[Senate Hearing 110-346]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 110-346
 
          VETERAN'S HEALTH: ENSURING CARE FOR OUR AGING HEROES 

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

                                HEARING

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                            OCTOBER 3, 2007

                               __________

                           Serial No. 110-15

         Printed for the use of the Special Committee on Aging



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                       SPECIAL COMMITTEE ON AGING

                     HERB KOHL, Wisconsin, Chairman
RON WYDEN, Oregon                    GORDON H. SMITH, Oregon
BLANCHE L. LINCOLN, Arkansas         RICHARD SHELBY, Alabama
EVAN BAYH, Indiana                   SUSAN COLLINS, Maine
THOMAS R. CARPER, Delaware           MEL MARTINEZ, Florida
BILL NELSON, Florida                 LARRY E. CRAIG, Idaho
HILLARY RODHAM CLINTON, New York     ELIZABETH DOLE, North Carolina
KEN SALAZAR, Colorado                NORM COLEMAN, Minnesota
ROBERT P. CASEY, Jr., Pennsylvania   DAVID VITTER, Louisiana
CLAIRE McCASKILL, Missouri           BOB CORKER, Tennessee
SHELDON WHITEHOUSE, Rhode Island     ARLEN SPECTER, Pennsylvania
                     Debra Whitman, Staff Director
            Catherine Finley, Ranking Member Staff Director

                                  (ii)

  





























































                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Senator Gordon H. Smith.....................     1
Opening Statement of Senator Herb Kohl...........................     3
Opening Statement of Senator Ron Wyden...........................     4
Opening Statement of Senator Susan Collins.......................     5
Opening Statement of Senator Bob Corker..........................     6
Opening Statement of Senator Claire McCaskill....................     6
Opening Statement of Senator Norm Coleman........................     7
Opening Statement of Senator Ken Salazar.........................     8
Opening Statement of Senator Blanche Lincoln.....................    18
Opening Statement of Senator Sheldon Whitehouse..................    20

                                Panel I

Robert Dole, Former United States Senator, Washington, DC........     9

                                Panel II

Michael Shepherd, senior physician, Office of Healthcare 
  Inspections, Office of Inspector General (OIG), Department of 
  Veterans Affairs, Washington, DC...............................    24
Larry Reinkemeyer, director, Kansas City Office of Audit, Office 
  of Inspector General, Department of Veterans Affairs, 
  Washington, DC.................................................    32

                               Panel III

Steven R. Berg, vice president for Programs and Policy, National 
  Alliance to End Homelessness, Washington, DC...................    48
Fred Cowell, associate director of Health Policy, Paralyzed 
  Veterans of America, Washington, DC............................    60
Mark S. Kaplan, professor of Community Health, Portland State 
  University, Portland, OR.......................................    74

                                APPENDIX

Prepared Statement of Robert P. Casey............................    97
Responses to Senator Smith's Questions from Dr. Shepherd.........    98
Responses to Senator Smith's Questions from Larry Reinkemeyer....    99
Responses to Senator Smith's Questions from Mark Kaplan..........   100
Letter from Department of Veterans Affairs, Washington, DC.......   102

                                 (iii)

  


          VETERANS' HEALTH: ENSURING CARE FOR OUR AGING HEROES

                              ----------                              --



                       WEDNESDAY, OCTOBER 3, 2007

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 11:48 a.m., in 
room 325, Russell Senate Office Building, Hon. Gordon H. Smith 
(ranking member of the committee) presiding.
    Present: Senators Kohl, Wyden, Lincoln, Salazar, McCaskill, 
Whitehouse, Smith, Collins, Coleman, and Corker.

