Minnesota, which returned from Iraq in July after a 16-
month deployment. Although almost 4,000 members of the unite had served 
22-months on active duty, roughly half had orders that called for 
active duty service for up to 730 days and half did not. Thus despite 
all having served equal lengths, only half are eligible for Chapter 30 
benefits.
    It is the Committee's understanding that the Department of Defense 
has elected to pursue a remedy in this specific case through the 
correction of military records. They have also indicated that they are 
working with the VA to establish a mechanism for the processing of 
claims for affected individuals in the most expeditious manner 
possible.
    If confirmed, I ask that you have appropriate officials work with 
DOD in an effort to avoid problems such as this in the future. Also, 
please let the Committee know if you believe a legislative remedy is 
necessary.
    Response. If confirmed I will insure that we work with DOD to 
address this problem and to find the solution to avoid such problems in 
the future.

    Question 55. VA research not only makes a major contribution to our 
national effort to combat disease, but it also serves to maintain a 
high quality of care for veterans through its impact on physician 
recruitment and retention. The Administration has made efforts to limit 
the types of VA research to those conditions associated with combat. 
What is your view of limiting the scope of research performed in VA 
facilities?
    Response. The many different age groups and an increasing gender 
mix of Veterans expand the scope of research that is relevant to 
Veterans issues. Our first priority in the use of our discretionary 
research funding is to insure we are the experts in service-connected 
medical issues, but the influence of those conditions over a lifetime 
allows our researchers latitude in the scope of their inquiry.

    Question 56. Through VA's vocational rehabilitation program, VA 
assumes certain responsibilities for the provision of employment 
assistance to veterans who complete a plan of vocational 
rehabilitation. This assistance can take a variety of forms. I believe 
it would be desirable that VA cooperate and coordinate with the 
department of Labor's Veterans' Employment and Training Service so that 
duplication of effort can be minimized. If confirmed as Secretary, what 
will you do to involve both DOL and DOD in efforts to ensure that 
employment-related issues are addressed seamlessly and without 
duplication of effort?
    Response. If confirmed, I pledge to work diligently with both DOL 
and DOD to have a collaborative environment supporting the very 
important outcome of employment for our returning Veterans.

    Question 57. What is your view of the VA's CARES process and VA's 
Capital Plan overall? How will you involve senior Veterans Health 
Administration leadership, Congress, veterans service organizations, 
affiliates, and other stakeholders in the remaining decisions related 
to the implementation of the Capital Plan?
    Response. I believe in the importance of an overarching strategic 
planning process for long-term restructuring of capital assets and 
investment to meet the projected future needs. I have not had the 
opportunity for detailed briefings on execution of the CARES 
recommendations. I do note that those recommendations were based upon 
data only as current as 2004. In moving forward, I appreciate the 
importance of engaging senior Veterans Health Administration 
leadership, Congress, Veteran Service Organizations and other 
stakeholders to insure that our investments support the projected needs 
and demographics of our Veterans while addressing the realities of the 
significantly aging capital infrastructure.

    Question 58. Diagnosis for substance use disorders (SUD) in 
veterans from the current war continue to increase. In your view, does 
combat play a role in increasing the likelihood for developing an SUD? 
Does VA have a particular responsibility for treating SUDs?
    Response. I am aware of recent studies from our current conflict 
that support the role of the stress of combat in the development of 
substance use disorders. There is documented co-morbidity with PTSD 
that is well recognized. VA does have a responsibility to treat 
substance use disorders as they do any health issue that prevents a 
Veteran's reintegration into society.

    Question 59. VBA has had some success in the past with improving 
the efficiency of claims processing by consolidating certain services 
into fewer offices. What are your views on the pros and cons of such 
consolidation?
    Response. I appreciate the importance of the issue of the claims 
backlog and the time required to process a claim in an accurate and 
timely manner. I support exploring new models of claims processing, 
measuring the outcomes, and adopting best practices. I have not been 
briefed to the extent that I have formed an opinion on the pros and 
cons of consolidation in this claims environment.

    Question 60. Under the VA's vocational rehabilitation program, 
there is authority for a program of independent living services for 
individuals who are severely disabled. However, there is an annual cap 
of 2,500 enrollees in this program. Concerns have been expressed that 
this enrollment cap may be adversely impacting the provision of 
services to those most severely injured in combat. Do you believe that 
this cap is appropriate or should these services be available to all 
who need them?
    Response. Independent living services must be available to all 
service-disabled veterans who can benefit from them. I need to learn 
more about this issue. If an annual cap is keeping any disabled veteran 
from participating in the program, I will work with Congress to resolve 
this issue.

    Question 61. Under current policies, there is a protracted period 
of evaluation and multiple reviews of decisions concerning seriously 
disabled veterans seeking independent living services. If confirmed, 
will you look into what steps might be taken to shorten the evaluation 
period and reduce the layers of review?
    Response. If confirmed, I will look into what steps might be taken 
to streamline the evaluation of independent living decisions.
                                 ______
                                 
Response to Written Questions from Hon. Daniel K. Akaka to LTG James B. 
     Peake, (Ret.) M.D., Nominee for Secretary of Veterans Affairs
    Question 1. In response to a pre-hearing question, you described 
different subsets of separating servicemembers--those with combat 
injuries, those with an active duty affiliation who elect to leave 
service prior to retirement, retiring servicemembers, and finally those 
in the National Guard and Reserves who are demobilizing while remaining 
in the reserve forces. Please expand on what you see as VA's response 
to each of these groups--what priority should be accorded to each and 
what should be the focus of VA's outreach and message to each?
    Response. I believe the VA has the same responsibility to the 
servicemember who becomes a veteran from each of the groups and that is 
a speedy and accurate adjudication of their claims, effective and 
efficient and compassionate delivery of their benefits, including the 
highest quality of health care. The difference in response is in 
finding the effective ways of reaching them, educating them on their 
benefits, assisting them in their access to the VA. The soldier 
separating from active duty without an unfitting condition has a period 
before discharge to plan his/her future, access to DOD support 
services, and the link to the VA system with the Benefits Delivery at 
Discharge (BDD) program. The retiring servicemember has a similar 
circumstance, but with the potential of dual eligibility for health 
care if there is service-connected disability. Again, the opportunity 
for education can be targeted and directed while on active duty. The 
reserve soldier who is demobilized may be eligible for VA benefits. 
Reaching this group for education, for screening, for helping them with 
service-related frustrations of getting back to their civilian jobs 
requires a different focus from the active component and it requires 
working with a different chain of command--both National Guard and 
Reserve. The family support structures are more of a challenge in the 
reserve component, yet are increasingly important as it is the family 
unit that needs to understand not only benefits, but issues of warning 
signs for service-related mental health issues such as I understand is 
being done for the active component families. Regarding the message, it 
is the same for each--``we value your service to country, we care about 
you, and support your successful transition back to the civilian world 
as a productive citizen of this great Nation. If you have been disabled 
by your military service, we want to insure you get the best in 
rehabilitative care for the most productive and rewarding life 
possible.''

    Question 2. You stated in a response to one of my pre-hearing 
questions that, as Army Surgeon General, you were a supporter of the 
development of a viable patient record that would capture a 
servicemembers' care from a MEPS facility to a VA Cemetery. At the same 
time, you also noted that you believe that a DOD-VA electronic health 
record system is an achievable goal that does not necessarily require a 
single system. Do you believe that these responses are contradictory, 
and if not, if confirmed what will be your priority for solving this 
problem?
    Response. I do not see these as contradictory responses. The 
important thing is that information is collected as close to the point 
of origin of that information as possible, that it is available to 
those who need it when it is needed and that it can be trended. That 
does require common standards, common definitions, and common 
protocols, which means very close cooperation and shared decision 
making in these areas. In a perfect world, a single system would seem 
desirable, but with that also comes vulnerabilities and acquisition 
challenges as well. As noted, this has been a particular interest of 
mine for many years and, if confirmed, the issue of common computable 
information will be a very high priority. I will quickly ask for 
updates from VA and DOD to find the best way to pursue this goal.

    Question 3. You also noted that, even without a perfect electronic 
transfer, it is important that providers have the information needed to 
provide outstanding care, appropriate to the continuum of care. At this 
point, how encumbered is VA by DOD's lack of a complete digital record 
system?
    Response. I know that the DOD has moved forward with computerized 
records for the ambulatory environment since I retired in 2004. I do 
not have current information on their progress, but do understand that 
there is agreement for both data and image sharing to be accomplished 
by October 2008. If confirmed, I would ask for detailed briefings on 
this area.

    Question 4. As I have stated many times, members of our Armed 
Forces serve at the call of our Nation 24 hours a day, 7 days a week. 
Recently, the Veterans' Disability Benefits Commission presented its 
report and, in that report, agreed with my view, concluding that there 
should be no distinction between combat and non-combat injured 
servicemembers. Do you believe that there should be a system of 
compensation for those injured in combat or training exercises that is 
different from those injured under other conditions?
    Response. I believe that those injured in combat or training 
exercises should be treated the same. I understand the Veterans' 
Disability Benefits Commission also supports an affirmative Line of 
Duty determination as a requirement for benefits, and I agree with that 
as well. I favor finding a way forward for a clear and simple to 
understand definition of benefits and look forward to studying the 
recommendations of the Scott Commission, the studies that I understand 
have been commissioned by the VA, the Dole-Shalala Commission and 
working with the Committee to provide assistance and support needed to 
those with service-connected disabilities.

    Question 5. In response to one of my pre-hearing questions, you 
noted that you've been told that VA has pushed the limits of the 
department's authority to provide medical support to family members who 
are supporting their injured and ill family members. Historically, VA 
has provided only limited direct care to veterans' family members. I 
see at least two areas where it might be appropriate to change that--
first, as part of the direct care of the veteran, such as providing 
counseling and other mental health care services to family members of 
veterans with PTSD; and second, as your answer suggested, when the 
family member is spending time in a VA facility or with VA caregivers 
in connection with the care of their family member. Please give me your 
initial thoughts on what you see as VA's role in this area and then, 
assuming your confirmation, please provide the Committee, within 60 
days, recommendations for any legislation that might be needed.
    Response. My initial thoughts are that the family is a unit when it 
comes to health--particularly to mental health. The spouse who becomes 
a caregiver for a severely injured/disabled veteran can best serve that 
role if mentally fit and that fitness can be challenged by this new 
role. VA should be able to be supportive. If confirmed, I will provide 
recommendations to the Committee within 60 days.

    Question 6. In your view, do the majority of individuals who are 
entering military service today regard that as a career decision, that 
is, as a career from which they will retire?
    Response. I believe that there are many factors motivating men and 
women to join the service today. One is the potential for a career from 
which they might retire. But, I believe that, while there may be an 
increased predisposition for a career in the volunteer force, most do 
not have that as a fundamental career commitment. In the Army it was 
clear that we recruited the individual, but retained families.

    Question 7. In response to my question regarding GI Bill 
educational assistance benefits, you did not elaborate on the value of 
these benefits as a ``retention'' tool. Do you see such a benefit?
    Response. I do believe that educational assistance is valuable as a 
retention and a recruiting tool.

    Question 8. In response to one of my pre-hearing questions, you 
made reference to the so-called ``Bradley report of 1956.'' To what 
extent has that report influenced your views on VA and veterans 
benefits and services?
    Response. The Bradley report of 1956 does highlight some of the 
same challenges for veterans that we see today. In that regard it is 
useful as a part of the background information that I will continue to 
read and consider as I further develop policy and recommendations for 
the way ahead. I appreciate the need to keep in mind the historical and 
societal context in which any report was written. It does remind us 
that the challenges to these newest of combat veterans are not without 
precedent. I appreciate the value that report gives to reintegration 
support.

    Question 9. With respect to VA adopting an e-commerce model for 
filing claims, would you support the move away from a requirement for 
an actual signature on a piece of paper to some form of an electronic 
signature and will you take steps to do whatever is necessary to move 
VA in this direction?
    Response. I do support this approach, note that industry 
successfully uses it, and I will do what is necessary to move VA in 
that direction to include a focus on security and oversight.

    Question 10. In response to questions concerning the Dole-Shalala 
Commission Recovery Coordinator recommendation you responded, ``As the 
care coordinator's role evolves it must involve the VA while the 
servicemember is still on active duty.'' Under the recently announced 
pilot, VA will be responsible for providing these coordinators. While I 
agree that VA should be involved in the process, do you believe that VA 
should be performing these services for servicemembers still on active 
duty?
    Response. I believe the Recovery Coordinator, though housed in the 
VA, is really a joint asset and must be supported by and supportive of 
both agencies. I will seek ways to insure this function serves the 
intended function of coordinating all resources according to a recovery 
plan. I am anxious to learn from the pilot program and adjust 
accordingly.

    Question 11. Do you believe that PTSD can be cured?
    Response. I am dubious of the word ``cured,'' in general. I do 
believe there are people who, at some point, meet the six criteria for 
the DSM IV diagnosis that, ``with treatment lead full and productive 
lives and whose response to the stressor causes no impact on their 
social or occupational life.'' In that case, a specific criterion for 
the diagnosis is gone and one could declare the patient cured. We must 
continue to do research to learn more about this particular mental 
health issue, the likelihood of recrudescence and the ways to prevent 
or mitigate that once a diagnosis is made. Also, we need to understand 
better the interventions for those at risk before the diagnostic 
criteria are met so that we prevent PTSD. Our focus must always be in 
supporting and enabling the veteran to be a full and productive member 
of society.

    Question 12. In your responses to pre-hearing questions, you 
addressed the decision-making process and the importance of reliable 
data upon which decisions can be made. Do you believe that all 
decisions can be quantified in some manner based on some data element, 
or do some decisions have to be made without such underlying data?
    Response. Where things can be measured, I favor understanding the 
data in support of decisions. I also appreciate the real problem of 
``paralysis by analysis'' and I do not intend to use the quest for 
perfect data as an excuse for not making a decision. There are some 
decisions which are based upon a philosophical principle--just doing 
what is right--that don't necessarily require a lot of data-driven 
analysis to decide.

    Question 13. Given VA's post-conflict and long-term responsibility 
for providing prosthetic services to veterans, do you believe that VA 
should consider assuming responsibility for the Center for the Intrepid 
at Brooke Army Medical Center and to operate it as a VA Center for 
Excellence in prosthetic recovery, rehabilitation, and research?
    Response. If confirmed, I would be willing to look at that. 
However, my first inclination is to find the right way to work jointly 
with the DOD. Ultimately, those patients will be at least a shared 
responsibility of the VA's, and to insure we have the excellence of the 
continuum of care and the excellence of progressive research in this 
military related area of rehab, I favor partnership. In fact, when I 
directed the establishment of the Army's Amputee Center of Excellence, 
I insisted that we invite governance participation from the VA.
                                 ______
                                 
    Question 14.A. I have attached a letter from Senator Bond with some 
additional questions for you. I believe you have already answered his 
first question.
  Response to Written Questions from Hon. Christopher S. Bond to LTG 
 James B. Peake, (Ret.) M.D., Nominee for Secretary of Veterans Affairs
    Question 1. Answered, as noted above.

    Question 2. What are your budgeting and staffing plans to address 
the increase in PTSD and TBI patients amongst the veteran population 
and the impact on homelessness, for both the newest wars and prior 
wars, now estimated at more than 52,000?
    Response. I have not had detailed briefings on the budget. I 
understand that VHA has made specific expansion of mental health 
workers to deal with these issues. I note that the Secretary of 
Veterans Affairs is one of the rotating chairs of the Interagency 
Council on Homelessness. I believe homelessness is a multifaceted 
problem that involves individual economics, skills development, mental 
health and social well-being. If confirmed, I look forward to 
supporting the inter-agency/interdisciplinary approach to understanding 
and supporting homeless veterans. I will also quickly assess the budget 
for mental health/TBI.

    Question 3. What are your detailed budgeting and staffing plans to 
address the backlog of PTSD claims? Would you consider expediting the 
process by establishing a presumption of service connection for PTSD 
claims for veterans deployed to Iraq and Afghanistan where the service 
record supports evidence of PTSD symptoms.
    Response. I have not had detailed briefings on the budget. I am 
aware that nearly 3,000 new claims personnel have been hired and are in 
various stages of training. If confirmed, I will further review the 
budget and the pros and cons of this presumption, as well as other 
potential alternatives for expediting claims processing. I am 
particularly interested in getting assistance to those in need and, as 
quickly as possible, engaging them to keep the reaction to combat 
stress from becoming a disabling condition.