  OPENING STATEMENT OF SENATOR GORDON H. SMITH, RANKING MEMBER

    Senator Smith. Good morning, ladies and gentlemen. We 
welcome you all to this hearing of the Senate Special Committee 
on Aging.
    Our Chairman is the senator from Wisconsin, Herb Kohl. The 
way that he and I have operated is he is the boss. I was in the 
last Congress, but we don't, frankly, much see that 
distinction. Each of us are able to call hearings.
    Our tradition is to work in a bipartisan way and focus on 
issues critical to aging Americans. Today we are going to focus 
on the ongoing and critical needs of our new and of our aging 
veterans and their physical and mental health needs.
    So to that end, we will begin. I will offer an opening 
statement. Our Chairman will do that, as well. We will have 5-
minute opening statements for others who wish to give them.
    There is no greater obligation than caring for those who 
have served this country with their military service. We would 
be remiss if we did not ensure that the health care of our 
heroes in arms is the finest medicine has to offer.
    While much of the focus in the media has been centered on 
the state of health care for our returning vets, it is the 
responsibility of this Committee to not forget those who have 
served in wars past.
    It was exactly 3 months ago today when, in Oregon, Senator 
Wyden and I chaired a hearing on the topic of veterans' health. 
At that time, we looked at the provision of mental health 
services for aging veterans. While that will remain a focus of 
today's discussion, we will also look forward to hearing 
testimony on all aspects of veterans' health care.
    As I made clear in July, we must ensure that our aging 
veterans are not left behind.
    In our Nation today, we have nearly 24 million veterans, 
about 40 percent of whom are 65 years and older.
    I think many of us have probably watched the Ken Burns 
series ``The War.'' If you have, you have a fuller 
understanding of just how much we owe to the greatest 
generation. Our first witness is more emblematic of that 
generation than perhaps any American that I know.
    The Veterans Health Administration serves about 5.5 million 
of them each year and employs 247,000 employees to attend to 
their care. I draw attention to these numbers to emphasize not 
only the scale of the system and, therefore, the noted 
difficulties in meeting all the needs at all times in such a 
large system, but also to reiterate that there are large 
numbers of veterans to whom we owe an enormous debt.
    We also know that too many veterans are falling through the 
cracks.
    Today, we will hear from the Department of Veterans Affairs 
Office's inspector general that wait times for outpatient care 
are actually longer than have been reported by the department. 
This report is important as we work to ensure that veterans, 
particularly those with time-sensitive health needs, are seen 
quickly.
    Today, we will also hear about the numbers and needs of 
homeless veterans in our Nation. We know that nationally 23 
percent of all homeless persons are veterans. In Portland, OR, 
that number could be as high as 30 percent. They suffer 
disproportionately from poor health, including mental health 
and substance abuse challenges.
    We are fortunate to have wonderful community-based groups, 
such as the Central City Concern, in Portland working to help 
those who are homeless to get the help and support they need. 
But we must do more.
    We will also hear today about the risks of suicide for our 
Nation's veterans.
    As reported earlier this year by Dr. Kaplan from Portland 
State University, and subsequently in various news reports, 
veterans in our Nation are at twice the risk of suicide as 
nonveterans. With the number and needs of our veterans ever-
increasing in our Nation, we must ensure that our mental health 
infrastructure is prepared to handle their unique needs.
    I will continue to work with the Department of Veterans 
Affairs, the Department of Defense, the Substance Abuse and 
Mental Health Services Administration, and our community-based 
mental health network to ensure that the needs of our veterans 
are met.
    I know that SAMHSA and the VA earlier this year worked to 
address the unique needs of veterans who call the National 
Suicide Hotline. For instance, when veterans call the hotline, 
they will be linked to professionals who specialize in the 
needs of veterans. Since the implementation in July, there have 
been nearly 8,000 calls made by veterans looking for a 
lifeline, including 177 from my home State of Oregon.
    I also look forward to hearing testimony on the needs of 
our aging veterans as it relates to long-term care.
    We know that in our Nation almost two-thirds of people 
receiving long-term care are over age 65, many of whom are 
veterans. We also know that this number is expected to double 
by 2030.
    There are many demands and constraints on the VA system, as 
well as Medicare and Medicaid, to ensure that aging veterans' 
health needs are being met. To better understand this need, we 
will first hear from Senator Bob Dole after my colleagues give 
their opening statements.
    Bob Dole is a friend of mine and a great American patriot. 
Senator Dole served and was injured twice in World War II while 
serving in Italy. For those injuries, he was hospitalized for 
more than 3 years.
    He was a distinguished legislator in this body and in the 
House for many years, where he was a strong supporter of 
veterans' issues, including a pivotal role in the creation of 
the World War II Memorial on our National Mall. Most recently, 
he served as Co-Chair of the President's Commission on the Care 
for America's Returning Wounded Warriors.
    I have only known Senator Dole to speak from his heart on 
these issues. I look forward today to hear his personal story 
and recommendations on how we on the Aging Committee can do a 
better job to facilitate in this great effort.
    With that, our Chairman, Senator Kohl.

        OPENING STATEMENT OF SENATOR HERB KOHL, CHAIRMAN

    Senator Kohl. I thank you, Senator Smith, for holding this 
important hearing. Ensuring quality care for our Nation's 
veterans both young and old is of great importance to 
everybody. So we welcome our witnesses and look forward to your 
testimony.
    In combat our veterans sacrifice their physical and mental 
wellbeing in order to defend our Nation and its values. In 
return they deserve the highest standard of care from our 
government.
    The war in Iraq is creating a new generation of veterans, 
many of whom are in need of critical care. They are joining the 
ranks of older veterans who have survived wars of the past and 
are still in need of, and certainly deserving of, our 
attention. Unfortunately, some of them are simply not getting 
the care they need.
    Scandals such as the deteriorating conditions at Walter 
Reed Army Medical Center demonstrate just part of the problem. 
We must also consider the broader faults in the system of 
veterans' health care.
    Recent reports--notably, the President's Commission on Care 
for America's Returning Wounded Warriors and the DOD Task Force 
on Mental Health--have documented complex bureaucratic 
processes and limited communication between government agencies 
that have allowed too many veterans to fall through the cracks.
    These problems have been around for a long time. They will 
not yield to easy fixes.
    While we work to improve treatment and health care for our 
veterans' bodies, we have also learned that it is just as 
important to treat their minds. Too many of our bravest men and 
women are suffering silently from mental health problems which 
can lead to personal struggles, homelessness, and even suicide.
    We have heard a great deal about how these problems affect 
the veterans returning now from Iraq and Afghanistan. But we 
certainly should not forget that for many of our older veterans 
time has not erased their mental battle scars. Our hope is that 
it is certainly not too late to help them.
    We are very pleased that our former Senate colleague, 
Senator Bob Dole, is here to share his thoughts on these 
issues.
    We welcome you back, Senator Dole. I have the fondest 
recollections of the time that we spent together. As I told 
you, I have the greatest respect for your service. We are very 
pleased that you could join us.
    We thank also of our witnesses for participating.
    I would like to remain for the entire hearing, Senator 
Smith, but I am Chairman of the Antitrust Subcommittee, which 
is having a hearing as we speak. So I am going to have to----
    Senator Smith. We will carry on in a bipartisan fashion. In 
that spirit and with your permission, we will go in this order: 
Senator Wyden, Senator Collins, Senator Corker, Senator 
McCaskill, Senator Coleman, Senator Salazar. I think that is 
the order of arrival.
    Senator Wyden.

             OPENING STATEMENT OF SENATOR RON WYDEN

    Senator Wyden. Thank you, Senator Smith. I want to commend 
you for this follow up on the very important hearing we held at 
home. I especially appreciate the bipartisan cooperation we 
have always had on this Committee with Senator Kohl.
    In our home state, from the woods of central Oregon to the 
streets of downtown Portland, older veterans are needlessly 
suffering because the veterans' health system has let them 
down.
    In the woods in our state, the veterans have had to 
establish camps trying to find a way in the woods to get by. I 
don't see how anyone can argue that having veterans try to get 
these kinds of services through camps in rural Oregon is 
acceptable in 2007.
    In the city, my state has worked with a number of older 
veterans who have drug problems. They have been able to get 
clean. But then they go into these extraordinarily long waiting 
lines for housing, which is representative of the bureaucratic 
water torture that our veterans are submitted to.
    Senator Dole is with us here today. He has really been a 
role model for a lot of us because he has shown on these key 
kinds of health issues that it is possible to bring together 
your head and your heart and to think sensibly about how to 
tackle the issues.
    Senator Dole, your report, as is always the case with your 
work, is chock full of useful recommendations. But I am 
especially pleased that you and Secretary Shalala have come up 
with this idea of a care coordinator. I think that is going to 
be especially helpful for the older veteran because, as Gordon 
and I got about the state and listened to veterans, we 
especially found the older veteran getting lost in this health 
care system.
    So your suggestion about the idea of a care coordinator, 
where somebody would actually be held accountable and the 
veteran wouldn't just be jostled from one place to another, is 
especially sensible.
    So we thank you, once again, for your contributions, 
something you have done again and again throughout your time in 
public service. I am just glad to have you here.
    I am an Oregonian now, but you and I will always have our 
Kansas roots. I thank you.
    Senator Smith. Thank you, Senator Wyden.
    Senator Collins.

           OPENING STATEMENT OF SENATOR SUSAN COLLINS

    Senator Collins. Thank you, Mr. Chairman. First, let me 
thank you for calling this hearing to examine the many 
challenges facing our Nation's older veterans and to consider 
possible policy changes that are necessary to ensure that 
veterans receive high-quality health care.
    Like the rest of my colleagues, I am absolutely delighted 
that Senator Dole is our leadoff witness today. He not only 
knows from personal experience the challenges that our veterans 
face, but I can't think of someone who has a greater knowledge 
of how the Congress works, plus how the veterans' health care 
system works, than Senator Dole.
    So he is indeed the ideal leadoff witness for this hearing. 
He is a person for whom all of us have the greatest admiration.
    So it is great to welcome you back, Senator Dole.
    My work on the Senate Armed Services Committee has only 
served to heighten my personal admiration for the men and women 
who wear the uniform of this country.
    Throughout our history, our Nation's veterans have done 
their duty with honor and with great dedication. For their 
sacrifices, we can never fully repay that debt that we owe 
them.
    But I also have a very deep personal connection to our 
veterans.
    My father is a member of the greatest generation. He is a 
World War II veteran who fought in the Battle of the Bulge. He 
was wounded twice and has a Purple Heart, Bronze Star, and Oak 
Leaf Cluster.
    Like so many veterans of his generation, he never talked 
much about the service that he rendered to our country. It was 
only now, as he has gotten older, that he has begun to share 
those stories with us and with his fellow veterans. But he was 
always very proud of that service.
    As I have gotten older I have appreciated even more his 
sacrifice and patriotism, so typical of those of that 
generation, so typical of those like Senator Dole.
    In the State of Maine, which is a large, rural state, we 
face two particular challenges in providing health care to our 
veterans. They both really have to do with access to health 
care.
    The first is transportation so that our elderly veterans 
are able to get to the one veterans' hospital that we have in 
our state. It is the Togus Hospital in Augusta. It is an 
excellent facility. But for some of our veterans, it is as far 
as 5 hours away.
    The second challenge has been funding, funding not only for 
Togus to ensure that it has the specialists that many of our 
veterans need so that they don't have to travel even further to 
the Boston area to get the care they need, but also funding for 
community-based outpatient clinics. These clinics are 
enormously successful because they provide much closer access 
to health care for our veterans.
    The ones that have been established work very well. But 
there are many that have been on the drawing board for a long 
time, delayed from opening due to funding constraints.
    I noticed Senator Salazar is here today. I was very pleased 
to co-sponsor last year a Veterans' Ride Bill that he developed 
to establish a grants program to help veterans travel to 
appointments at our VA clinics and our VA hospital.
    But I think transportation and funding are the two biggest 
challenges that I see for providing this care.
    So again, thank you, Mr. Chairman, for holding this 
hearing.
    Senator Dole, what an honor it is to have you here today.
    Senator Smith. Thank you, Senator Collins.
    Senator Corker.

            OPENING STATEMENT OF SENATOR BOB CORKER

    Senator Corker. Mr. Chairman, thank you for holding this 
hearing.
    We are honored to have Senator Dole, who can help us with 
this issue, help introduce it, help us be focused on it the 
right way.
    He also, I think, can help us with civility in the Senate 
in general. We were talking a little bit about that before we 
began.
    But in order to be able to hear him today, I am going to 
withhold any comments and questions until after the testimony, 
but thank you.
    Senator Smith. Thank you, Senator Corker.
    Senator McCaskill.