    Question 4. What are your plans to address the significant 
disparity among the number of Iraq and Afghanistan war veterans 
diagnosed by VA with PTSD (52, 375), compared to the much smaller 
number of Iraq and Afghanistan veterans receiving disability 
compensation for PTSD (19,015)?
    Response. I am not familiar with the detail behind these numbers. 
If confirmed, I will aggressively investigate this disparity and 
propose solutions to address unfair practices.
                                 ______
                                 
    Question 14.B. Attached are also some question from the Physicians 
for Human Rights.
 Response to Written Questions from Physicians for Human Rights to LTG 
 James B. Peake, (Ret.) M.D., Nominee for Secretary of Veterans Affairs
    Question 1. During your tenure as Army Surgeon General, from 2000 
to 2004, what involvement, if any, did you have in the development or 
approval of the BSCT (Behavioral Science Consultative Teams) program at 
Guantanamo and other facilities, which employed psychologists as 
interrogators in a military intelligence program using abusive tactics?
    Response. Personnel were assigned to join these teams which were 
not under my command authority. To my knowledge medical personnel did 
not act as interrogators.

    Question 2. What efforts did your office take to address the 
credible evidence of physicians and other health professionals serving 
as ``safety'' officers during abusive interrogations? Also, did you 
support the utilization of personnel within your command to provide 
sign-off on whether a detainee was physically or mentally ``capable'' 
to undergo SERE method interrogations?
    Response. I am aware that medical personnel, not in a patient care 
capacity for the prisoners, provided medical advice to the 
interrogators in support of humane treatment of prisoners. I supported 
this policy. Care of prisoners was performed by different competent 
medical personnel assigned for this task. I was not briefed 
specifically on ``SERE'' method and cannot comment.

    Question 3. Military medical personnel who practiced torture and 
other abuses of POWs and enemy combatants may well suffer lasting 
medical and psychological effects. These individuals who participated 
in torture or abuse may have unique problems with the potential to lead 
to significant social consequences. If confirmed, what steps will you 
take to ensure that the Veteran's Administration is prepared to 
adequately address the medical and psychological needs of these 
veterans?
    Response. I am not aware of any medical personnel who practiced 
torture. Torture is illegal and is not supported by the military. As 
with all of our military personnel, exposures to the activities of war 
create the potential risk to psychological health. Our medical 
personnel in the combat support hospitals, for example, are exposed 
daily to severely injured U.S. and coalition servicemembers. If 
confirmed, I will keep the mental health sequellae of war to include 
PTSD, substance use disorders, and other potential co-morbid conditions 
as a focused area of treatment and research 
inquiry.
                                 ______
                                 
 Response to Written Questions from Hon. Richard Burr to LTG James B. 
     Peake, (Ret.) M.D., Nominee for Secretary of Veterans Affairs
    Question 15. Dr. Peake, you retired from the Army having attained 
the highest rank and position possible for a medical doctor--wearing 
three stars on your shoulders and serving as the Army Surgeon General. 
You had authority over and responsibility for the entire Army medical 
system. What lessons did you learn while serving in that position that 
you believe would help you to serve as an effective Secretary?
    Response. I have learned that the only way one can get anything 
accomplished in an organization much larger than even an infantry 
company, let alone an organization the size of the VA, is through 
delegation. But, with the delegation must come accountability supported 
by data. I have learned to do my homework on issues and ask questions 
to understand the issues. As the ``intent'' of policy is communicated, 
my expectation is that those many operational decisions made at levels 
below the Secretary are made consistent with that ``intent''. In 
decision making, I will welcome all input, encourage the dissenting 
view, and seek outside critical thinking. However, with that input, I 
will make decisions with or without consensus. I recognize that without 
clear consensus, I have an increased obligation to communicate my 
rationale; engage and see the decision to success (ownership); and the 
responsibility to change course if I am wrong.

    Question 16. For many years, there have been serious concerns about 
the backlog of claims at the Department of Veterans Affairs, the length 
of time it takes to process claims, and the accuracy of VA's decisions. 
Have you thought about a strategy for how you would address these 
enormous challenges if you are confirmed?
    Response. I understand that Admiral Cooper has been able to expand 
his claims workforce and has put in place an aggressive training 
program. If confirmed, I will be anxious to see the results of that. I 
also believe that a key to the future is automation and decision 
support tools for those who have to adjudicate records. Getting the 
right information up front, (and with this newest generation, working 
right now with DOD to do so) is important. The DD-214 that is now 
shared electronically is an example. Simplifying the disability system 
is also part of the road to more accurate and efficient claims 
processing and adjudication.

    Question 17. Earlier this year, Secretary Nicholson started a new 
initiative at the Department of Veterans Affairs to provide priority 
claims processing for all OIF/OEF veterans' disability claims. Although 
all claims are important and deserve prompt attention, do you share the 
view that we should provide a higher priority to veterans of the 
current conflicts who are transitioning to civilian life and seeking 
disability compensation for the first time?
    Response. I am a believer in putting the systems in place to do 
``today's work today.'' This includes resources, processes, people, 
equipment, and time. If those resources are not calibrated to the 
demand, managers must prioritize. Up to 60% of claims, as I understand 
it, are reopened claims of veterans who are already getting benefits. 
We need to move these along expeditiously and to standard, but I do 
believe that those who need access to the benefits to reintegrate into 
society, to rehab from fresh battle experience and service-connected 
wounds ought to have priority while we develop the resources, human and 
otherwise, to meet all of the claims in line with that ``today's work 
today'' philosophy.

    Question 18.
     Dr. Peake, if confirmed by the Senate, your tenure as 
Secretary will likely last just about one year. That's not a very long 
time to serve in any post. Why did you agree to leave the private 
sector for this temporary, one-year position?
    Response. I can think of no higher calling that serving the country 
and particularly having the opportunity to care for our veterans. It is 
an extension of what I have devoted my adult life to doing. I consider 
it an honor and a privilege as well as a responsibility of citizenship.

     More importantly, with such a limited tenure likely at the 
helm of VA have you given any thought to what you would like to 
accomplish in that time period?
    Response. We are a Nation at war. We have the best of this nation, 
our young men and women, in harm's way and returning as our newest 
generation of veterans. I will do my very best to set the azimuth for 
their future as veterans while working the more immediate issues of 
transition that insures continuity of care for those who need that; 
open the access to those whose health needs become apparent after 
transition; and remember the rehabilitation/reintegration missions as 
ones whose outcomes are jobs and economic self-sufficiency.
    The issue of PTSD is an important one, as is the issue of TBI. We 
must get the best of science to help us guide the way we deal with this 
for our veterans--both our newest veterans and those who have served in 
prior conflicts.

    Question 19. Dr. Peake, DOD continues to struggle to implement a 
fully-operational electronic health record. And we, in Congress, have 
been pushing DOD and VA to create a complete interoperable health 
record between the two agencies.

     First, how well do you think the Army has progressed in 
its implementation of an electronic health record system?
    Response. I have not had a recent update on the electronic record 
for the military health system--to clarify it is a joint system. I do 
know there were some technical and cultural challenges and particular 
segments, some specialties for example, found it more difficult to 
adopt. But, having a longitudinal, queriable patient record that is 
accessible to all who need it for the care of the trooper is the right 
objective.

     Second, do you think an interoperable record between VA 
and DOD is attainable? And why do you think we continue to struggle to 
attain that goal?
    Response. I do believe it is an obtainable goal and one we should 
fight to obtain. It is not just about hardware and software. I believe 
it has to do with developing the standard lexicons, the common 
processes that promote interoperability. It means creating a common 
information culture, the forums for shared decision making. With the 
centralization of IT at VA (a cultural shift in itself) the opportunity 
may be enhanced.

    Question 20. North Carolina has a number of VA medical centers and 
outpatient clinics throughout the state, yet I am told that VA medical 
examinations for disability compensation claims are only provided at 
the Winston-Salem VA outpatient clinic.
     Are you aware of any reasons why it would be appropriate 
to require veterans to travel, in some cases up to four hours, to the 
Winston-Salem clinic when other VA facilities are closer to them?
    Response. I have not been briefed on the issues of access related 
to the North Carolina VA network. I have heard repeated concerns about 
timeliness and ease of access from Members of this Committee. If 
confirmed, I will review this matter and respond.

     Do you believe that veterans may be better served, and 
that VA may even save money on travel reimbursements for scheduled 
examinations, if a wider selection of VA examination sites were 
available?
    Response. The C&P examination can be quite complex. It is important 
that the quality of the examination is maintained. That focus will 
reduce rework, reduce remand rates, and provide a more timely and 
accurate adjudication. If confirmed, I will work with VHA and VBA to 
find creative solutions to the quality and access issues inherent in 
this question.

     Do you commit to examining this issue, specifically for 
North Carolina veterans, but also nationally, if you are confirmed?
    Response. I do.
                                 ______
                                 
 Response to Written Questions from Hon. John D. Rockefeller IV to LTG 
 James B. Peake, (Ret.) M.D., Nominee for Secretary of Veterans Affairs
    Question 21. The press reports on PTSD and mental health issues 
among our returning veterans are compelling. In private roundtables 
with West Virginia veterans, I believe that many more veterans may come 
forward with such concerns over time. Given your career in the 
military, you have a unique ability to understand and appreciate the 
stigma that soldiers and veterans may face in seeking mental health 
care. Can you share your views and possible strategies to help combat 
the stigma veterans face in seeking mental health care in the VA, and 
with the public?
    Response. I will start with an anecdote. Immediately after 9/11, 
with the Pentagon housing the remains of an airplane and having visited 
all of the wounded from that attack, it was clear to me that mental 
health of the pentagon workforce had to be addressed proactively. I 
assembled my mental health team in a crisis action mode and with their 
recommendation, supported and resourced flooding the pentagon with 
mental health workers available in-clinic, outside of clinic on-call, 
outside of clinic walking around and visiting EVERY organization and 
office; outside of clinical settings, but in easily-accessible 
locations; and mental health workers located in the primary care areas 
that service the military and military dependent workforce. The 
approach was with medical professionals, but without medical records 
developed except for those referred for more advanced and in-depth 
therapeutic assistance. The senior army leadership, specifically 
General Shinseki, our Chief of Staff, and General Keane, our Vice Chief 
of Staff, personally, and forcefully encouraged the Army Staff 
leadership to ensure that EVERY person availed themselves individually 
on in-group sessions of this mental health access.
    This was not done in response to someone acting ``crazy'' or having 
a traumatic response; rather, it was done proactively--effectively 
saying to people that they could normally expect to have been affected 
emotionally by the event and that it was ok and expected that they 
would avail themselves of the support, and that they could expect to be 
better. It worked! It is hard to prove the negative, but after a year, 
there were no suicides in that group of workers and there were a number 
of people who had, without fanfare, received longer-term treatment 
while the majority went back to work even while the pentagon was 
rebuilt. This anecdote has colored my thinking on this subject.
    It prompted me to aggressively support an employee assistance 
program type of system that became Army One Source (now evolved to 
Military One Source). It provides a hotline for help; it allows up to 6 
counseling sessions without medical records and without reporting 
(unless a serious mental health issue is surfaced); family and 
servicemember alike have access.

     What will you do to reach out to Guard and Reserve 
soldiers who may be less likely to seek VA care, and may have more 
difficulty with the paperwork and eligibility?
    Response. I believe the VA must work with both the active duty and 
the reserve chains of command to insure we reach the Citizen Soldiers 
with meaningful engagement before they demobilize to educate them about 
benefits and the processes to get them. Particularly, we need to team 
with the DOD to have all of the Reserve Component Servicemembers who 
have deployed complete the Post Deployment Health Care Reassessment 
(PDHRA) and be proactive to assure the resulting follow-up plans are 
executed. In parallel we to need move forward with simplifying the 
disability system and the processes by which it is administered.

    Question 22. As a follow up, Dr. Peake, I wanted to share estimates 
according to the DOD Task Force on Mental Health from June of 2007.

     Among active duty soldiers, it estimates to be up to 38% 
with general mental health needs
     For Marines, it estimates 31% will have general mental 
health
     Among, National Guard & Reserve soldiers it is higher, 
with as many as 49% facing general mental health issues.

    The report also suggests that psychological concerns are 
significantly higher among soldiers with repeated deployments, and the 
numbers of such soldiers is growing. This is a stark summary of the 
problem we face. How do you intend to approach this once confirmed as 
the VA Secretary? How will you work with us on the major issues of 
resources and reforms to meet the stunning needs of our soldiers?
    Response. I am familiar with the study and agree with the sense of 
the magnitude of the problem. If confirmed, I will work to strengthen 
and build upon the ongoing collaboration between the departments. It 
will be important to distinguish those among the groups above that 
truly have a Post Traumatic Stress Disorder diagnosis. As you 
rightfully point out, these numbers above include general health needs. 
Many of these can benefit from early recognition and early intervention 
and their negative effects can be significantly mitigated or even 
eliminated. Others will require more extensive intervention and may be 
compromised in their employment or life skills even with intervention. 
We do not want to treat these all the same. I will, if confirmed, give 
strong support to research as we continue to advance the science of 
mental health issues as military sequellae. I look forward to exploring 
innovative ways to engage the family unit of veterans who do not have 
the benefit of the DOD initiatives that might come out of the study. If 
confirmed, I will work within the administration, with the stakeholders 
represented by veterans, veterans service organizations, military 
service organization and the best researchers to identify the programs, 
resource the programs, and measure the outcomes.

    Question 23. Traumatic Brain Injury (TBI) is a serious issue for 
veterans from Iraq and Afghanistan. The severe cases of TBI are getting 
real attention, but what about the moderate cases and the potential 
long-term effects? What research will VA engage in to study this 
problem?
    Response. I have not had detailed briefings on the specific VA 
research initiatives in TBI, but am aware of the high interest in this 
area and the expansion of the polytrauma centers and polytrauma network 
that has a focus on the problem of TBI. I also am aware that both the 
Dole-Shalala Commission and the Marsh-West Independent Review Group 
both highlighted this issue. If confirmed, I look forward to 
proactively engaging with Colonel (promotable) Loree Sutton, a military 
psychiatrist who is tasked leading DOD's study of TBI, specifically, 
and ensuring active collaboration in her efforts and access to VA 
experts of our polytrauma team.

     How can we track veterans who do not have problems now, 
but may develop problems over time due to multiple exposures to TBI 
during combat?
    Response. I believe this represents a long-term epidemiologic 
problem that must be studied in this population. Sports-related 
concussion (akin to ``mild TBI'') does have a body of evidence that 
suggests mild TBI recovers generally well, but again I do believe long-
term studies are needed. In the meantime, perhaps we should be 
referring to that as concussion rather than Traumatic Brain Injury, 
which seems to take on an ominous connotation with servicemember and 
family member. Work is being done on cognitive testing, but again, I 
support research to tell us what productive screening might be useful 
as we look to problems over time.

    Question 24. I realize that VA faces funding problems, but how can 
we justify a ban on Category 8 veterans, many who many be uninsured 
according to a private study this fall, and earning as little as 
$28,000 per year? Rather than using administrative authority to bar 
enrollment, shouldn't we work together to get the funding we need to 
provide VA health care for such veterans?
    Response. My understanding is that the Category 8 designation was 
established in 2003 as the system was overwhelmed and the core mission 
of excellent care for those veterans with service-connected 
disabilities and those veterans in need would be compromised. If 
confirmed, I will look forward to working with you to consider 
approaches to understanding the needs of non-service-connected veterans 
for health care coverage that is affordable and looking at the means 
testing that is currently in place with the ``Category 7'' veterans. It 
is essential that the core mission of specialized care and care for 
those service-disabled veterans and veterans in need, not be 
compromised.

    Question 25. In 1990, there were only 1.2 million female veterans, 
by 2010, there will be 1.8 million female veterans. The number of 
female veterans is on the rise, as the number of male veterans is 
declining. Some estimate that by 2010, female veterans will be about 
10% of the veteran population--that is less than 3 years away.
    A VA task force notes that of the more than 263,000 veterans 
seeking VA care from Iraq and Afghanistan, 12% (or over 31,000) are 
women veterans. How will VA expand its outreach and adjust its services 
to provide care and meet the needs of the rising number of female 
veterans? What needs to change at our Vet Centers and in our medical 
centers to accommodate our female veterans?
    Response. I believe the challenges include facilities, culture, and 
expertise in women's health issues that have not traditionally resided 
within the VA. Military medicine has traditionally cared for all family 
members, with delivery of babies one of the most common admissions in 
that system. Even with that base, we had adjustments to the deployment 
culture as more women came into the force. The importance of ambience, 
a sense of caring, of attention to the privacy needs and sensitivities 
to security are important, in addition to the expertise and 
availability of equipment and services to address the physical and 
emotional needs of women veterans. These capabilities need to be 
planned for prospectively as the number of women veterans grows to the 
anticipated 10% of the veteran population by 2020. I am pleased to know 
that there is a specific organization with a focus on women veterans' 
issues, and, if confirmed, will work within VA to insure this area has 
focus and resources.