         OPENING STATEMENT OF SENATOR CLAIRE MCCASKILL

    Senator McCaskill. Thank you, Mr. Chairman.
    I am always self-conscious when we all talk before a 
witness testifies, but somehow I have a feeling you understand, 
Senator Dole, about the need of all of us to say a few words 
before we begin. I want to welcome you and thank you for all 
you have done for our country.
    As you well know, I am your neighbor. I will tell you one 
thing.
    When I was being brought up in Columbia, MO--both of my 
parents being graduates of Mizzou--my father told me, without a 
smile on his face, that I could go to college anywhere I wanted 
to go, but if I went to KU I had to pay for it myself. 
[Laughter.]
    So with the one exception of the rivalry between the 
Jayhawks and the Tigers, I am a big fan of yours and welcome 
you here today.
    When I did my veterans tour back on the week after Memorial 
Day, I traveled all over the state. I was blessed to have the 
opportunity to visit with hundreds and hundreds and hundreds of 
Missouri veterans of all ages. I was struck by that when I went 
to Iraq about a month later because in every unit I visited, I 
saw some variation of the theme leave no fallen comrade behind.
    I reflected on the ethic that imbues our military about 
taking care of one another; taking care of your unit. I 
realized what an incredible lonely and solitary journey it must 
be, particularly for those men and women who come home with 
mental health issues.
    After you have been surrounded by this all-enveloping 
culture that it is about taking care of one another, you all of 
a sudden are facing an incredibly lonely time. The stigma 
associated with it can be almost as paralyzing, I think, as a 
physical paralyzation.
    I think it is so important as we move forward that we be 
very aggressive reaching out in giving these men and women the 
kind of moral support and the kind of bureaucratic support 
within this bureaucracy that removes the loneliness from that 
journey and works very hard on the stigma. I think so much of 
your work on the commission will go toward that end.
    I am also anxious to hear from the other witnesses today, 
particularly the IGs, about some of the internal problems we 
have within Veterans Affairs in terms of the bureaucracy. I am 
particularly offended by this game they are playing with 
waiting lists.
    You know, we owe our veterans a lot, but we sure owe them a 
straight shot in being truthful with them about how long they 
are going to have to wait to see a doctor. This idea that we 
are playing games with waiting lists to try to make us look 
better is so offensive, I think, to the military and what they 
mean to our country.
    So I thank you for being here today. I look forward to your 
testimony and the testimony of the other witnesses.
    Senator Smith. Thank you, Senator McCaskill.
    Senator Coleman.

           OPENING STATEMENT OF SENATOR NORM COLEMAN

    Senator Coleman. Thank you, Mr. Chairman.
    Mr. Chairman, I would like my full statement to be entered 
into the record and----
    Senator Smith. Without objection.
    Senator Coleman. Let me just say one brief comment, because 
I look forward to hearing Senator Dole's testimony.
    I recently buried my dad in Arlington Cemetery just less 
than a couple of months ago. He was a veteran of World War II, 
on the beach in the early morning hours of D-day at Normandy; 
like Senator Collins' dad, was at the Battle of the Bulge, 
wounded, received his Purple Heart there.
    My dad and his generation--and, Senator Dole, your 
generation--experienced the Depression, world war, holocaust, 
defeated two isms--fascism and communism--and came back with 
this unbridled optimism that has given us the opportunity to 
have all that we have.
    For that, we say, ``Thanks.'' For that, we owe you and 
those who have served a debt of gratitude. We owe you and those 
who you speak for a system in which there aren't waiting lines, 
in which there is adequate mental health facilities.
    I just want to thank you for being a voice for so many 
whose voices have been stilled by time and circumstance.
    Senator Dole is a patriot. He is a great American.
    Senator, I thank you for your service. I look forward to 
your testimony.
    Senator Smith. Senator Salazar.

            OPENING STATEMENT OF SENATOR KEN SALAZAR

    Senator Salazar. Thank you very much, Senator Smith. I just 
want to thank Chairman Kohl for also holding this hearing on 
veterans' issues.
    I will just change chairs. [Laughter.]
    Let me just begin first by thanking both Senator Kohl and 
Senator Smith for holding this hearing. It is truly an example 
of bipartisanship here in the Senate that I am very proud of.
    Second, to you, Senator Dole, we are all very, very proud 
of you. I think, when we look at you, most of us are in that 
generation where we know that we have stood on your shoulders 
and the shoulders of our parents. In the same way that Senator 
Coleman and Senator Collins were talking about their parents, 
I, too, could talk about both my father and my mother and their 
efforts in World War II. So we appreciate your service to our 
country.
    The issues of veterans for us are very important. It is not 
a Democratic or a Republican issue. It is an American issue.
    For me and my service on the Veterans' Committee for the 
first 2 years that I was in the Senate, there were a number of 
issues that I was very concerned about. Hopefully, during your 
testimony you might address a few of those issues.
    The first of those had to do with rural veterans and the 
disparity of health treatment and health care availability to 
veterans in rural areas in comparison to those in urban areas. 
Then-Undersecretary Perlin had done a very comprehensive study 
that demonstrated the huge disparity that existed in terms of 
health care treatment for veterans in far-away places in rural 
areas and those in urban areas.
    In my state, we have tried to address some of those issues 
over the last several years with community-based outreach 
clinics and have had some success there. But I continue to 
believe that that disparity still exists.
    Second, there is an issue of long-term care. In my view, I 
do not believe that the VA has done an adequate job in terms of 
putting together a long-term care plan for our veterans, for 
our Nation. It is something that I have legislation which has 
been passed which has directed the VA to develop a plan with 
respect to long-term care.
    Then third, an issue which has been very hot here in 
Washington, DC, but it is a very real issue that some of my 
colleagues have addressed, and that is the issue of mental 
health. Especially now with the bulge of veterans that we will 
see from Operation Iraqi Freedom and Operation Enduring 
Freedom, it is going to be important for us to make sure that 
we are doing what we have to do with mental health care.
    Finally, let me just once again echo my thanks to you and 
the pride that we have in people like you who have really shown 
us the way here in America. Thank you.
    Senator Smith. Thank you, Senator Salazar.
    Senator Dole, I have been given a long introduction, but I 
don't think you want to hear it. We all are here in part as a 
reflection of the esteem in which we hold you. We thank you for 
being here and for being patient to hear us out, as well. We 
are anxious to receive your testimony.

    STATEMENT OF FORMER SENATOR ROBERT DOLE, WASHINGTON, DC

    Senator Dole. Well, thank you very much. Herb had to leave. 
Mr. Chairman had to leave, but I appreciate all your 
statements.
    I know all of you. You are all doing a great job. This is 
one Committee where you can come in and have a bipartisan 
meeting and agreement and everybody leaves thinking, you know, 
we have done the right thing.
    I think before I--I don't have a very long statement, which 
I read to Elizabeth last evening. She is a member of the 
Committee, and she approved it. I said, ``Well, you don't have 
to come then,'' so---- [Laughter.]
    Senator Dole [continuing]. I gave her an excuse.
    But the one thing that I think--there are a lot of 
problems. Secretary Shalala, I must say, is the original 
Energizer bunny. I mean, she is doing something every second.
    We work very well together and never got into any political 
differences. We didn't even know the politics of the other 
seven of members.
    Of the other 7 members, 2 were Iraq veterans--1 who lost an 
arm, 1 who had a badly damaged leg--another was the wife of a 
husband who had burns on 70 percent of his body, and then the 
other was Ed Eckenhoff, who directs the National Rehabilitation 
Center, who has a very difficult problem.
    So there are 5 out of the 9 with disabilities. So we 
understood a little about what we were supposed to do. We 
relied a lot on these younger veterans.
    But the point I want to make right up front--I mean, there 
are so many negative stories about DOD and Walter Reed and the 
VA. The one thing that we found almost without exception is 
that these patients--young, old, men, or women--would brag 
about their doctors, brag about their nurses, brag about their 
therapists. The care was good or excellent. It was after you 
get into the outpatient category, when you start trying to make 
appointments and things of that kind, that we found 
difficulties.
    Now, Walter Reed is a great hospital. I have been going 
there for 30-some years as a patient and to visit other 
patients.
    Building 18 was a facilities problem, but it was a 
disaster. The Washington Post story kind of was a wakeup call. 
Certainly everybody is focusing on veterans and veterans' 
health care, which is a good thing.
    But I think the morale sometimes of these hardworking 
people in the VA hospitals--I know at Walter Reed because I 
have talked to some of the professionals--is sort of down 
because they read the stories and they watch television. The 
inference is that, ``I am not taking care of this young man or 
this older man or this older woman or young woman.'' That is 
certainly not the case. I know none of you--I think you all 
agree that it is not the case.
    The individuals, for the most part, in the Veterans 
Administration and all the DOD facilities are just good, 
hardworking men and women doing a job, trying to help our 
veterans.
    That doesn't mean there aren't some mistakes or 
bureaucracies.
    You go out to Walter Reed or you go to a VA hospital for a 
better example and you see people lined up for hours waiting 
for their drugs. They like the program. The formulary is not 
really--could be bigger--but it is a great program.
    So we traveled all over the country. We only had 4 months. 
We went to the different VA and DOD facilities and talked to 
the patients away from the doctors so there wouldn't be any 
intimidation--perceived intimidation. I want to report to this 
group that there may be some--obviously there are some--but 
very few would say anything but good things about their 
treatment.
    We wanted to make certain that Walter Reed was in A-1 
condition until somebody finally turned off the lights 3 or 4 
years from now. So one thing we did is to urge Congress to 
offer incentives to contract doctors or other staff, military 
or whatever, to keep them there until Walter Reed finally 
closes, because 27 percent or 28 percent of those who come from 
Iraq or Afghanistan, their first stop is Walter Reed. So it has 
got to be kept an A-1 facility. We can't let it diminish to any 
extent at all.
    Well, anyway, I feel at home here before the Aging 
Committee. I know I am the oldest one here. Every day I feel 
more qualified to be here.
    But I am reminded this morning of the words of General 
George Marshall who, during World War II, was asked if America 
had a secret weapon that would ensure a victory. ``Yes,'' he 
said, ``America does have a secret weapon. It is the best darn 
kids in the world.'' What was true in World War II has been 
true ever since in places like Korea and Vietnam and 
Afghanistan and Iraq and the Gulf crisis.
    So we remain free and we remain strong because there are 
always the young men and women out there willing to make 
sacrifices for the rest of us. Today, most of us the only 
sacrifice you make is getting on an airplane and that is about 
it. But the families make sacrifices and obviously the young 
men and women who are injured or wounded make sacrifices.
    I think whatever you think of President Bush and whatever 
you think of war--we didn't get into that in our Committee--but 
the President told us--told me and Secretary Shalala--he said, 
``Do whatever it takes.'' We never had raised any question 
about the cost.
    Now, I don't think our recommendations are perfect. We have 
only had 4 months. We are already getting a little push back in 
certain areas from certain veterans' groups, and that is to be 
expected. But we think overall, you know, it is a good, 
balanced program.
    One thing that Ron mentioned--excuse me, Senator Wyden 
mentioned--was the care coordinator.
    Now, you know, we were limited to Iraq and Afghanistan in 
our charter. But I think it is a good idea to expand it to the 
older veterans. That program is already started.
    They already started training these care coordinators on 
October 1. So the Administration is moving quickly in the areas 
where they should move quickly.
    I met a young man on our commission, Jose Ramos, who lost 
an arm above the elbow. He did a lot of work in the disability 
area. He had so many caseworkers he couldn't remember their 
names.
    That is where, you know, if somebody meets you at the door 