    Question 26. Staffing at VA Medical Centers and Vet Centers is 
vital to quality care. What is your philosophy on staffing centers, 
routing directors of VAMC, and replacing leadership?
    Response. I am pleased to know that the Senate has recently 
confirmed Mr. Michael Hager as the new Assistant Secretary for Human 
Resources and Management. If confirmed, I look forward to working with 
him to get a detailed understanding of our personnel management 
programs and alternatives for the future. My experience in the military 
suggests that there is an advantage to movement in leadership 
positions, but not as frequent as dictated by military life. Managing 
the human resource with developmental opportunities and progressive 
responsibility allows a career path with a future and also affords a 
succession planning bench to insure the future of the VA leadership.

    Question 27. The attached news article published in June of this 
year reported concern that of an upcoming $90 million contract for 
information technology asset management software being directed to a 
particular company without the benefit of competition. If the press 
report is accurate, it is an indication of serious problems within the 
Department with regard to contracting procedures and compliance with 
the mandates of the Competition in Contracting Act including the 
requirements for full and open competition. As a new Secretary, how 
will you ensure that this particular procurement is properly competed 
and that all Department procurements meet statutory requirements for 
competition?
    Response. I have not been briefed on this particular contract and 
do not know if the press report is accurate. However, I do believe in 
full and open competition. It is my understanding that this Committee 
has supported a new position, an Assistant Secretary for Acquisition. I 
strongly support this new position and believe that focused leadership 
and development of the acquisition workforce of the VA will improve 
what we ultimately are able to do for our veterans. Regarding this 
particular procurement, if confirmed, I will ask for a detailed 
briefing to address your concerns and take corrective action as 
required.

    [Federal Computer Week Article follows:]
Federal Computer Week, Vendors claim VA contracts unfair
    Industry alleges agency decisions give IBM wired advantage to win 
10-year contracts. By Jason Miller, Published on June 11, 2007. 
Editor's note: This story was updated at 11:08 a.m. June 11, 2007. 
Please go to Corrections & Clarifications to see what has changed.
    Several industry sources said two Veterans Affairs Department 
contracts for information technology asset management software and 
services worth $90 million over 10 years appear to be wired for IBM. VA 
issued the contract solicitations through NASA's government-wide 
acquisition contract (GWAC).
    Industry sources, who requested anonymity because they did not want 
to damage their relationships with VA, pointed to several unusual 
decisions the agency has made in the past few months and to specific 
instances in the agency's request for proposals to support their 
suspicions.
    Those sources alleged that VA's decision to use NASA's Solutions 
for Enterprisewide Procurement (SEWP) GWAC and to require integration 
with IBM's Maximo Software Suite are among the most troubling aspects 
of the procurement.
    Industry sources said IBM is the only vendor on SEWP IV that 
provides software that easily integrates with the Maximo Software 
Suite. They also said other resellers in the market could compete on 
the contract if it were awarded through the General Services 
Administration's Federal Supply Schedule or FedBizOpps.gov.
    ``VA is looking for an agent-based solution as they say in the RFP, 
and Maximo is the only one'' on the Solutions for Enterprisewide 
Procurement, said an industry executive. ``All I'm looking for is full 
and open competition.''
    Industry sources said BDNA, CA and EMC Software are among the 
vendors that could compete in full and open competition.
    A VA spokesperson denied the contract is wired to IBM, and said the 
agency wants as much competition as possible from SEWP vendors. VA 
officials in July 2006 mandated all software purchases must go through 
SEWP, the spokesperson said.
    But because IBM is the only vendor on SEWP to provide these 
services, the industry sources said the procurement is unfair.
    The spokesperson said VA is trying to ensure competition. ``In 
addition to requesting information, the RFI affords vendors the 
opportunity to establish required relationships with resellers to 
further enhance competition,'' the spokesperson said.
    Another red flag, industry sources said, is VA's request for 
205,000 software licenses. On IBM's SEWP listing for Maximo, IBM quotes 
a price for 205,000 licenses, a price available only to VA.
    ``When IBM created their SEWP IV offering, isn't it striking that 
they had the insight to know that it should be 205,000 assets, and only 
VA could use it,'' said another industry executive. ``And then there is 
an RFI that aligns directly with IBM's offering. Maybe if I was a 
little more naive, I would believe it was an accident.''
    An IBM official said VA is simply adding new modules to 
applications VA already uses.
    The VA spokesperson said the agency specifically asked for Maximo 
because the other applications, including the IT asset management 
software, will run on IBM's Maximo.
    Under the services contract, which is estimated to be worth $54 
million over 10 years, several vendors could provide integration, 
operation and maintenance support services.
    However, several industry sources said VA is trying to direct the 
procurement to IBM, which according to procurement experts isn't 
necessarily illegal.
    ``Agencies go out of their way consistently to hide the fact that 
they are buying very large dollar amounts of goods and services by 
using indefinite-quantity, indefinite-delivery contracts to limit 
competition,'' said Bill Shook, a procurement attorney at Kirkpatrick & 
Lockhart Preston Gates Ellis, who is not representing any party in the 
dispute.
                                 ______
                                 
 Response to Written Questions from Hon. Patty Murray to LTG James B. 
     Peake, (Ret.) M.D., Nominee for Secretary of Veterans Affairs
    Question 28. VA disability reform--oversight of changes:
    In the pre-hearing questions you answered for this Committee, you 
pledged to work closely with Congress, DOD and the VSOs to create and 
manage the change necessary to reform the Disability Compensation 
Schedule. You also talked about bringing accountability to the VA, if 
confirmed, in these pre-hearing questions.
    As you know, the Veterans' Disability Benefits Commission, which 
was chaired by General Scott, recommended we establish an executive 
oversight group to ensure that the commission's recommendations are 
implemented quickly and effectively.
    From what I can tell, the Administration's draft legislation 
doesn't include an oversight function to monitor the implementation of 
the action steps included in the bill. Given the monumental task of 
reforming the VA disability system, do you think establishing an 
oversight group is important--and if confirmed, will you do so?
    Response. If confirmed, I will look at the Senior Oversight 
Committee (SOC) that might be re-chartered quickly as an initial 
oversight group leveraging what I understand to be established and 
effective working relationships. As the strategic plan is developed, it 
might be best to charter a new oversight group with more focused 
membership and expanded to other agencies as appropriate. I would work 
with the Committee to confer on the most satisfactory oversight 
approaches.

    Question 29. Family members: I'm sure you would agree that veteran 
families are very much on the front line of this conflict, and often 
sacrifice to care for their loved ones. What more can the VA do to help 
veterans' families and give them the support that they need when 
assisting their loved ones?
    Response. I believe the family unit is a social and an economic 
entity. The other family members of the veteran are also affected by 
the veteran's experiences with injury--physical or psychological. A 
healthy family caregiver and supporter is important to the veteran and 
to the family unit. The ability to provide appropriate medical support, 
particularly mental health support, including medications and the 
ability to support the family engagement in the therapeutic process in 
the form of finances, housing, and transportation when it is needed are 
potentially ways in which VA might support veterans' families.

    Question 30. Mental health providers: How do you plan to address 
VA's workforce shortages in the mental health field, particularly as 
they relate to rural areas?
    Response. If confirmed, I will work to quickly get a sense of the 
scope and demography of the problem. I am aware that there has been an 
expansion of the mental health workforce and a targeting of outpatient 
clinics. Though I am not familiar with all the programs the VA might 
have in place now, I believe there is a range of options to explore to 
expand mental health access that is a particular problem in the rural 
areas. These might include salary incentives, training subsidies in 
exchange for remote location service, tele-medicine as a tool, call 
centers, contract providers, and targeted educational programs for 
health professionals of other agencies.

    Question 31. PTSD: Dr. Peake, do you believe that PTSD is a 
legitimate illness that has the capacity to impair the daily 
functioning of our men and women in uniform?
    Response. Yes

     Do you believe that extended deployments, as well as 
multiple deployments increase the risk of developing PTSD?
    Response. Rather than the deployment itself, it is the repeated 
exposures to specific ``stressors'' that are more problematic in 
increasing the risk of PTSD. Deployment itself can be stressful with 
family separations, unknown durations, austere living conditions and 
may have an impact on mental health that is not necessarily Post 
Traumatic Stress Disorder.

     As a career military officer, what is your feeling on 
sending troops back into theatre who suffer from PTSD?
    Response. I do not favor sending dysfunctional troops into a combat 
zone where they can be a danger to themselves and to their fellow 
soldiers. I believe the military supports this philosophy. However, I 
do not believe that everyone who carries a diagnosis of PTSD is 
dysfunctional. Rather there is a spectrum of symptoms, individual 
resiliency, and response to treatment that offers opportunity for 
individualized consideration. Blanket determinations can increase the 
stigma about which we are all concerned. I also believe that there are 
many different environments within the theatre that are less stressful 
and with greater levels of support for the servicemember than others. 
It is a decision that commanders must make, but with the best medical 
advice.

    Question 32. Dual Diagnosis: As you know, PTSD is a risk factor for 
the development of substance abuse disorders and many veterans have 
both. What will you do as Secretary to address the problem of dual 
diagnosis disorders?
    Response. If confirmed, I will support research to find the best 
ways to deal with the co-morbid conditions. I am aware of recent 
reports documenting an increase in post deployment alcohol abuse and 
recognize the potential long-term adverse outcomes that can result from 
employment impact, family distress, and homelessness. I will look for 
ways for the VA to be proactive by understanding programs in place now 
and what new programs might be needed to deal with this new generation 
of veterans. I look forward to establishing a constructive relationship 
with DOD to insure a common message on substance abuse, education of 
the servicemember and family, so that signs can be recognized early. I 
recognize that it is difficult to help someone who does not recognize a 
problem or who does not want to be helped.

    Question 33. Waiting times: General Peake, as you found out in your 
meetings with Members of this Committee, waiting times for veterans to 
see doctors are a big concern among our constituents. If confirmed, 
what will you do to tackle this problem?
    Response. If confirmed, I will ask for a detailed review and 
include the Inspector General who, I understand, has some disagreement 
with VHA. I am particularly interested in stratifying the problem to 
understand if it is access in general, or in specific areas, so that we 
focus on solutions that will have as quick an impact as possible while 
we evaluate a more comprehensive approach.

    Question 34. Guard and Reserve Mental Health Problems: A recent 
Army study found that Guard and Reserve soldiers suffer from mental 
health problems at twice the rate of active duty soldiers. Given this 
discrepancy, how can the VA change to better reach out to Guard and 
Reserve soldiers, many of whom live in rural areas far away from VA 
facilities?
    Response. I believe the VA must work with both the active duty and 
the reserve chains of command to insure we reach the Citizen Soldiers 
with meaningful engagement before they demobilize to educate them about 
benefits and the processes to get them. Particularly, we need to team 
with the DOD to have all of the Reserve Component Servicemembers who 
have deployed complete the Post Deployment Health Care Reassessment 
(PDHRA), and be proactive to assure the resulting follow-up plans are 
executed. In question 30 above I have described potential approaches to 
providing increased mental health services access, but providing a 
proactive outreach, perhaps even past the PDHRA, is worth exploring as 
part of a preventive program for psychological wellness. In parallel we 
need to move forward with simplifying the disability system and the 
processes by which it is administered.

    Question 35. Mental Health: Given the attention in the media about 
mental illness in our servicemembers, why do you think a stigma still 
exists with respect to these illnesses in the military and what can be 
done to overcome this stigma?
    Response. The DOD Task Force on Mental Health devotes a 
considerable amount of work on this continuing problem. They identify 
the need to create a culture of psychological health with a number of 
specific recommendations that include revising regulations that give 
the appearance of mental health issues leading to adverse career 
outcomes, while finding ways to protect the servicemember and the unit 
if the mental health issue would compromise the mission. Educating and 
inculcating mental health throughout military life is another of the 
recommendations that includes training leaders, training family members 
and training medical personnel. After 9/11 I supported additional 
mental health providers to be incorporated into the primary care 
environments, as well as having them circulate throughout the Pentagon 
and visiting every office space on a periodic basis to provide non-
stigmatizing ease of access. Imbedding mental health workers in 
military units is another recommendation. Promoting early recognition 
and intervention in alcohol abuse; facilitating command referral are 
all important recommendations. Stigma is not restricted to the 
military. It is an area that I believe needs to be explored in relation 
to reemployment of our returning Reservists. I have heard anecdotes of 
the returning servicemember being asked if he or she is ok mentally 
after having been to war. This may represent a concern of companies, 
about functionality or about assuming liability; in either case, it 
sets up the stigma issues that the military is trying to actively 
combat. If confirmed, I look forward to working on this important 
subset of the larger mental health issues facing our returning 
servicemembers and newest veterans.

    Question 36. Procurement: Dr. Peake, I assume that as Secretary of 
Veterans Affairs, you will be committed to ensuring that Department 
procurement policies will be formulated and executed to acquire the 
best products and services available at the lowest cost to the 
government. These principles ensure that both agency beneficiaries and 
the taxpayers at large receive the best services and the best value 
that the market can provide. To that end, I would be grateful if, upon 
your confirmation, you look into the Department's use of non-
competitive inter-agency agreements to contract for human capital 
management systems and services in order to avoid using open 
competition that would also examine solutions available from the 
private sector. In particular, I am concerned with the announced 
purchase of a staffing system from the Office of Personnel Management 
and a position classification system from the Department of Health and 
Human Services. In both cases, I believe private sector solutions were 
available that were superior and more cost effective. If confirmed, 
will you look into this?
    Response. If confirmed, I will.
                                 ______
                                 
  Response to Written Questions from Hon. Barak Obama to LTG James B. 
     Peake, (Ret.) M.D., Nominee for Secretary of Veterans Affairs
    Question 37. Congress has voted to hire additional claims workers 
to ease the backlog at the VA. What other immediate steps would you 
take to ensure that veterans receive quality, timely decisions about 
benefits?
    Response. If confirmed, I would support the investment in training 
to make these people as productive as possible as rapidly as possible. 
I believe there are wait-time barriers to the speed of adjudication 
that have been put in place to offer support to the claimant. However, 
I believe some of these time frames if waived by an informed claimant 
could significantly speed up the process. I believe the opportunity for 
information technology support in records maintenance and decision 
support tools is great and I would invest in them. Fundamentally, I 
believe that the disability rating system is in need of revision and 
simplification and I would work with all stakeholders and Congress to 
find the way forward in this important area.

    Question 38. In your view, in the lead-up to the war in Iraq, did 
the Administration adequately plan for the needs of our returning 
veteran population? What is your view on the appropriate role of the VA 
in planning for a possible military conflict? At what stage should the 
VA be involved with the Pentagon in anticipating and planning for the 
needs of returning servicemembers? What surge capacities should exist 
within the VA in order for the agency to be able to adjust during 
future military conflicts?
    Response. I cannot speak for the VA pre-war planning; however, the 
military did expand its medical reception and evacuation platforms in 
anticipation of an acute surge. Reserve medical personnel were 
mobilized to support the backfill of active duty medical personnel who 
had deployed. Anticipating an increased number of amputees, the amputee 
centers of excellence at Walter Reed and Brooke Army Medical Centers 
were put in place and the burn unit was expanded at Brooke and a 
network of burn units across the country was coordinated. As the nature 
of war wounds evolved and the deployments have become protracted and 
repeated both systems have worked to adjust to the current picture of 
returning veterans. I believe the VA should be engaged as early in the 
planning process as casualty estimates are made. The ability of the VA 
to surge should be carefully examined in light, not only of supporting 
war returning veterans, but in the event of ``war'' here at home from 
terrorism to natural epidemics, to disasters. If confirmed, I will 
review existing surge capacity and review recommendations for the 
future.

    Question 39. In your pre-hearing responses, you stated that the 
Secretary must use actuarially supported data combined with real 
information from practice patterns, along with collaboration with DOD, 
to provide accurate forecasting for the VA's budgeting needs. Given 
past VA budget shortfalls, what do you believe are the current 
weaknesses in VA's budget planning process, and what actions would you 
take to correct these weaknesses?
    Response. I have not had detailed briefing on the budget process. 
If confirmed, I recognize that we are going quickly into the ``budget 
season'' and I will quickly need to assess this process and will take 
action if weakness are found.