at Walter Reed when you come here, whether you are wounded, 
sick, whatever, and if you are in serious condition and a care 
coordinator meets you at the door and follows you all the way 
through--they may have two or three others, too--but they 
follow you all the way through to the time you go back to your 
unit or the time you go back to the farm or back over to the VA 
or wherever it may be. That will make a big, big difference 
when it comes to efficiency.
    Most of our complaints were people waiting for appointments 
and then having them delayed.
    Another thing that Ken mentioned, the fact that--the rural 
areas--I think it is very important. One thing we stress in 
this--and you have, I think Norm mentioned, too--rural areas.
    You know, it is a long way to a VA hospital in states like 
Colorado, Minnesota, even my State of Kansas, Missouri, 
wherever. We stress that there should be available to this 
person private-sector care.
    If there is someone, you know, in a city, not Denver, but 
some smaller place closer to this person's home that can 
provide adequate high-quality care, then they ought to have it. 
They shouldn't have to travel 300 or 400 miles to go to a VA 
hospital.
    You know, there may be some in the VA who think, ``Well, 
that may mean we will have fewer patients.'' But we had a 
patient-centered commission.
    We were only concerned about the patient. We were concerned 
about the DOD facilities and the VA facilities. But our primary 
responsibility was what can we do for the patient?
    The care coordinator is a little thing, but it is a very, 
very important thing. I think you have a great idea, if 
Congress will expand it, because there are some older people--
and I said before this hearing started, I visit a lot of VA 
hospitals. I have been to the Portland VA hospital, for 
example, and I have been to a lot of hospitals.
    But you got to think of these men in their 1980's--and we 
are down to about 4.5 million out of 16.5 million--and if they 
are hospitalized, you know, maybe their family's a couple 
hundred miles away. They probably see the person who mops the 
floor and brings in their food and that is about it.
    You know, it is a pretty lonely life. I know there are a 
lot of activities and a lot of people come, but it is still a 
pretty lonely life.
    Anything you can do in those areas to sort of give them a 
life--and there is a little program going on right now that I 
think some of your states are participating in. But it is 
something each of you could start. It is called Honor Flight.
    They would go to Portland, ME, for example, and raise say 
$50,000, charter an airplane, put people like your father on 
this airplane early in the morning. They would fly to 
Washington, visit the memorials, have a boxed lunch at the 
World War II Memorial, and just spend a couple or 3 hours 
there.
    Let us see, I think we have had a group from Missouri. I 
don't think any other--maybe a group from Minnesota. Right. We 
had a group from Minnesota.
    But anyway, it is a great program.
    You ought to see the faces of these 80-, 85-, 90-year-old 
men when they get off that bus or somebody pushes their 
wheelchair and they get into that memorial. Suddenly they are 
thinking about what? I don't know. When they were young, where 
they were in the service?
    You know, it is just a great thing. It doesn't cost them 
one cent. Many could never make the trip because of the cost or 
because of their disability. They can't get on a plane, if, you 
know, they are in bad shape and in a wheelchair.
    So get it on the Web site. It is Honor Flight. Look into 
it. It is a great program.
    It is now in about 18 States. Some fellow who ran a 
laundromat--well, he had several--in North Carolina came up 
with this idea because of his father.
    You know, you talk about making the day for this World War 
II vet, it makes his whole life in some cases.
    Well, I didn't mean to get off on that.
    But we are going to testify before our--Secretary Shalala 
and I--before the Senate Veterans' Committee on the 17th of 
this month. I think the purview of this Committee--I know it 
deals with people what, a little older than the Iraq and Afghan 
veterans? But I think it is important because a lot of these 
things that we recommend will also affect older veterans.
    One thing we do that I think is very important, that 
applies to the Iraq and Afghan veterans, for the first time we 
have a quality of life payment. You know, when you get your VA 
rating somebody may say, ``Well, the quality of life may be 
different,'' but it has never been explicit.
    So there is going to be--when they add up your total check, 
there is going to be a little box there: quality of life. Now, 
if you lose your sight, your quality of life has gone from a 10 
to what, 1, 2, 3? Or any loss of limb or whatever, burns, 
whatever the injury might be.
    We also think it is important when some person leaves the 
service that they have a transition payment, maybe 3 months 
paid, to get back home and get settled and get back to work 
and, you know, get the kids in school; little things.
    We also believe that where you have got a seriously injured 
spouse, the other spouse should have educational benefits, aid 
and attendant care, and respite care so they can take a break.
    These are all things that we didn't apply to Vietnam or 
World War II or Korean veterans or Gulf veterans but, you know, 
they are available.
    The toughest part is in the benefits section. That will be 
the area that I think we need to work out with Congress and the 
veterans' groups.
    But you have got to keep in mind that you are dealing with 
a group that probably hasn't had a uniform on in 60 years. That 
is a long time.
    Now, a few of these guys that come on these Honor Flights 
still can wear their original uniform. They are very proud of 
it, that they haven't changed that much.
    But we just can't diminish our commitment to our veterans, 
whether 24 million, 25 million. Not all of them have a problem.
    I still get a lot of mail from veterans. I spend, I think, 
about 2 hours--I think I can say maybe an hour-and-a-half a day 
answering emails from veterans across the country. Some because 
they have read about the commission or the World War II 