    Question 40. If you thought that the VA required an appropriation 
on the scale of several billion dollars more than what the White House 
was willing to request from Congress, would you take your case straight 
to the President?
    Response. Yes.

    Question 41. During your time as Army Surgeon General, what warning 
signs, if any, did you receive about the woeful conditions and 
shortfalls in care at facilities like Walter Reed? In hindsight, were 
there preemptive actions you should have taken in that role in order to 
prevent our soldiers from having to wage a second battle at home to 
receive benefits and care?
    Response. I left the Army in September of 2004. We had not had the 
huge number of returning wounded at that point and, for example, we did 
not have patients in ``building 18''. I visited Walter Reed frequently 
and was focused on the high quality of inpatient care (which, by all 
accounts, was maintained, and even with the problems in outpatient 
care, board processing, and housing, was lauded by even the harsh 
critics). Warning signs that I should have picked up on might have been 
the burden on the staff, the experience at FT Stewart where, though not 
returning wounded, similar problems with outpatient access and 
disability processing were experienced. Prior to this and before the 
war, the issue of the disability system was on my scope. I had insisted 
that the compassionate and efficient processing of the soldier who is 
medically unable to return to duty be placed as a key performance 
process on the Balanced Score Card Strategy Map for the United States 
Army Medical Command. In hindsight, I could have recognized that the 
peacetime processing standards (a problem already) were inadequate to 
support a surge that potentially would come of wartime. I might have 
anticipated the impact of the flawed policy, since corrected, regarding 
the retention of soldiers unfit at the time of mobilization and fought 
harder to change it prospectively. I might have worked harder to create 
the imperative to reengineer the disability system.

    Question 42. With regard to Walter Reed and other military 
treatment facilities, you mentioned in your pre-hearing responses that 
you might have pushed harder for improvements that were more aggressive 
than the 50 VA caseworkers that you welcomed into Army hospitals. As VA 
Secretary, in addition to the new pilot program of joint DOD-VA 
disability evaluation, what other aggressive changes would you pursue 
to better integrate and coordinate DOD and VA care for our wounded 
warriors? Given the stream of returning wounded servicemembers, is 
there a ``right size'' for a VA presence at DOD medical facilities?
    Response. The Recovery Coordinator program suggested by the Dole-
Shalala Commission is in its inception. Working closely with DOD to 
make this a valuable joint asset with a focus on an overarching 
recovery plan for each wounded warrior and family and someone who can 
``bureaucracy bust'' to insure it is effectively implemented can be a 
major step forward. There is significant variability among DOD medical 
facilities in the number and types of wounded warriors seen. If 
confirmed, I will explore with DOD optimal staffing to support the 
education, outreach, and benefits counseling not only for wounded 
warriors, but for servicemembers, active and reserve, leaving the 
active force.

    Question 43. You have said you would recuse yourself from any 
future VA decisions or dealings that involve QTC. More broadly, what do 
you believe should be the appropriate role for private firms like QTC 
in performing core VA functions? When is it appropriate for a firm like 
QTC to perform VA functions; and how do you judge the right balance of 
using outside firms while avoiding any weakening of this important 
federal agency?
    Response. I believe the correct focus ought to be on the veteran, 
insuring access and high quality for him or her, and mindful of their 
families. If provided within the VA facilities we must insure that the 
service is first rate and timely. If VA facilities are not available 
within reasonable access standards and services can be purchased, 
whether from another agency or from commercial vendors, a high quality 
acquisition and contracting function can contract for and provide 
contract oversight to insure high quality. As the demographics of our 
veteran population changes, we must keep them in our focus. A balance 
that must be made is in measuring and then maintaining the surge 
capacity needed to respond to crisis of the variety discussed earlier. 
If confirmed, I look forward to strengthening the acquisition and 
contracting function.

    Question 44. What areas of VA specialty care should be expanded, 
and in what ways? Do you believe there should be a priority for certain 
areas of specialty care?
    Response. VA is known for its focus and excellence in many areas 
such as spinal cord injury, Post Traumatic Stress, polytrauma 
rehabilitation, and blind veterans programs. VHA has led the way in 
using data for quality improvement and as the veteran population has 
aged, the clinical and research has moved to look at aging issues. If 
confirmed, I will review the current areas of specialty focus and their 
quality markers. I do anticipate that this next generation of combat 
veterans will define new areas that need to be created or refocused on 
a young population fresh from battle--a population that will include a 
significant increase in the number of women veterans. I want to insure 
that our way ahead will include the prosthetic support that will keep 
these new, highly-enabled amputees at the cutting edge of assisted 
functionality as they age. As our research into PTSD and TBI gives 
greater understanding of these potentially signature injuries of this 
current war, I believe specialty focus throughout the VA will be 
important to apply those lessons learned for the benefit of the 
veteran. The specialty must, beyond just medical care, include 
understanding the best way to motivate, encourage, enable a veteran to 
be as independently productive and self sufficient as possible.
                                 ______
                                 
  Response to Written Questions from Hon. Jon Tester to LTG James B. 
     Peake, (Ret.) M.D., Nominee for Secretary of Veterans Affairs
    Question 45. As you know, the Wounded Warriors legislation, which 
is expected to be attached to the Defense Authorization bill, contains 
language that would allow the VA to raise the rate of travel 
reimbursement given to vets from 11 cents a mile to 28.5 cents per 
mile. The VA provides this benefit to veterans in recognition of the 
fact that the cost of travel can actually be prohibitive to receiving 
needed care. However, the current price of gasoline appears to be 
having an adverse impact on VA patient care despite the existing 
benefit. As you know, federal employees receive 48.5 cents per mile 
when they travel on official business. Now that you have had the 
opportunity to review the matter, do you view the 17.5 cent increase as 
sufficient, or do you believe that vets should get the same deal as 
federal employees?
    Response. It is clear to me that the 11 cent a mile rate is 
inadequate reimbursement for travel given the cost of gasoline. If 
confirmed, I will have the opportunity to review this in detail to 
include the way that this benefit is administered to reasonably 
reimburse for the veteran's cost. I support the rate increase to 28.5 
cents and commit to reviewing the need for increases in the future.

    Question 46. At your confirmation hearing, I asked your opinion of 
raising the mileage reimbursement rates for veterans who must travel to 
a VA facility for care. What is your opinion of this legislation? Do 
you think it will adversely impact your budget? Do you think that it is 
time to recognize the costs borne by the veterans who travel, in some 
cases, great distances to VA?
    Response. I believe the mileage reimbursement should be raised. I 
have not seen the legislation. The additional cost will have a budget 
impact, but if appropriately administered I would not anticipate that 
to be a show stopper. It is the policy now to provide the veteran 
reimbursement for travel. I agree that should continue with realistic 
reimbursement adjusted for the increased cost of gasoline for those 
veterans who are required to travel beyond a reasonable distance.

    Question 47. I am extremely concerned about the pace at which the 
Office of Rural Health is moving. As I understand it, the ORH is 
staffed by only two people, even though 6 million veterans in America 
live in areas considered rural. What criteria will you use to determine 
how best to staff the ORH? What is your vision for the ORH's role in 
the VA? How will you use the ORH to improve the lives of veterans who 
reside in rural or frontier areas?
    Response. I have heard from many Senators on this Committee and 
others about their concerns of rural health for veterans. I was pleased 
to understand that an Office had been established, but was surprised to 
learn that it had only two people to deal with this problem. If 
confirmed, I will assess the expertise, the size, and the authority of 
this office. I will review, for currency or cause, to be created a 
strategic plan for moving the ball forward in relation to serving 
Veterans in rural areas. I have committed to you that I will accept 
your invitation to visit your state and see and hear, first-hand, the 
issues around the rural veteran.
                                 ______
                                 
 Response to Written Questions from Hon. Arlen Specter to LTG James B. 
     Peake, (Ret.) M.D., Nominee for Secretary of Veterans Affairs
    Question 48. Veterans are an important constituency to me and I 
have long supported providing them the benefits they deserve. They 
served our country with valor, courage, and bravery. Many times there 
is a disagreement on whether veterans should be granted benefits. How 
do you see the current system for the adjudication of claims for VA 
benefits? Is it working efficiently, and what role do you see your 
office playing in ensuring that veterans who are entitled to benefits 
actually receive them?
    Response. Though I have not been in position for detailed briefings 
I am aware of the chronic excessive time periods for adjudication of 
claims, and understand that many of these claims are resubmitted. I 
also understand the concern that there is inconsistent rating of claims 
for the same/similar disabilities. Having walked through several VA 
Regional Offices, I see serial processing, periods of required waiting, 
little in the way of automation of what is largely a paper-based system 
and legalistic communication to veterans that is prone to confuse. 
Acquiring the appropriate information to adjudicate the claim, whether 
military history or medical history, seems to be a rate limiting step. 
I also am aware that the number of claimed conditions has increased 
significantly, which increases the complexity of the claim. I 
understand that Admiral Cooper has been able to expand his claims 
workforce and has put in place an aggressive training program. If 
confirmed, I will be anxious to see the results of that effort. I also 
believe that a key to the future is automation and decision support 
tools for those who have to adjudicate records. Getting the right 
information up front, (and with this newest generation of veterans, 
working right now with DOD to do so) is important. The DD-214 is an 
example that is now shared electronically.

    Question 49. I am aware that the VA had proposed a regulation that 
would require all attorneys practicing before the VA to pass a written 
accreditation exam. I believe this is unnecessary and 
counterproductive, especially considering the 109th Congress passed S. 
3421, the Veterans Benefits, Health Care, and Information Technology 
Act of 2006, that eliminated the Civil War era policy prohibiting 
veterans from hiring lawyers to assist with claims for benefits until 
after the VA administrative process has been completed. Has the VA 
moved forward with this proposed regulation? If not, what does the VA 
plan on doing in relation to this issue?
    Response. I have been advised of and, if confirmed, will support 
the final rule being proposed by the VA that will not contain an 
attorney examination requirement.

    Question 50. If you are confirmed, you would be the first doctor to 
head the Department of Veterans Affairs. How do you think your 
experience in this field will impact the entire Department? How will 
this affect the role of the current Under Secretary for Health, Dr. 
Michael Kussman?
    Response. Because of the mission of the Department of Veterans 
Affairs--Caring for those who have borne the battle . . . and their 
widows and orphans--I do believe my 38+ years in the Army, with service 
in the line as an infantry officer and, particularly, in medicine as a 
physician and 38 years of taking care of soldiers, provides a personal 
background of caring, understanding and empathy that will keep my 
decisions true to the mission.
    The VA is extremely fortunate to have Dr. Kussman as the Under 
Secretary for Health, its ``Top Doc''. He has assembled a very talented 
team of professionals. If confirmed, I will seek to complement Dr. 
Kussman's efforts and initiatives in leading his administration, not to 
compete. With my medical background, I anticipate being able to more 
quickly make the decisions that he might bring to me since I do not 
anticipate needing ``Medicine 101''. As I execute my responsibilities 
as Secretary, I would anticipate that my guidance to him will be well-
informed because of my medical background and my military background. 
If anything, I anticipate a greater synergy supported by our common 
medical background and our long association.

    Question 51. The key to any successful organization or agency is 
the manner of leadership from those at the top level of management. How 
do you intend to execute the mission of the VA, and how do you intend 
to ensure there are open lines of communication to all employees and 
veterans themselves?
    Response. I do not anticipate a fundamental difference in my 
leadership style which I would characterize as integrity based, mission 
focused and recognizing that the only way to succeed is through the men 
and women at every level who do the real work of the organization. To 
accomplish this I will make focused efforts on communication to insure 
clarity of intent; to insure that those men and women know that I value 
them and count on them; and to let them get to know me.
    The only way one can get anything accomplished in an organization 
much larger than even an infantry company, let alone an organization 
the size of the VA, is through delegation. But, with the delegation 
must come accountability supported by data. I do my homework on issues 
and ask questions to understand the issues. In that sense, I am a hands 
on manager. As the ``intent'' of policy is communicated, my expectation 
is that those many operational decisions made at levels below the 
Secretary are made consistent with that ``intent''. In decision making, 
I welcome all input, encourage the dissenting view, and seek outside 
critical thinking. I am always impressed that a product can be made 
better. However, with that input, I will make decisions with or without 
consensus. As a corollary, when there is not full consensus, I 
recognize my increased obligation to communicate my rationale; engaging 
and seeing the decision to success (ownership); and in changing course 
if I am wrong.
    Visibility and accessibility are important as a leader. I will use 
the spectrum of means to communicate with the men and women of the VA. 
That will include e-mail broadcast, video broadcasts, a column in the 
magazine that is published bimonthly, and group sessions when I travel 
to visit the VA organizations in the field.

    Question 52. It is my understanding that as centralization occurs, 
the VA is finding unique problems involving inconsistencies in 
hardware, software, and processes. How do you intend to ensure that 
there is a smooth transition to a centralized system under the Office 
of Information Technology?
    Response. Though I have only had the opportunity for a brief 
courtesy visit with Major General (Ret.) Bob Howard, the ``CIO'' for 
VA, I was impressed with his evolving organizational structure, as well 
as the challenges in this major effort. The challenges are not only 
technical with hardware and software, but cultural. There are many 
legacy systems in the VA that have devolved as local modifications have 
been done. VISTA, one of the stars in the VA IT portfolio, particularly 
has the legacy MUMPS platform and will need to migrate to a new 
operating environment. Documentation has not always followed the local 
modifications, and clear and consistent IT policies have, apparently, 
in the past, not been the rule. If confirmed, I will take an active 
role in monitoring and resourcing this process and working to insure 
that the users of the IT tools are getting what they need to do their 
jobs effectively and efficiently. That secretary-level engagement and 
championship of the user will help with the cultural adaptations that 
are important to the success of this venture. I also believe in 
shoring-up the VA acquisition workforce so that these large and 
expensive programs have the best and brightest in support.
                                 ______
                                 
  Response to Written Questions from Hon. John Ensign to LTG James B. 
     Peake, (Ret.) M.D., Nominee for Secretary of Veterans Affairs
    On November 5, 2007, prior to your hearing, we had the opportunity 
sit down in my office and discuss some VA issues that are important to 
me and the people of Nevada. These questions are a follow-up to our 
discussion.

    Question 53. During this meeting we discussed the construction of 
the new veterans medical complex in North Las Vegas and your views on 
the VA's CARES process. My understanding is that this complex is now 
scheduled to be completed in 2010 and start receiving patients in 2011. 
This is almost two years later than first planned. Can you provide my 
office with an update of how this project is progressing? Additionally, 
what will you do as Secretary of the VA to ensure that additional 
delays and cost overruns do not occur?
    Response. If confirmed, I will provide an update shortly after my 
appointment. As Secretary, I will require routine updates on our major 
construction programs as part of monitoring a strategic capital program 
and will demand accountability for ongoing projects, as well as 
realistic forecasting and programming for future projects.

    Question 54. You emphasized in our meeting that you understood the 
difficulties of making sure veterans living in rural areas receive 
quality health care from the VA. Can you provide a status update of the 
Community-Based Outpatient Clinic (CBOC) in Fallon, the Henderson CBOC, 
and the Elko Outreach Clinic? Additionally, as Secretary of the VA, 
what are your plans to ensure that veterans in rural areas receive 
quality health care?
    Response. If confirmed, I will obtain and provide a status update 
on the Fallon, and Henderson CBOCs and of the ELKO Outreach Clinic. I 
have heard from many Senators on this Committee and others about their 
concerns of rural health for veterans. I was pleased to understand that 
an Office of Rural Health has been established, but learned that it had 
only two people to deal with this problem. If confirmed, I will assess 
the expertise, the size, and the authority of this office. I will 
review for currency or cause to be created a strategic plan for moving 
the ball forward in relation to serving Veterans in rural areas. I have 
committed to visiting rural areas to see and hear first-hand the issues 
around the rural veteran.

    Question 55. Earlier this year we learned that in 2006 the VA paid 
out annual bonuses to senior officials in the amounts ranging from 
$7,000 to $33,000. This was of particular concern given that at the 
time the VA had a backlog of 500,000 veterans' claims and that 
approximately a year ago the VA was forced to request emergency funding 
based on its own budget forecasts being short billions of dollars. I am 
fully aware of the need to attract and retain the highest caliber 
employees in government service, and I am not opposed to awarding 
reasonable financial bonuses to federal employees in recognition of 
superlative performance. However, I also believe that the individual 
performance being recognized with a bonus must truly be superlative and 
the amount of the bonus awarded must not be excessive. In light of the 
reported bonuses I committed to the people of Nevada that I would 
continue to monitor this situation and would raise your concerns in 
upcoming hearings and meetings with department officials. What are your 
views on issuing bonuses for those in government service and what will 
you do in your tenure to attract and retain the best, brightest, and 
hardest working individuals?
    Response. I do not have first-hand knowledge of the incentive 
program for the VA although I did read of the concerns in the 
newspaper. I am very pleased to know that the Senate has recently 
confirmed and the President has appointed Mr. Michael Hager as the new 
Assistant Secretary for Human Resources and Management. If confirmed, I 
look forward to working with him to create a measurable, realistic, and 
transparent bonus program for the VA executive leadership. The bonus 
program is only one incentive and perhaps not the most important in 
attracting and retaining the best, brightest and hardest working for 
government service. If confirmed, I would work to acknowledge their 
individual contribution to the mission, to provide the sense of 
personal, as well as corporate accomplishment in service to our 
veterans.
                                 ______
                                 
 Response to Additional Written Questions Submitted by Hon. Daniel K. 
 Akaka to LTG James B. Peake, (Ret.) M.D., Nominee to be Secretary of 
                            Veterans Affairs

    Question 1. Recent media accounts have highlighted the issue of 
substance abuse among returning veterans. What additional steps should 
VA be taking, in coordination with DOD, to address this serious 
problem?
    Response. I am aware of recent reports documenting an increase in 
post deployment alcohol abuse and recognize the potential long term 
adverse outcomes that can result from employment impact, family 
distress, and homelessness. If confirmed, I will support research to 
find the best ways to deal with the co-morbid conditions. I will look 
for ways for the VA to be proactive by understanding programs in place 
now and what new programs might be needed to deal with this new 
generation of Veterans. I look forward to establishing a constructive 
relationship with DOD to insure a common message on substance abuse, 
education of the servicemember and family so that signs can be 
recognized early. I recognize that it is difficult to help someone who 
does not recognize a problem or who does not want to be helped. 
Creating the supporting environment and de-stigmatizing receiving 
assistance with substance abuse will encourage early intervention.

    Question 2. What specific policy changes, if any, would you support 
to improve access to rural health care for our Nation's veterans? What 
would be your preferred approach to provide care for veterans in areas 
in which VA coverage is inadequate or non-existent?
    Response. I have heard from many Senators on this Committee and 
others about their concerns regarding rural health care for veterans. I 
was pleased to understand that an office had been established, but 
learned that it had only two people to deal with this problem. If 
confirmed, I will assess the expertise, the size, and the authority of 
this office. I will review for currency or cause to be created a 
strategic plan for moving the ball forward in relation to serving 
veterans in rural areas. I have committed to visiting rural areas to 
see and hear first hand the issues around the rural veteran. I am 
willing to look at models that partner with other agencies, which 
leverage telemedicine, expanding VA services where feasible or that 
purchases care where needed and ensures the appropriate oversight for 
quality and integration of that medical care information into the VA 
system of health for the purpose of continuity of care.

    Question 3. Current education benefits provided to our veterans 
have not kept pace with the rising cost of education. What principles 
would you apply to reforming and updating GI Bill benefits? What level 
of educational benefits do you believe we owe to those who have worn 
the uniform?
    Response. From my years in the military I appreciate the value that 
soldiers place on their educational benefits. For many it is a way to 
take an economic burden of education off of their parents, for others, 
the GI Bill represents the only route to additional schooling post high 
school. The current GI Bill was formulated in a peacetime environment. 
I believe with this current generation of combat veterans engaged in a 
shooting war, their required contribution for eligibility should be 
reevaluated and ways to meet a greater level of their educational costs 
should be explored. I would consider partnerships with educational 
institutions that might support our veterans, as well as assistance 
with tuition, subsistence and educational materials if a full-time 
student.

    Question 4. An increase in unexpected surgical deaths at the VA 
Medical Center (VAMC) in Marion, IL recently revealed major lapses in 
the VA's health quality assurance mechanisms, as well as its 
credentialing and privileging processes. It has become clear--although 
it took 6 months after the fact--that at least one physician involved 
in these deaths should not have been practicing at all. What immediate 
steps would you take as Secretary to institute safeguards so that such 
tragedies don't occur at other facilities?
    Response. I understand that an extensive series of investigations 
is ongoing regarding Marion and that a wide review of credentialed 
providers systemwide has begun. If confirmed, I will review in detail 
the findings from these initiatives to understand if there is a lack or 
shortfall in procedural safeguards and process or an oversight function 
that needs to be strengthened to insure compliance, or both. Consistent 
application across the entire VA system is needed so that tragedies do 
not occur at other facilities. I have spoken earlier with Senator 
Durbin on this issue, discussed its importance, and have committed to 
taking aggressive action to meet this goal based upon the 
investigations.

    Question 5. As you know, recent media accounts suggest that the 
military has been improperly and inconsistently using the diagnosis of 
a pre-existing personality disorder as a basis for administratively 
separating servicemembers who may have been suffering instead from 
other service-connected psychological injuries. When such a diagnosis 
occurs, it can result in a loss of benefits or access to VA care for 
treatment, such as PTSD counseling. I have worked in the Senate to stop 
this unfair practice and review the military's current policies. Until 
comprehensive reform takes place, what degree of latitude and authority 
will you exercise as Secretary to ensure any servicemembers who may 
have been discharged with a personality disorder can still access VA 
mental health care?
    Response. I have read of such allegations in the press, but have 
not been briefed by VA or DOD on them. In my personal experience, I 
have not seen intentional use of discharge for personality disorder to 
avoid a ratable psychiatric diagnosis, but recognize that such an error 
can be made. I do understand that the Secretary has a level of case-by-
case authority for waiver in such circumstances. I favor providing 
mental health assessment and assistance to servicemembers to mitigate 
the potential worsening of a mental health condition and to correct, 
where indicated, a missed diagnosis. If confirmed, I would err on the 
side of the veteran to provide this assistance.
                                 ______
                                 
 Response to Additional Written Questions Submitted by Hon. Jon Tester 
to LTG James B. Peake, (Ret.) M.D., Nominee to be Secretary of Veterans 
                                Affairs
    Question 6. I understand that the VA has committed to eliminating 
the wide disparity in disability compensation provided to Iraq and 
Afghanistan veterans diagnosed with PTSD. However, I have received 
reports that the level of disability compensation for PTSD cases in 
Montana is far below the national average, and that fewer than one-
quarter of Montanans are diagnosed at 50 percent or above for PTSD--
also far below the national average. This data suggests that VA is far 
from eliminating these disparities. Can you commit to examining why 
Montana's rate of PTSD diagnosis and compensation is so far below the 
national average? Will you also work to eliminate the wide disparity in 
PTSD-related disability compensation awards among regional offices?
    Response. I share the commitment to improving consistency in 
rating. I know that other Senators share your concerns on rating 
disparity. Simplifying the claims system, supporting it with decision 
support automation, and enhancing the training of those who do the 
rating are some approaches. If confirmed, I will examine the issue of 
rating disparity in general and particularly the issue of PTSD and will 
work to eliminate such disparities. I will also examine this issue 
specifically as it relates to Montana.
                                 ______
                                 