Memorial or they think I am still here. [Laughter.]
    So, you know, we try to send it on to whoever we can, 
probably one of you.
    But there is no doubt about it. The VA can be bureaucratic. 
I am sure that has always been the case.
    We went way back to a commission chaired by General Omar 
Bradley in 19--what, what, 50--I don't know--early 1950's. We 
haven't really changed the system since then. We just believe--
and, again, it is a little beyond the purview of this 
Committee--that it is time to simplify and update this system.
    The young men and women today are going to be the seniors 
of tomorrow. They want to be compensated, don't misunderstand 
me. But they want a life. They want an education. They want an 
opportunity.
    So we sprinkled the educational part with incentives to 
keep people in the program. If you stayed a second year, you 
get a 10 percent increase; a third year, 10 percent more; a 
fourth year, 10 percent more, plus a stipend. So they would be 
able to, you know, really make a contribution.
    But I know you have got some great panels coming up to deal 
with long-term care and homeless veterans and paralyzed 
veterans.
    The PVA does a great job for paralyzed veterans. I do a lot 
of work with the PVA. They are just a great group, as are the 
other VSOs. But obviously they are going to tell you things 
that we didn't get into.
    But the thing we don't want to forget, that somebody--I 
think, Gordon, you said or Herb--just because we are getting 
old, don't forget us. You know, we are still here. We are still 
breathing. We are still watching ``Law and Order''--I know I 
do, or whatever--and things like that. We are still making 
contributions.
    You see some of these fellows at the World War II Memorial 
who are in a wheelchair, and they are in their nineties. The 
fellow yesterday I met from Findlay, OH, 92 years old. I said, 
``Well, you just stay in the chair, and I will get--'' ``Oh, 
no, I am going to stand up.'' He stood up straight as a string. 
He said, ``I am the smartest guy in this group.'' He probably 
was. He had been around longer.
    So that is sort of where we come from.
    We had a good commission. We worked hard. We know it is not 
perfect. We didn't try to overhaul the whole system.
    But we do understand the importance of this Committee 
hearing and what it may mean to, you know, senior veterans, 
because you have got these baby boomers coming along, and we 
are going to have to get ready for them. I think we have got a 
lot of good people on this Committee who put the patient ahead 
of anything else. That is what it is all about.
    If anybody has any questions, I will be----
    Senator Smith. Thank you, Senator Dole.
    To your last point, obviously the focus of this Committee 
is on our older veterans.
    Clearly, we are doing a lot to take care of those coming 
home from Afghanistan and Iraq. We need to do more. But is it 
your view that we will, by taking care of them, the older ones 
will automatically be included, or do we need to put a special 
focus and emphasis that they not be forgotten?
    Senator Dole. I think what you may want to do, if I were up 
here, is go through this recommendation, maybe do a little 
cherry picking, and say, ``Oh, that would be great for, you 
know, World War II veterans.'' It is going to cost money, but 
that is--I have a view that if we spend billions to get them 
there in harm's way, we ought to spend whatever it takes to, 
you know, get them back to as normal as possible.
    But I think there are some of the recommendations, even 
though they are now limited to, I think, people who entered the 
service after 2001, the others can stay in the old system so we 
don't touch the old system. But I think you may find some 
things in there that you might want to apply to World War II, 
Korea, certainly Vietnam.
    Senator Smith. Senator, I have never been in battle. I can 
only imagine its horrors from watching documentaries like many 
Americans have just finished watching about the second world 
war.
    But as a student of history, I am aware that there have 
been many ways to describe post-traumatic stress syndrome. It 
has been called soldier's heart, soldier blues, shell shock, 
battle fatigue. All of these relate to mental health issues.
    Now, we know that, you know, General Patton used to go 
through and slap a soldier occasionally. Clearly, we have come 
a long way since then.
    But I wonder if you can speak to at least your impressions 
as to how we are dealing with battle fatigue now. Are we doing 
it adequately? Does it enjoy----
    Senator Dole. Oh, we spent a lot of time on PTSD and TBI.
    They are different stages of traumatic brain injury. Right 
now, we have four VA polytrauma centers in Richmond and Tampa 
and Minneapolis and Palo Alto, CA, where they sort of 
specialize in TBI treatment.
    They are about 250 severe TBI cases from the present 
conflict. The rate of PTSD claims is probably going to reach 
15, 20 percent.
    I would always ask the question, when we had these people 
in front of the mental health experts, ``If I brought somebody 
in who had PTSD symptoms, would you all reach the same 
conclusion?'' They always told me yes. But I don't know how 
they do that because they are--there may be guidelines that I 
am not aware of you can follow.
    But another thing we recommend is that every 3 years this 
person ought to have a checkup by the VA. That anybody who has 
PTSD symptoms, the VA is obligated to take them whenever it 
happens, if it is 3 years from now, 5 years from now, whatever. 
We think a 3-year review is good because you might find some 
other things the veteran needs help for.
    But we did spend a lot of time on that. It is a big, big 
problem.
    In our generation, it was battle fatigue or see your 
chaplain or whatever. But now it is real. It is out there. 
People have, you know, nightmares and all kinds of experiences.
    Senator Smith. Do you believe that enjoys an equal 
legitimacy with physical wounds?
    Senator Dole. Oh, yes, in the VA.
    Senator Smith. OK.
    Senator Dole. I think our commission was not properly 
named. It was called Wounded Warriors. But you don't have to be 
shot, you know, to be the line of duty, combat-related, 