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t                                 
    Senator Akaka. Thank you very much, Dr. Peake.
    I want the Committee to know I intend to have two question 
periods here of 5 minutes each. I will begin with this 
question, Dr. Peake.
    If confirmed by the Senate, you will have just a little 
over one year in which to leave your mark on the Department of 
Veterans Affairs. As Secretary, what do you hope to leave 
behind as your legacy?
    Dr. Peake. Well, Mr. Chairman, I am not much of a legacy 
guy, because everything is done with a team, but I will tell 
you what I believe I can add to this is: the ability to reach 
across and work with the Department of Defense as we work out 
this transition issue for the new generation of veterans. I 
believe I can bring my network of experience and colleagues and 
acquaintances to really come to common understandings and cross 
the cultural issues that we have on both sides of the two 
Departments.
    I believe that understanding this issue of PTSD and TBI is 
an important one, and how that relates to this transition is 
something that I can bring an experience to bear on as well. 
So, I look forward to the opportunity of working with DOD and 
making that happen, and with this Committee to make sure that 
the things that are put in place are executable on behalf of 
the veteran.
    Senator Akaka. Dr. Peake, early in fiscal year 2005, when 
the Congress was debating the status of VA funding, then-
Secretary Nicholson--despite his personal knowledge that 
budgeted funds were not adequate to furnish timely care and 
service to the numbers of veterans coming for care--wrote a 
letter saying that VA had sufficient funding. In response to a 
pre-hearing question, you indicated that, if confirmed, you 
would have the responsibility for advocating for veterans.
    If you become aware in the coming year that funding is not 
sufficient for VA to keep up with the demand or that something 
is slipping, will you come to Congress and request additional 
funding?
    Dr. Peake. Mr. Chairman, I would. I would work hard with 
the administration, with OMB, and be able to come forward, if I 
needed to, to get additional funding.
    Senator Akaka. It seems as though, Dr. Peake, the problems 
identified at Walter Reed earlier this year are directly 
related to those which occurred years earlier at Fort Stewart 
and Fort Knox while you were Army Surgeon General. Poor living 
conditions for the medical hold and holdover detachments, an 
overwhelmed chain of command, poor case management, and 
difficulties with a complicated, out-of-date disability process 
were noted.
    In your response to pre-hearing questions, you stated that 
in connection with the initial problems of Fort Stewart, you 
immediately mobilized a team to respond to these concerns, 
mandated a case manager to stay with each soldier through the 
hand-off to VA, and worked with the Army leadership to garner 
and allocate resources to solve the problem.
    In your view, why did this fairly comprehensive action plan 
not translate then or later to Walter Reed?
    Dr. Peake. You know, Senator, I ask myself what I could 
have done differently as part of that, as well. When I saw that 
soldiers were living, again, in unsatisfactory conditions, 
there was a sense of--or at least a perception of--a lack of 
caring for those who had transitioned out; patient care. I was 
concerned as well. And when I look back at the Fort Stewart 
issues, our quick response did, in fact, do some of the things 
that would have helped if we had carried those forward with 
Walter Reed.
    I am 3 years from retiring from the Army, so I do not have 
direct knowledge of what was going on at Walter Reed; but I can 
tell you that when I was the Surgeon General, we had not seen 
that large number of returning wounded from Iraq and 
Afghanistan at that point. At Fort Stewart, we had a policy 
issue that kept soldiers who had just reported to the 
mobilization station on active duty, even if they were unfit, 
and that policy, ultimately, was reversed.
    So, part of this is getting the policies right, and then 
following through with actions to correct the things that one 
can correct.
    Senator Akaka. Thank you very much.
    Senator Burr?
    Senator Burr. Thank you, Mr. Chairman.
    Again, Dr. Peake, welcome. We are truly blessed that we 
have got somebody of your caliber, your experience, your 
expertise, that would consider this role for one year at a very 
difficult time. Senator Akaka and I were sent a letter by 
Senator Bond asking us to ask four questions. I am going to ask 
for unanimous consent to send those in writing to you, but I 
would like to ask one of them in public for the record, if I 
may.
    Veterans groups have been raising concerns about the impact 
of PTSD and TBI on our servicemembers deployed in the Iraq and 
Afghanistan wars. What did you do, as Army Surgeon General, to 
prepare for the long-term outpatient treatment and disability 
benefits for PTSD and TBI patients observed by Army medical 
personnel during your tenure as the Army's senior medical 
officer?
    Dr. Peake. My record on mental health in this particular 
environment goes back to 9/11 when we had an airplane in the 
building with us over there at the Pentagon. What we did 
immediately was create an operation called ``Operation 
Solace,'' where we were very concerned about making sure that 
people had access to mental health counselors. We brought them 
into the building. We flooded the building with them--had them 
walking around--so that we tried to avoid any appearance of 
stigma, so it was not medicalized there. We had the senior Army 
leadership like General Shinseki stand up and really direct the 
Army staff to make sure you get your people out, because it is 
the right thing to do--to get them seen by these mental health 
providers.
    We put mental health providers into the primary care system 
because we expected and my experts in this area expected the 
potential of somatization of mental health kinds of problems. 
And I think that was a very, very successful intervention, if 
you will, for a population of about 20,000-some people there in 
the Pentagon.
    In the early days of Iraq, we invested in putting a mental 
health assessment team into the combat zone--earlier than we 
have ever done that kind of thing before--because I was very 
concerned whether we had the mental health assets right there. 
Because, if you take care of it at the front end of the battle 
area, the idea is that it would improve the returning veteran 
and returning soldier, so that they do not have the problems 
that, potentially, we would have to deal with.
    I think there is a lot to learn about PTSD we do not know 
about. The VA, I know, is one of the leading experts in all of 
that, but there is still a lot to learn about it. And so, what 
I wanted to do is set the base for that. Ultimately, during my 
time, there were two teams that went over, and we reported out 
fully because we did discover problems. We did discover things 
that we wanted to do differently. We did identify the number of 
people that at least had some of the stressors that might lead 
to PTSD.
    We invested in surveys to try to understand--anonymous 
surveys, to try to understand what the soldiers were saying 
about it as well. It led to published papers in the New England 
Journal of Medicine. Recently, the follow-on was just in the 
end of November--a follow-up. It led to the post-deployment 
health assessment. We wanted to get that up front as far as we 
could, so we started looking at that, and putting it into 
Kuwait on hand-held computers, so that the soldiers could get 
into that early on.
    Then, the post-deployment health reassessment has just been 
restudied, and we find even a larger number of veterans and 
soldiers that are reporting at the second go-round that did not 
report at the first go-round.
    I guess the point I am making, sir, is that I have been 
involved in looking prospectively at mental health to try to 
understand what things are needed now. I think that there is a 
lot more to do. I think we are learning that we can be 
proactive. I do believe this is treatable and that we can 
intervene, and I look forward, if confirmed, to working on the 
VA side of the house and walking across to the DOD to make sure 
that there is a continuum in this treatment of what we are 
understanding better of the mental health consequences of war.
    Senator Burr. Dr. Peake, I thank you for that thorough 
answer, and, Mr. Chairman, I see the clock. I will wait for the 
second round for my questions.
    Senator Akaka. Thank you very much, Senator Burr.
    Senator Murray?
    Senator Murray. Mr. Chairman, thank you very much. I know 
you are waiting to be called ``Mr. Secretary,'' but I am 
curious. Do you want us to call you ``General'' or ``Doctor''?
    Dr. Peake. Ma'am, I am comfortable being called whatever 
people are comfortable calling me, to be perfectly honest with 
you.
    Senator Murray. Okay. Well, thank you very much. I have 
tried to listen closely to your answers so far. I did want to 
follow up on the Chairman's question. He referenced a situation 
where we had a previous Secretary who was not forthcoming with 
knowledge about the budget, and that is a really critical issue 
for our Committee. I have often said that the VA Secretary has 
to be a truthful advocate for our veterans, not an apologist 
for any administration. And nowhere is this more important than 
in the Secretary's dealings with the annual budget process. And 
I know, as the former Army Surgeon General, you are no-doubt 
familiar with that annual budget process and the conflicts that 
you are inevitably going to face.
    There will be times when, in order to get resources for 
your troops, you will have to stand up to pressure from this 
administration to keep spending down. We know that is going to 
occur.
    Can you share with this Committee an example from your time 
as Army Surgeon General when you bucked your chain of command 
and advocated for increased funding?
    Dr. Peake. I can give you an example of a time when I 
garnered resources that weren't in the budget as we went 
through the hearings. I tried to explain what I couldn't do 
with the budget that I had, and what I talked about at that 
time was the opportunity that we had to do some things if I had 
only had the resources to be able to do them. And what came of 
that was a notion of a venture capital fund that came with no 
year money. It was not huge amounts in terms of perhaps the VA 
budget, but for me it was significant. They gave some $30 
million for each Surgeon General to have as an incentive fund 
to do the right thing, in terms of investment, that would allow 
us to be more efficient.
    I was counseled that I should not be talking about venture 
capital in front of the Congress, but in my testimony that is 
what I did. I will tell you that I do believe in working within 
the system.
    I will tell you, as I said in my written remarks, I 
understand I am part of the administration, but also I have a 
responsibility to the administration and to this Committee to 
lay out the issues as I see them, openly and honestly, and 
fight for the resources to do my job--which is to take care of 
veterans.
    And so, if confirmed, ma'am, I will be working with this 
Committee very closely to try to do the right thing by our 
veterans.
    Senator Murray. If you are confirmed, you know that you are 
going to get pushback from OMB on funding requests that you may 
see inside the VA as inadequate for the needs of the veterans. 
How do you reconcile the role of being a loyal member of the 
President's Cabinet and your role as the top advocate for 
veterans as the VA Secretary?
    Dr. Peake. Well, I am aware that there is, I understand, 
about $4 billion more than what was in the President's budget 
that is coming forward. I would be advocating getting that bill 
forward and getting it passed. I mean, we will be able to use 
that money to do good things for our veterans.
    Senator Murray. Can we count on you, as a Committee that 
certainly cares across the aisle on both sides, to be honest 
with us about what the real needs are?
    Dr. Peake. I will be honest with you about the real needs, 
Senator.
    Senator Murray. Dr. Peake, I want to ask you about a story 
that I saw in the Washington Post this past Sunday that was 
very disturbing. It was about a young woman, First Lieutenant 
Elizabeth Whiteside. I do not know if you saw the article? She 
apparently served in the Army for 7 years, had exemplary 
service, and when she was in Iraq, according to the story, she 
presented herself to a psychiatric nurse and said she was 
suffering mental health problems that were related to stress 
from serving in the combat zone. From the story, it said she, 
ultimately, fired her weapon into the ceiling and shot herself 
in the chest, and is now, as we know, being treated at Walter 
Reed where her psychiatrists are saying she was insane at the 
time of the incident in Iraq.
    Major General Erik Schoomaker, I understand, has 
recommended dismissal of the charges, but the Army is 
apparently proceeding anyway, and this is forcing Lieutenant 
Whiteside to choose between accepting a less than honorable 
discharge and the loss of all of her veterans' medical benefits 
or a court-martial where she could be sentenced to life in 
prison.
    In your experience, General Peake, are psychiatric findings 
routinely ignored by military authorities, as has apparently 
occurred in Lieutenant Whiteside's case?
    Dr. Peake. Ma'am, I cannot address this particular case 
because all I know is what I read in the papers also. I will 
tell you my experience is that oftentimes the process needs to 
work its way through. I do not know that it has been decided 
that she is going to be court-martialed. I did not get that 
from the newspaper, actually. But my experience is that the 
medical evidence is fully considered; and, it generally is--
again, in my experience--accepted and appropriately weighed, 
and that the right decision will be made by, ultimately, the 
line chain of command, which has the legal responsibility.
    Senator Murray. Well, in her case, to use it as an example, 
she is going to either be court-martialed or she is going to be 
dishonorably discharged and lose all of her veterans' benefits.
    Dr. Peake. I am not sure that is true, actually. From what 
I read, that is not exactly how I interpreted it. But, again, I 
am not sure--I would rather not comment on a specific case that 
I do not know.
    Senator Murray. Clearly, this goes to the issue at-hand 
before all of us: in recognizing Post Traumatic Stress 
Syndrome; what occurs, what happens; and having that be part of 
understanding rather than something that is used against 
somebody. Maybe you could share with us, as Secretary of the 
VA, how we could move forward and correct injustices that 
appear like this.
    Dr. Peake. I completely agree with you about the issue of 
looking at mental illness and not taking unfavorable action 
against an individual because of a mental illness, just like 
you would not because of a traumatic injury. If there is some 
problem about a veteran who may have a question of their access 
to the system, I believe those kinds of things are potentially 
waivable by the Secretary, and I would look favorably at 
ensuring that veterans who need care get care.
    Senator Murray. Can you just tell me if someone like 
Lieutenant Whiteside is court-martialed, what kind of mental 
health care they would expect to get?
    Dr. Peake. Ma'am, I would need to understand the legal 
issues specifically, and I would be happy to get back to you 
for the record about the particulars.
    Senator Murray. Well, let me ask a more general question.
    Dr. Peake. Sure.
    Senator Murray. How do we get to a point where we recognize 
Post Traumatic Stress Syndrome, the impacts of that, and use it 
in a realistic way, so we are not punishing people for a real 
wound of war?
    Dr. Peake. I agree with you that these are real wounds of 
war. I tried to make that point in my opening statement, and I 
think they need to be treated that way. It needs to be, and I 
believe it is, treatable. I think it is the kind of thing that 
you can make interventions and really make a difference in 
people's lives. I think we owe the soldier and the veteran that 
intervention.
    Senator Murray. Okay. My time is up and I have more 
questions, but I think that the case is that we hear a lot of 
rhetoric about people talking about Post Traumatic Stress 
Syndrome in a better way. I am delighted to hear the rhetoric, 
but there are real live case issues that keep coming in front 
of us where the rules, the attitudes, and other things go 
against everything we are trying to do in trying to make mental 
health care wounds recognized and treated in an appropriate 
manner.
    Thank you.
    Senator Akaka. Thank you, Senator Murray.
    Senator Hutchison?
    Senator Hutchison. Thank you very much.
    I would just like to ask--I so appreciate what you said in 
your opening statement about Gulf War illness and the need to 
know--not only for the people who have come back with these 
debilitating illnesses and symptoms, but also for our future 
veterans. And I wanted to ask on that and the research on 
prostheses, what would you consider the priorities for the 
Veterans Administration on these research projects for the 
injuries of today?
    Dr. Peake. I think, Senator, that at the front-end we are 
doing a lot of things with the prostheses; and giving our 
soldiers and our veterans the best in terms of the prostheses, 
at the beginning. We need to know where this is going to go for 
the future, because these veterans are going to someday be, you 
know, my age, and the opportunity for the advances in 
prosthetic care to continue are absolutely there. And, I think 
that between DOD and the VA, we ought to be, absolutely, the 
leaders in that. And, as the veteran moves through his or her 
life with a prosthesis, they ought to continually get the best 
that is available. I think we need to continue to do the 
research to make sure that that happens, as well as the 
investment to make sure that that happens.
    Senator Hutchison. On the issue of the electronic records 
and melding the Department of Defense with the Veterans 
Administration, there are committees that are working on trying 
to make this happen. Do you think that in your year, if you are 
confirmed--and I certainly hope you will be before the end of 
this year--in your year, can you give me a confidence that you 
believe that can be accomplished by pushing it and making it a 
priority?
    Dr. Peake. Senator, I do believe that we can make 
substantial progress in sharing information. I understand 
already that there are mandates by 2008 to have shared records, 
to share the images; and that there are already timelines 
leading to that. I understand that there have been studies 
commissioned to look at a common in-hospital record, and I 
would commit to you that, if confirmed. I would put this as a 
very high priority and find the ways to share the information 
between these two departments. I believe that really getting a 
common lexicon and common processes will go a long way at 
trying to be able to have computable information, and really 
interoperable patient records between the two agencies.
    Senator Hutchison. Well, I would say it would be among the 
very top priorities. And I know a lot of work has been done 
already, but it is essential that that be accomplished. And, it 
seems to me that a year would be a reasonable time frame. But, 
I would like to have periodic reports, if you are confirmed--
back every quarter--to tell us what the progress is and if 
there is anything that needs to be done here to add to your 
ability to accomplish that.
    Let me ask you another question on that and the claims 
processing, because that has also been mentioned. If we had the 
seamless transfer of electronic records, would that also 
expedite the claims processing for the disability benefits and 
care?
    Dr. Peake. Senator, I think it would. The issue of claims 
processing--one of the issues, as I understand it--is getting 
all of the information you need finally gathered so that you 
can make a good adjudication of the claim. And the longer that 
takes, the longer it takes for the claim. If we can get all the 
information--not just the medical information, but all of the 
information about the soldier, sailor, airman, and Marine--
available right away from DOD and be able to share that all 
electronically. I think an advance has already been made with 
the DD-214, and that is an important step. But it is not all 
the information that is always required. So, to get that and 
the medical information I think would speed up the claims 
processing significantly.
    Senator Hutchison. What other specific things do you think 
you could do to speed up that claims processing?
    Dr. Peake. I believe the issue of people and training is 
already being addressed, as you commented in your first 
remarks. I think that is important--making sure that there is 
quality training that is consistent across the system so that 
you have good inter-rater reliability. I do believe that we 
need to look at simplifying the system. It is complex, as about 
everybody that has looked at it has said. I have commented 
before, it is a 1945 system--is based really on the system that 
has been put in place back in 1945--and really needs to be 
relooked. And I think there is an opportunity for simplifying 
it so that the veteran himself and the people that are trying 
to do the adjudication have an easier time of being able to 
come to the right decision.
    Senator Hutchison. Thank you. My time is up, but I 
certainly hope that these priorities can have a game plan very 
quickly after you are confirmed, and I look forward to reports. 
Thank you.
    Dr. Peake. Thank you, ma'am.
    Senator Akaka. Thank you very much, Senator Hutchison.
    Senator Tester?
    Senator Tester. Thank you, Mr. Chairman. I also want to 
once again thank General Peake for his willingness to serve in 
this position.
    I want to talk a little bit about staffing. Over the last 
11 months, I have had many listening sessions in Montana about 
staffing at the hospital, and particularly at the clinics. And 
one of the comments that comes up quite regularly, is that the 
clinics and the hospital are understaffed--particularly the 
clinics--from a receptionist standpoint, to a nurse standpoint, 
to a doctor standpoint; there are some problems.
    I have of a couple of questions around this. Number one, do 
you think that there is a staffing problem, and understaffing 
problem? My perspective comes from a rural perspective because 
Montana is a rural State. It may also be there in the urban 
areas, too. Do you think there is an understaffing problem in 
the rural areas? Do you think there is an understaffing problem 
in the urban areas? And if there is, how are you going to solve 
it?
    Dr. Peake. Well, Senator, I have not had detailed briefings 
on what the staffing levels are or the staffing formulas. But 
if confirmed, I will take a look at that very quickly and come 
back to you.
    Senator Tester. That would be great. How would you 
anticipate solving it if it comes back and says, yes, we are 
understaffed--we need more doctors, nurses, and administrative 
personnel in the field? How would you solve that problem?
    Dr. Peake. Well, in terms of the recruiting efforts and the 
locality adjustments, which those kinds of things are tools 
that, you know, the HR folks would have to be able to expand 
the workforce. We have talked in rural areas sometimes--that 
workforce is not there or is engaged in the civilian community. 
In those kind of cases, we need to take a look at how do we 
partner perhaps with other agencies, perhaps with DOD, perhaps 
with the civilian community, to make sure that there is access 
to care for the veteran.
    Senator Tester. Okay. I want to talk about the Office of 
Rural Health for just a second. The Office of Rural Health is 
staffed by two people, even though, as Senator Dole said, there 
are 25 million plus veterans; there are 6 million, I believe, 
that live in rural areas. Do you believe this staffing level is 
adequate in the Office of Rural Health? And if it is or is not, 
what is your vision for the Office of Rural Health?
    Dr. Peake. I have not been over to meet the people in the 
Office of Rural Health, but I will quickly look at rural 
health. It is an issue that has come up while talking to many 
of the Members of this Committee. And I would look to ensure 
that we have an adequate staff to address these issues. If that 
is more than the staff that is available currently, I would 
expand it.
    Senator Tester. Okay. I want to step back a little bit to 
rural clinics, and you said that you did not--and it is 
reasonable. You do not have a firsthand knowledge of what the 
staffing levels are and if those claims are, in fact, true. Are 
you going to have the time to get out to see it? Or how are you 
going to get the information?
    Dr. Peake. Senator, I would do a combination of things to 
get the information and get a feel for this big organization 
that I hopefully will be confirmed to run, and that is getting 
good briefings from the staff. From my time in the Army, you 
have got to get out and kick the tires and see the troops. So, 
I would make a commitment to you to get out and see the people, 
not only in the medical centers, but in the rural health areas 
as well, and to our outpatient clinics as well, because 
outpatient care has become a huge piece of and importance to 
the Department.
    Senator Tester. I look forward to that, and you have a 
standing invitation from Montana.
    One of the things that I heard that was quite disturbing at 
one of the field hearings--in fact, a couple of the field 
hearings that we had, listening sessions--and I have said this 
before in this Committee--is that oftentimes veterans feel like 
the Veterans Administration is working against them, trying to 
outlive them.
    What would you do? It is a delicate balance. Trust me, I 
know that, because you have got some people that deserve the 
benefits that are not getting them; others that claim they 
should get the benefits that maybe should not. How do you 
change that image? I agree with Senator Hutchison when she said 
there are a lot of good things that VA does, and I hear tons 
and tons of good stuff. But we want to solve some problems, so 
that is why I am talking about some of the negatives. How do 
you change that image where the VA will not allow people in and 
they are trying to outlive them? How do you fix that?
    Dr. Peake. Well, sir, I would tell you I do believe that it 
may be a perception. I am not sure about the reality of that. 
My personal experience is that the quality of the people in the 
VA is excellent and they do care about the veteran.
    Telling that story and getting out and communicating with 
the veterans themselves is an important piece. To be able to, 
you know, share the message is an important piece of it. And I 
would be anxious to work to try to get that message out, and 
not only to get the message out, but to make sure there are no 
pockets of real problems that need to be corrected. Because 
sometimes it is the anecdote that has some truth to it that, 
unfortunately, colors the whole organization.
    Senator Tester. Okay. I have run out of time. We will come 
back to that in the next round. Thank you very much.
    Senator Akaka. Thank you very much, Senator Tester.
    Senator Webb?
    Senator Webb. Thank you, Mr. Chairman.
    General, first I would say that the sentence that I most 
greatly appreciated in your written testimony was the one where 
you said, a veteran should not need a lawyer to figure out his 
benefits or to get that benefit. You know, you should not have 
to pay a lawyer to get your hearing aid. And, you know, we have 
had a debate back and forth on the extent of allowable legal 
representation and all that sort of thing. But for my part, I 
would like to say, having been around this system for 30 years 
now, from the time I was a counsel on the House side, the 
veterans groups--in particular, the Disabled American 
Veterans--have done an extraordinary job in developing a career 
cycle service officer program where they really do understand 
Title 38 and 38 C.F.R., and they are the greatest friend that 
the veterans have.
    In fact, Mr. Chairman, we lost a real friend of the 
American veterans. We buried Butch Joeckel today in Arlington 
National Cemetery. He was a very fine Marine during Vietnam, a 
double amputee, did a long period of service with the DAV.
    I read your written comments with respect to this GI bill 
issue, and I sense that you would philosophically agree with 
what we are trying to do here. I know that this administration 
has not supported this legislation. Having sat on the Defense 
Resources Board for four years, I can guarantee you I could 
find the money, you know, looking at these huge amounts that 
are going over to places like Iraq and Afghanistan. I know you 
could find the money for this. Do you have any thoughts or any 
perspectives on how to change the mind of the administration on 
this?
    Dr. Peake. Senator, as you know, the Montgomery Bill, I 
guess, was really done in peacetime.
    Senator Webb. Yes.
    Dr. Peake. And things have changed. We are not in peacetime 
anymore, and my sense is this administration wants to do 
something right by these veterans that are coming home. And I 
would look forward to working with you to try to figure out the 
right road ahead to make a difference, like you showed in your 
charts and like all three of us at this table this morning had 
as opportunities.
    So, I think that things are different than when the current 
GI bill was put in place, and we have the opportunity to take a 
look at what some new approaches might be. I look forward to 
working----
    Senator Webb. The clock is ticking in terms of people 
getting out of the military, and as I said, I think the U.S. 
military is doing a very fine job managing its career force, 
and I think it is doing a not very good job assisting people 
who are transitioning out. And the presumption--even when we 
had the Dole-Shalala Commission--the presumption was, since 
this is a volunteer system it is a career system. And as you 
know, it is an odd beast. Part of it is career, but a large 
part of the American military is people who come in with the 
intention of getting out. They want to check the box. I served 
the country, I honored my ancestors; you know, the country was 
in crisis, whatever their motivation is. A lot of them are 
hitting a brick wall, legitimately. This is not just rhetoric, 
you know, in a lot of these articles.
    So, I would hope that you could work with us to figure out 
something that makes sense here. It is an affirmative tool to 
give somebody respect in a community and an avenue toward the 
future.
    I was listening to the testimony thinking about all the 
different problems in the VA, and you are not expected to be 
the master of the process at this point. But, sort of an 
analytical prototype came to my mind while I was sitting here, 
and that is, when I was Assistant Secretary of Defense, we had 
moved into the Total Force Concept over a period of years. You 
would be very familiar with this, having been in the Army, 
where in 1968 the Army was fielding 18\2/3\ divisions with 
about, as I recall, 1.7 million active duty people. By 1985, 
they still had 18 divisions, but they only had 761,000 active 
duty. And a lot of the active divisions were stovepiped with 
Guard and Reserve units, combat support, combat service 
support, it was not functioning terribly well when you started 
thinking about mobilization.
    Cap Weinberger turned around to me one day--because I had 
all the Guard and Reserve programs; I had that first 120 days 
of war. He basically said, ``I want you to show me where the 
broken points are.'' And I took a year with our staff; we 
worked on this for a year. We laid out at that time where the 
break points were in terms of moving forward in things like: 
are we really making the right casualty estimates; where is the 
medical system; where should the combat medical stuff go; what 
does strategic airlift look like; have we really got the right 
balance; can we train these Guard and Reserve people at the 
same tempo that we do the actives when one out of every five 
was over the age of 40, as opposed to 5 percent on the active 
side; et cetera, et cetera, et cetera.
    So, I put this report out and a lot of people in the Army 
were rather skeptical, because Weinberger then made me 
Secretary of the Navy. But, a part of this report was, 
basically, where is the breaking point; what can be fixed, and 
under the present system, honestly, what cannot be fixed. You 
may be in this job for a year; then, again, we never know how 
political futures work, so you may be in the job longer than a 
year. But one thing that I am thinking, that with your 
background you might be able to truly contribute a study at the 
end of this. Some of the stuff is budget, some of it is policy, 
but some of it is just the momentum over the years of 
management policies here in the VA when we have got these 
backlogs and we have got all these different problems.
    You know, maybe you could ask and work on from your 
perspective a management analysis of the VA, just from your 
perspective. What are the problems? Why do we have them? And 
what needs to be done--from your perspective or to your 
successor--to make this system work? Because it is not working.
    Dr. Peake. You know, sir, in the Army I participated in 
TRADOC for a while and spent time with the ``Army after next'' 
looking out. I think you do need to have the long-term vision, 
and as I suggested in my remarks, these issues need some short-
term solutions and they need some long-term solutions.
    Perhaps one of the advantages I bring is that, even though 
I have had no significant exposure to the VA over quite a 
while, I am not an inside guy. And so to come in and to be able 
to step back a little and look and get the wisdom from----
    Senator Webb. I think you would be uniquely qualified to 
make that contribution. My clock is over, but I hope we can 
talk about that some more.
    Dr. Peake. I look forward to following up with you.
    Senator Webb. Thank you, Mr. Chairman.
    Senator Akaka. Thank you very much, Senator Webb.
    Senator Specter?

               STATEMENT OF HON. ARLEN SPECTER, 
                 U.S. SENATOR FROM PENNSYLVANIA

    Senator Specter. Thank you, Mr. Chairman.
    General Peake, I commend the President for your nomination 
for this very important post, and you certainly have 
extraordinary qualifications to undertake what may be the most 
important job right now in dealing with America's veterans who 
are coming back from the battlefields. My light is on, but I do 
not know how the projection here is. I will move a little 
closer. Senator Thurmond used to say, ``Pull the machine a 
little closer.'' [Laughter.]
    Senator Thurmond was on this Committee for many years, and 
he was the quintessential veteran. In fact, it was in this room 
that he had his famous 100th birthday party on December 2, 
2002, then served another month to be at a ripe old age of 100 
years and one month when he left the Senate. But this machine 
is stationary, General Peake, so I cannot pull it forward. I 
have to move forward myself.
    The attendance here does not reflect the importance of this 
Committee's work--there are so many other hearings going on 
simultaneously. I just came from the Judiciary Committee where 
we are reauthorizing the Juvenile Justice Act, and people are 
moving in many, many directions.
    The background you bring is really extraordinary. You were 
simultaneously the Surgeon General and commander of the Army 
Medical Command at the same time. Combat experience, being 
wounded; hard to think of someone who has more credentials for 
this job than you do.
    My concern for veterans benefits comes from the first 
veteran I knew, who was my father, Harry Specter. He was an 
immigrant from Russia and served in World War I, carried 
shrapnel in his legs until the day he died from the Argonne 
Forest. And I recall as a very young child--I think I recall, 
or I have read the history books about it--but the U.S. 
Government broke the promise to give the veterans a $500 bonus, 
and there was a march on Washington. Veterans assembled on The 
Mall, and President Hoover called out the Army. The Chief of 
Staff was General Douglas MacArthur. There is a very famous 
picture of him on The Mall with his aide de camp, Major Dwight 
Eisenhower. The Army fired on veterans that day--one of the 
blackest days in American history. And in a sense, in a 
metaphor, I say, I have been on my way to Washington ever since 
to get my father's bonus. I have not gotten it yet, so I am 
running for re-election. There's a lot of work to do.
    But I would urge you to become an advocate--an advocate for 
the veterans. It is a very rough and tumble process as to what 
happens at the Office of Management and Budget. And when we get 
the administration's figures, we have very substantial 
limitations as to what we can do; although, characteristically, 
the Congress does add funding because we are lot closer to the 
situation than the bean counters in the administration.
    I think you are in a very unique position to be the 
advocate for veterans with this experience you bring.
    General Peake, how tough can you be?
    Dr. Peake. Well, Senator Specter, I think I can be pretty 
tough. My job is to fight for our veterans, to take care of 
them, and to make sure that we do that effectively and 
efficiently. As I have spoken with Senator Murray about this, I 
will come to this Committee to work with this Committee to make 
sure that we have the resources needed to do the right thing 
for our veterans.
    Senator Specter. Well, we will back you up, General Peake. 
We will back you up. If you give us the leadership on the 
specifics as to what you need, this Committee will back you up. 
The whole Congress will.
    Dr. Peake. Sir, I appreciate that, and that is absolutely 
clearly the sense that I have gotten from this Committee, 
meeting with folks individually, as well as the reassurance of 
that today.
    Senator Specter. Well, you have a great staff backing you 
up. I see Bill Tuerk sitting in the front row. Bill was the 
Staff Director when I chaired this Committee for six years; he 
really knows his stuff. There are a lot of other good 
personnel--I do not mean to pick Bill out. Well, I guess I do 
mean to pick Bill out, especially. I saw his work when he was 
Staff Director here, and we will back you up.
    I have questions which I want to submit for the record. My 
red light just went on. Thank you very much for taking this 
job, General Peake, and thank you, Mr. Chairman.
    Dr. Peake. Thank you, Senator.
    Senator Akaka. Thank you very much, Senator Specter.
    We will begin with a second round of questions, Dr. Peake. 
In response to a pre-hearing question, you indicated a 
willingness to study the proposal for mandatory or guaranteed 
funding for VA health care. The multi-billion-dollar shortfall 
in fiscal year 2005-2006 indicates that something needs to be 
done. How and when do you propose to look more closely at this 
issue?
    Dr. Peake. Senator, if confirmed, I will very early in my 
tenure get the full set of briefings on this issue. I 
understand the complexity of this issue, and I also understand 
the concerns that some pat formula, as opposed to really good 
actuarial forecasting, may not give the budget definition that 
the VA, particularly the VHA (because it is the largest piece 
of that), would need. But, as I mentioned in my comments, sir, 
I do have an open mind on this, and I would really want to 
understand the issue in detail.
    Senator Akaka. Thank you. In response to one of my pre-
hearing questions, you stated the following, and I am quoting: 
``Working with Congress and the administration to revise the 
disability system offers the opportunity to simplify the 
process, create a way ahead for an equitable and uniformly 
administered system, while meeting the needs of each of the 
tiers that might be identified.''
    I am concerned that the creation of dual systems of 
compensation, as some have suggested, is inherently 
inequitable. In your opinion, would the creation of a system of 
disability compensation that offers varying amounts of 
compensation dependent upon an era of service for the same 
disability be equitable?
    Dr. Peake. Senator, almost by definition it is not 
equitable. However, I do think that there are different needs 
by the different groups of our veterans. And the most important 
thing is to meet those needs.
    We have an obligation to this next generation of veterans 
to make sure that we get it right for their future so it is not 
confusing. It takes, as I understand it, two to three years to 
be able to get a VSR person that can adjudicate a claim fully 
trained. That alone talks to the complexity of the disability 
system. What I want to do is really understand the results of 
the studies that are being done, to analyze all of the 
information that has come forward from the people that have 
looked at this--with General Scott's commission as an example--
to really understand what the right direction forward is, and 
then find a way to move that system. It is a big system, and 
there are many, many people that are involved with it.
    So, I want to do the right thing, but I do not see anybody 
being disadvantaged from their current position as we would 
move forward, sir.
    Senator Akaka. I agree with you that the issue of the 
transition from active duty service to veteran status is a key 
challenge. I am hopeful that if you are confirmed, your 
background will be helpful in the ongoing effort to improve 
that process.
    You mentioned in response to a pre-hearing question that 
for injured servicemembers, there is an incentive not to move 
from one system--that is, DOD--to the other, VA. I think that 
is a crucial point in the transition effort. Please expand on 
what you think is an incentive not to move from DOD to VA and 
what, if anything, VA can do in response to that incentive.
    Dr. Peake. Part of the lack of the incentive to move is 
sort of the fear of the unknown. Part of it is the ability of 
the servicemember and the servicemember's family to understand 
what their real benefits are going to be as they move forward. 
And that, again, talks to the complexity of the system as it 
stands now.
    The other is the notion of how well we can take care of the 
families. Because the family unit now is often a working spouse 
that is contributing substantially to the financial well-being 
of the family, if that spouse stops being a provider and starts 
being a care provider instead of a financial provider, that 
changes the dynamic of the family. Somehow we need to be able 
to take that into account and give them the confidence that, as 
they move to the VA system, they will be able to get all of the 
care that is required and be able to be supported as a family 
unit as well.
    Senator Akaka. Thank you, Doctor.
    Senator Murray?
    Senator Murray. Yes, thank you very much.
    In my opening remarks, I talked about the CBS News report 
that was aired recently. I do not know if you saw it.
    Dr. Peake. The----
    Senator Murray. On suicide.
    Dr. Peake. Yes, I did.
    Senator Murray. I was particularly struck by the veterans 
aged 20 to 24--whose rates are 4 times higher than civilians 
the same age. Can you comment on that and tell me what you 
think the VA could be doing better?
    Dr. Peake. I think this is another one of those issues, 
Senator, that really is part of this transition piece, because 
what goes on on the DOD side and the emphasis there on the 
family reunion, as the deployment cycle support kinds of 
aspects that help identify people that might have a problem, is 
important at the front end.
    As we move into the VA system, we touch the people that 
have come to us. The question is, how can we outreach? And part 
of it is identifying for the family members what they ought to 
be looking for, and not just family members, but also 
coworkers. So, part of it is getting folks to recognize what 
the danger signs are.
    My understanding is that the VA is already doing a lot to 
reach out. They're asking folks, ``Are you okay?''--you know, 
all the right questions. ``Have you thought about harming 
yourself?'' All those kinds of things are really, I think, 
being inculcated--as I understand it from my at least 
preliminary discussions--into the primary care settings of the 
VA. So, there is that sensitivity of a safety net to find that 
individual that might have a problem.
    I believe in the post-deployment health assessment, the 
post-deployment health reassessment. I would like to work with 
DOD to make sure we have all that information, that we are 
sharing; that, in fact, all of the Reserve soldiers that come 
back get that second follow-up, so that we can identify the 
ones that we can reach out to. We do not want to just be 
passive and stand in the back waiting for somebody to have a 
problem if there are ways to reach out; and that will help de-
stigmatize as well, I believe.
    Senator Murray. And will that be a priority of your 
administration?
    Dr. Peake. It will be. It is something that I think is a 
different approach to this issue of the panoply of mental 
health issues. As we discussed in your office, ma'am, I think 
not everything is PTSD, because there are six criteria to have 
that as a diagnosis. But, there are things short of PTSD or 
other mental health issues that are amenable to intervention 
and treatment and improving the well-being of our veterans.
    Senator Murray. Part of the Joshua Omvig Suicide Prevention 
Act that we have passed requires all of the folks at the VA to 
be better advocates in dealing with veterans who are calling. I 
assume that you will really move forward to make sure that 
happens?
    Dr. Peake. I will. And as I say, my understanding is that 
there is a lot being done from, you know, Mike Kussman and crew 
already in that arena. But I agree with you that it is one that 
we just need to continually stay on and push.
    Senator Murray. All right. Let me change the topic a little 
bit. You are well aware that some of the veterans have raised 
some concerns about your previous employment with the QTC and 
possible conflicts of interest with the duties of being VA 
Secretary. You answered the pre-hearing questions in a very 
clear way that if you are confirmed, you will terminate all 
your connections to QTC; you will have no financial interest in 
QTC, remove yourself from all matters related to QTC. And we 
very much appreciate that clarification, but I would like to 
ask you how do you envision being able to perform your duties 
at Secretary if you cannot make decisions about a contract that 
is worth, as I am told, up to $1 billion?
    Dr. Peake. QTC has been in business with the VA since 
1998--perhaps that figure is over the course of that whole 
period of time. But I would tell you that I have been with QTC 
less than a year when this was announced. I would be happy to 
work with this Committee; however you feel is the best way to 
deal with this. I will have, as you pointed out, no ongoing 
financial interest with them. I will not go back to them. I 
have made that clear and made that decision. I will have no 
deferred compensation or bonus or anything of that nature.
    So, I do not see that I will really have a conflict. We 
have ways to create whatever firewalls are necessary.
    Senator Murray. I understand from your statement that you 
are going to separate yourself from any decisions about that, 
but it is a contract that is worth up to $1 billion, so who 
will make those decisions about that? And how will that be done 
if you, yourself, cannot do it? That is my question.
    Dr. Peake. I will work with the Office of Government Ethics 
and with the ethics people at VA to make sure that the decision 
level will be at the Deputy, I would assume, but it would need 
to create whatever is necessary to have the appropriate 
oversight of the contract, which is important, I think, of any 
contract: is to have appropriate oversight and 
accountabilities. And so, I honestly will work however you want 
to be able to make this very clear, because I want no 
perception of any favoritism. I believe in full and open 
competition, and I would support that.
    Senator Murray. Well, you will be out and about and hear 
much of what we hear; and I hear, you know, concerns about the 
system. I hear about providers who do not have the expertise in 
relevant areas. We have providers with poor English skills; 
evaluations that do not focus on the problems that have been 
identified; absence of VA medical records; QTC billing for more 
time than the provider spends with the veterans. And you will 
hear this as you are out there.
    What will you tell veterans when you hear concerns about 
QTC in the field?
    Dr. Peake. I will collect those concerns. I would take them 
seriously, and I would put them into the system to get them 
resolved appropriately through the contracting authorities.
    Senator Murray [presiding]. Okay. My time has expired. I do 
have some more questions. Senator Tester, I will turn to you.
    Senator Tester. Thank you. There are a lot of issues here, 
but when we ended up, we talked about VA working for vets 
versus an adversarial situation with the vets. And I have been 
thinking about that as the other questions go around. I will 
just tell you that I have heard many times in Montana about 
getting through the door, the red tape that is involved, and 
the lost records that are involved, and there are excuses or 
issues, however you want to phrase it, down the line. And I 
will just say, I think it is really incumbent upon you and us 
to make sure that the veterans who deserve the health care get 
it, and that is really the bottom line.
    I want to talk a little bit about contracting and how it 
applies to rural areas and what is your vision for contracting 
out VA services in rural areas.
    Dr. Peake. Senator, what I would tell you is I want, as you 
said, to make sure veterans get the care that they need. My 
responsibility then will be to look at all of the ways in which 
we can make that happen--to make sure that it is not just, 
``okay, you got the care,'' but to make sure that that care is 
of the quality that Mike Kussman runs in the VHA and our 
system; that it is care that is integrated; and that we get the 
information that is needed so that if there is other care that 
is done within the system, it is integrated into the full 
continuity of care.
    And so, I think that what I want to do is make sure that 
the standards of access and the standards of quality are met, 
and how best to do that, as was pointed out earlier by, I 
think, Senator Dole--the VHA is an outstanding system, and we 
do not want that to go away. I have no philosophy about trying 
to get rid of the VA system if that is what you are asking, 
sir. But what I do want to do is make sure our veterans have 
access to the care that they deserve and that it is of the same 
high quality that we have within our VHA system.
    Senator Tester. In areas that are rural/frontier, would you 
be amenable to contracting out to local hospitals for VA 
services?
    Dr. Peake. If we can ensure that the quality is of the 
nature needed and that we can get that information back into 
our system so that we can, in fact, have the quality of 
continuity for the veteran.
    Senator Tester. I appreciate that answer. How would you 
ensure that quality of care? I mean, because it is going to be 
on your shoulders to do that.
    Dr. Peake. I think it is certainly something that I would 
have to study and to understand what mechanisms we have in 
place to be able to reach it. But, if we are providing that 
care and we are paying for that care, we have the opportunity 
to monitor it, whether it is through records or through the 
claims processing or whatever; and perhaps surveying our 
veterans to understand what they think about their care.
    Senator Tester. Okay. I had a piece of legislation that was 
put on an amendment on a bill, the defense authorization bill, 
that would increase mileage from 11 cents to 28.5 cents per 
mile for disabled vets. Currently, Federal employees are 
receiving 48.5 cents a mile. Do you see this increase as 
adequate? Do you think it is a good idea? I am talking about 
mileage reimbursement for disabled vets to get to clinics and 
hospitals. Do you think it is adequate? Do you think it is a 
good idea? Do you support it?
    Dr. Peake. I do not know about the specific numbers because 
I have not studied that, sir, but I do understand that the 
price of gas has gone up, and I do understand that it is a 
burden on the veteran that needs to be looked at and 
appropriately adjusted.
    Senator Tester. Okay. We are short on time so I will not 
follow up, but that really did not get to my point, that 
answer. I need to know if you think it should be increased up 
to 28.5 cents. Would you support that? And do you think that is 
adequate? Yes or no. Or, yes, I think it should be 28.5 cents, 
or, no, it is taking too much money from other programs, or 
whatever.
    Dr. Peake. Senator, to be honest with you, I have not 
looked at that as an issue, and I----
    Senator Tester. No problem. I want to talk about----
    Dr. Peake [continuing]. I can come back to you.
    Senator Tester [continuing]. Another problem real quickly, 
but it is not a problem we can discuss real quickly. It has 
been brought up here several times, and that is TBI, PTSD, the 
whole issue that revolves around mental health. And I want to 
talk about telepsychiatry because you mentioned it in your 
questions. And I have some reservations about it, but I am not 
a doctor. My question is: How familiar are you with 
telepsychiatry? And what kind of assurance are you going to 
utilize to make sure that this fits the need? Because we are 
talking about folks, as it has been pointed earlier by Senator 
Murray and others, who need help. And do you think 
telepsychiatry can really give them the kind of help they need, 
I mean functionally, to actually get them through incredibly 
difficult times?
    Dr. Peake. Sir, I do believe that telepsychiatry has a 
role. It is not the panacea. There is usually not a silver 
bullet for any one of these things. There is not one thing that 
will fix everything. But, I do believe it is one of the tools 
that really ought to be in the armamentarium. It is one of the 
areas of telemedicine that very early on has been, I think, 
demonstrated to be effective in certain circumstances.
    I do not claim to be an expert in telepsychiatry, but I 
have more than just a passing familiarity with it. I do believe 
that the whole notion of telemedicine, as we start to look at 
the full spectrum of that, where it reaches--has the potential 
to reach into somebody's home and monitor their vital signs and 
keep them out of emergency rooms--are the kinds of things that 
we ought to be looking at. That is particularly useful in the 
rural environment.
    Senator Tester. Okay. I have run out of time long ago, and 
I have got other questions, and I am not going to stick around 
because I have another meeting at noon, unfortunately; and we 
have been at this a while. But, I wanted in closing to say, I 
intend--unless something comes up between now and the 
confirmation out of this Committee or on the floor--I intend to 
vote for your confirmation. I think you are a good guy. I think 
you have got a tremendous responsibility ahead of you, and it 
is only 13 months or 12 months. You can do so much good for so 
many veterans in this country that I really hope that you grab 
the bull by the horns and really lead this agency. I think it 
is critically important. I think you have got a lot of great 
people in it. I think you have got a lot of great people in the 
field and clinics and hospitals that work incredible hours and 
make incredible sacrifices for service. And I would hope that 
you recognize that and move forward and make this agency all it 
can be, because I think the pressure on this agency over the 
next decade is going to be amazing. And if we are able to 
respond in a way that is appropriate, it can really be a golden 
time in this country's history.
    So, thank you very much for your willingness to serve.
    Dr. Peake. Senator, thank you very much.
    Senator Akaka. Thank you, Senator Tester.
    Let me follow up with a couple questions, and I will also 
ask Senator Murray and you, Senator Tester, for any follow-ups 
here before we close.
    Dr. Peake, going back to the transition and your comments 
about the fact that there is an incentive not to move from one 
system--that is, DOD--to VA, and then you touched on an issue 
that I think is at the core of the lack of success in the 
transition effort: the cultural gap between the military 
services and VA--a gap that is particularly noticeable in the 
context of an all-volunteer military.
    What do you believe that VA might try to do to bridge that 
gap?
    Dr. Peake. Sir, I think the opportunity for the VA to reach 
into all of the military facilities where we do briefings of 
people that are getting ready to leave--to work with at the 
senior level, to make sure that they have welcome reception on 
the DOD side, to come in and really tell the VA's story and to 
help people understand what those potential benefits are--is 
really an important thing. It is better educating--and that has 
been brought up a couple of places here today--the soldier, 
sailor, airman, or Marine about what the VA really has to offer 
them, from educational benefits, to voc rehab, to their health 
care. So, getting that message out is of number one importance.
    The other is making it easy to do, comfortable for them to 
put in their claim, to establish the linkage, and apply for the 
appropriate benefit.
    Senator Akaka. It seems that one of the biggest hurdles 
that must be overcome is identifying the right time for what I 
call ``the hand-off'' from DOD to VA to occur. For instance, 
many injured servicemembers wish to remain on active duty. What 
role, if any, should VA play in either the decision about 
whether someone is leaving active duty or in working with an 
injured servicemember who may not be leaving active duty?
    Dr. Peake. I believe that it is appropriate for the VA and 
the Care Coordinator for the servicemember that is injured to, 
early on, have somebody from the VA be a part of their recovery 
team. I think that the service really needs to make the 
decision about whether they are going to be fit for duty or 
not. That is really a service-specific decision, the way I see 
it, sir.
    I am very open and would encourage looking at bringing even 
an active duty servicemember into the VA system, and we do that 
in specialized areas now. But for rehab and then, if possible, 
they want to go back to the service and they are capable of 
going back to the service, that ought to be a nice route back--
one that is easy and coordinated with the services to do that. 
And then if they are not able to recover to that level or to be 
rehabilitated to that level, then we have got our arms wrapped 
around them as the VA that is going to give them the 
appropriate care for the rest of their lives.
    Senator Akaka. Thank you very much.
    Senator Murray?
    Senator Murray. Yes, thank you, Mr. Chairman.
    I want to talk to you about an issue that is very near and 
dear to my heart, and that is the Walla Walla VA Medical 
Center. As you may have known, it was slated to be closed, and 
after numerous closed-door meetings with the VA and the Senate 
VA Committee field hearing that occurred there, the right 
decision was made--to keep that open. The community has been 
very, very involved with it, and the VA has now approved a 
90,000-square-foot outpatient clinic to replace an existing 
facility there.
    I have been told by the VA that the design and construction 
of that outpatient clinic is now going to be delayed by several 
years, and I want you to know that is totally unacceptable, and 
I would like to hear, if you are confirmed, if you will pledge 
to work with me to speed that construction up. This is a 
vitally needed center. The vets there have been told one thing 
and another for so long. They need the confirmation that their 
country is with them. I would just like to hear from you that 
you will work with me to make sure of that, and I would love to 
have you come out and see it personally.
    Dr. Peake. Senator, I will commit to both, coming out there 
and visiting with you and holding a hearing in your area if you 
want me to. And I will commit to you that I will work with you 
to look at Walla Walla and what needs to be done there.
    Senator Murray. I appreciate that, both for Walla Walla, 
and I want to follow up with you on that, but I also think as 
Secretary you need to be on the ground to hear what we are 
hearing. The world is very different inside of VA's circle here 
versus what you see on the ground out there, as you can imagine 
in any agency. But I think you need to hear the passion, both 
from community members who support veterans and are concerned 
about what is going on, and from the veterans themselves--the 
frustrations they have felt. This is why I gave you that button 
saying, ``it cannot be business as usual.'' The attitude needs 
to change. And I would love to have you come out to my State. 
We have a number of very, very active places, as you know from 
having been at Madigan. Come see what is happening at Madigan 
all the way through the VA system. I would love to have you 
join me there once, if you are confirmed.
    Dr. Peake. If confirmed, I appreciate the invitation and I 
look forward to accepting.
    Senator Murray. Okay, good. One other question and then I 
have a comment. We have heard a lot about this issue of 
personality disorders discharges, and in the last 6 years, the 
military has diagnosed and discharged more than 22,000 
servicemembers because of so-called pre-existing personality 
disorders. I wanted to find out from you what your 
understanding of administrative discharges from the armed 
forces are, based on this diagnosis of personality disorder.
    Dr. Peake. Can you clarify the question? You have a person 
with an administrative discharge----
    Senator Murray. There is a concern about the process being 
fair. We are hearing from a lot of men and women who have been 
discharged because of a so-called pre-existing personality 
disorder, and they feel they are not being treated fairly. Are 
you aware of this issue?
    Dr. Peake. I am aware of the issue. I would need to 
understand more specifically the individual cases.
    Senator Murray. Okay. Well, that is a question I would like 
to work on with you. There is a very strong and real sense of 
the process not being fair, and I think it is something we need 
to pay some attention to.
    Mr. Chairman, I do have a couple of other questions I will 
submit for the record.
    I will say this, General Peake: We have had a vacuum at the 
top of the VA for some time that has to be filled. I am likely 
to support your nomination unless something else occurs. I 
cannot imagine that it will. We expect you to take this job and 
to take it seriously, and obviously, being confirmed is a major 
recognition of an achievement. But, I think where history will 
really judge this confirmation is a year from now; and whether 
you can begin to turn around an agency that for too long has 
really not gotten into the ball game at a time when men and 
women are at war and we have thousands of people returning, as 
well as those from previous generations, who really feel that 
they have not been given the service they need.
    So, an attitude change at the top will, I think, serve all 
of us well. There are thousands of VA employees who work very, 
very hard, both within the agency here and out in the field, 
who I think are open and ready to take on a new challenge and 
to make sure that they are seen visibly as an agency that 
serves our veterans well, and I think leadership at the top a 
year from now will be judged on what that attitude is.
    So, I look forward to working with you very much.
    Dr. Peake. And I with you, Senator. Thank you.
    Senator Murray. Thank you.
    Senator Akaka. Thank you, Senator Murray.
    Thank you, Dr. Peake, for your full and open participation 
in today's hearing. Every organization needs an unquestioned 
leader. It is not optimal for the Department of Veterans 
Affairs to have an acting leader for an indefinite period of 
time. With this in mind, I will work to bring your nomination 
before the Committee and the full Senate as soon as feasible, 
following time for any post-hearing questions to be asked and 
answered. And so I will ask that all members submit any such 
questions before the end of this week to move it along.
    With that, again, I want to say thank you so much. I want 
to thank you for what responses you have given. To have your 
radio man here to support you is great. I want to say also 
please convey our aloha to your family, and I wish you well in 
this process.
    With that, this hearing is adjourned.
    Dr. Peake. Thank you, Senator.
    [Whereupon, at 12:08 p.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


                                                  November 2, 2007.
Hon. Daniel K. Akaka,
Chairman,
Hon. Richard Murr,
Ranking Member,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Chairman and Ranking Member: Recently, President Bush 
nominated Lieutenant General James B. Peake to serve as the next 
Secretary of Veterans Affairs. As Members of Congress representing the 
San Antonio area who have worked closely with Dr. Peake, we urge the 
Senate to give him the utmost consideration during confirmation 
proceedings.
    As you may know, Dr. Peake has impeccable credentials that we 
believe can be beneficial at the Veterans Administration (VA). Dr. 
Peake is the former U.S. Army Surgeon General as well as a recipient of 
the Silver Star, Bronze Star and the Purple Heart. Along with his 
public service, Dr. Peake has served in the private sector as Chief 
medical director and chief operating officer at QTC Management Inc.
    Dr. Peake began his Army medical career as a general surgery 
resident at Brooke Army Medical Center at Fort Sam Houston in San 
Antonio. He later went on to serve as both the commander of the U.S. 
Army Medical Department Center and School as well as commander of Fort 
Sam Houston.
    The San Antonio area is in a critical period of expanding services 
to both our active duty troops as well as veterans. Fort Sam Houston is 
in the transformation stages to become the hub for training of all 
branches of service's enlisted medical personnel. The Center for the 
Intrepid, a four-story, 55.000 square-foot facility adjacent to Brooke 
Army Medical Center, was recently opened to provide advanced 
rehabilitation for amputees and burn victims. Additionally, San Antonio 
was recently selected as the home for the newest Level One Polytrauma 
Rehabilitation Center at Audie Murphy VA Hospital.
    Because of Dr. Peake's familiarity with our community, we believe 
that he would serve with the needs of San Antonio veterans in mind. 
Although the VA is improving, it certainly is still in need of 
leadership to better prepare the agency to serve the growing number of 
new veterans while fulfilling the needs of current veterans. As Members 
of Congress from San Antonio, we hope you will closely consider his 
nomination to this important position and we thank you in advance for 
your prompt consideration.
            Sincerely,
                                   Ciro D. Rodriquez,
                                   Charles A. Gonzalez,
                                   Lamar Smith,
                                   Henry Cuellar,
                           Members of Congress, San Antonio, Texas.
                                 ______
                                 
                                    Wounded Warrior Project
                                Jacksonville, FL, December 3, 2007.
Hon. Daniel K. Akaka,
Chairman,
Hon. Richard Burr,
Ranking Member,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman and Mr. Burr: The Wounded Warrior Project (WWP), 
a non-profit organization that serves the men and women of the United 
States Armed Forces who have been injured during the current conflicts, 
strongly supports the nomination of Lieutenant General (Ret.) James B. 
Peake to be Secretary of Veterans Affairs (VA).
    LTG Peake has spent more than 40 years as a soldier and physician 
in the U.S. Army. He has dedicated his adult life to serving our Nation 
as a platoon leader in the 101st Airborne Division in Vietnam, as a 
thoracic surgeon in the U.S. Army, and finally as the Surgeon General 
of the U.S. Army from 2000 to 2004.
    The situation at Walter Reed highlighted the many obstacles our 
wounded warriors face. As a wounded Vietnam veteran and physician, LTG 
Peake would bring his personal and professional perspective to the 
Department of Veterans Affairs. In addition, his career-long experience 
in the military will enhance the cooperative efforts between the VA and 
the Department of Defense for the benefit of those injured in service 
to our country.
    If confirmed, WWP looks forward to working with LTG Peake in his 
capacity as the Secretary of Veterans Affairs. Thank you and we look 
forward to his timely confirmation.
            Sincerely,
                                                John Melia,
                                                Executive Director.
                                 ______
                                 
                                                  December 4, 2007.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
    Mr. Chairman: As you prepare for tomorrow's confirmation hearing 
for Lt. Gen. James Peake (Ret.) as Secretary of the Department of 
Veterans' Affairs, I would like to share my concerns and the concerns 
of some of my constituents.
    In particular, I want to encourage you to consider not only the 
candidate, but the critically important challenges the next Secretary 
will face, and his or her ability to address them.
    I am confident that Lt. Gen. Peake is a well qualified physician, 
and he has proven himself as a budget-conscious administrator as 
Surgeon General of the Army. He has deservedly earned respect and 
accolades from his colleagues and Members of Congress for this service 
in the Army.
    However, making the necessary changes at the VA will require more 
than a few minor policy adjustments. The problems are so significant 
and systemic that I believe the next Secretary will need to lead a 
cultural shift. The status quo is unacceptable and our veterans cannot 
afford a Secretary who merely marks time until the next Administration. 
The next Secretary must be an active and effective agent of positive 
change.
    The House Veterans' Affairs Subcommittee on Oversight and 
Investigations has uncovered some matters of serious concern, including 
the urgency to fix the 400,000 disability claims backlog, the 
continuous inability of the Defense Department to share medical records 
with the VA, and numerous bureaucratic hurdles facing servicemembers 
and their families when they return from war.
    I am proud that this Congress has made veterans' benefits a 
priority, but as you are well aware, there is more work to be done. In 
the coming year we will be working to ensure that veterans receive the 
college education they have earned and deserve by modernizing the GI 
Bill. We will also be working on legislation to implement the 
recommendations of the Veterans' Disability Benefits Commission.
    There is no doubt that these are all serious challenges. Now more 
than ever our nation's veterans need a Secretary who is committed to 
working with Congress, in a bipartisan way, to ensure that the men and 
women who have defended our freedom receive the health care and vital 
assistance they earned.
    I appreciate you holding these hearings in such a timely manner. 
Your committee has worked tirelessly this year to improve the lives of 
our nation's veterans, and I urge you not to let up as you prepare for 
this week's hearing. Again, thank you for your consideration.
            Sincerely,
                                         Harry E. Mitchell,
                                Member of Congress, Tempe, Arizona.

  

                                  
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