whatever-injured.
    Senator Smith. Yes.
    Senator Dole. You don't have to get shot. So I thought the 
name of our commission was a little too narrow. But we didn't 
really worry about the title.
    Yes. It is equivalent.
    Senator Smith. OK. That is a very important answer for me.
    Senator Dole. Oh, I mean, what is the difference? I mean--
--
    Senator Smith. Yes.
    Senator Dole [continuing]. If somebody, you know, well, you 
know what--if somebody experiences that, it ought to be treated 
just the same as if it was combat-related, line of duty. It 
ought to be compensable.
    Senator Smith. Nobody says to them, ``Look, you buck it up. 
Get over it.''
    Senator Dole. Yes. Well, that might have been--I think 
there are some who might game the system. Let us be very honest 
about it. You need to caution it. But that is a very small 
number.
    Senator Smith. Yes.
    Senator Dole. It is hard--I am not an expert so I couldn't 
detect it, but the experts can detect it. You may have members 
on the other panels who are experts in that area.
    It is out there. We need to deal with it. The people who 
suffer from it need to be compensated and entitled to all the 
benefits the same as anybody who may have lost an arm or been 
burned or whatever.
    Senator Smith. I just have one other question.
    You mentioned that there are some veterans' groups that are 
disagreeing with some of the recommendations. I wonder if one 
of the disagreements would be the idea of a care coordinator 
that would coordinate----
    Senator Dole. They like that----
    Senator Smith [continuing]. Care in the private sector. 
They like that?
    Senator Dole. Well, they didn't like--initially, we were 
going to have the Public Health Service--Secretary Shalala had 
done a lot of work with Public Health Service, and she thought, 
instead of the VA or DOD doing it, let us get some third party 
that doesn't have any bias. I think VSOs thought that wasn't a 
good idea, thought it would be another layer of bureaucracy. 
They may be right.
    So we decided the PHS would help train the coordinator, but 
it would be a VA person.
    Senator Smith. OK.
    Senator Dole. But you have got to give that person some 
authority, otherwise some colonel's going to come along and 
say, ``You know, get out of here.'' They have got to have 
authority to cut through the----
    Senator Smith. The bureaucracy.
    Senator Wyden.
    Senator Wyden. Let me pick up there, Senator Dole, and as 
always, when we listen to you, you always get the sense Senator 
Dole's being too logical for Washington---- [Laughter.]
    --just coming in here and offering unvarnished common 
sense.
    One of the reasons that I came up with this thought about 
having a care coordinator for older people is that I thought 
that you logically said it is useful for the Iraq and 
Afghanistan veterans. What we have seen in Oregon is that it is 
usually the older veteran who is least equipped to kind of 
navigate all these various, bureaucracies and systems.
    I wanted to get your sense on one point with respect to the 
idea of a care coordinator for older veterans.
    I don't get the sense that this is primarily going to be a 
big ticket financial item. It is primarily an organizational 
challenge, because right now the veteran is supposed to have a 
case manager and, as we heard, various other people to help. 
But it seems so often that one of these systems doesn't 
communicate with the other and then the veteran ends up being 
sort of lost somewhere in the bureaucracy.
    So my thought was, if we could take your idea as it relates 
to Iraq and Afghanistan veterans, apply it to the older, 
person, make sure that there would be one person accountable, 
one person to be the care coordinator, all you would be talking 
about is reorganizing most of what is going on today so that 
somebody would be accountable.
    I think it would be helpful to have your sense about 
whether this is going to be a big expense item because I don't 
get the sense it will be.
    Senator Dole. You know, I hadn't thought of this. But, you 
know, some of these senior men and women have maybe 
Alzheimer's. They really need help.
    I certainly do not denigrate the case workers. I think in 
most cases they do--.
    Senator Wyden. Right.
    Senator Dole. But they get transferred or they----
    Senator Wyden. Right.
    Senator Dole [continuing]. Leave or something, so somebody 
has to pick it up.
    We are not talking about--we think 50 care coordinators is 
what we need right now, 50. I mean, that is not a lot of 
people.
    You can extend that to certain VA cases. You know, most of 
these people they don't need it. They are only hospitalized for 
a while.
    But some are there for 1 year, 2 years, 3 years, 6 months. 
They need help; the families who are there, the spouse or the 
mother. Then you also work with them.
    So, yes, I think it just makes sense that when I go to the 
hospital that somebody is going to watch out for me, not 10 
somebodies, but one person. That doesn't mean that there might 
be cases where they have to move on or something, but rarely.
    Senator Wyden. If I have a----
    Senator Dole. That was Secretary Shalala's thought. She 
just thought it would be a good move, and she was right.
    Senator Wyden. If I am in trouble on the floor of the 
Senate, I am going to bring you and Secretary Shalala out so we 
get this done.
    Senator Dole. Well, we think they need a coordinator for 
the Senate, too. [Laughter.]
    Senator Wyden. Well, there, again, getting logical. 
[Laughter.]
    Thank you for all you have done, Senator Dole.
    Senator Smith. Senator Collins.
    Senator Dole. I don't mean that. You know, I am only 
kidding. [Laughter.]
    Senator Collins. Actually, Mr. Chairman, when Senator Dole 
made that comment, I thought it would take way more than one 
coordinator for the Senate, probably per senator, in order to 
coordinate things.
    Senator Dole, I mentioned in my opening statement my 
concern about access to care in a large rural state like mine.
    I realize that your commission was looking more at the 
problems of the recently returned younger veterans from Iraq 
and Afghanistan. But are there any lessons that you learned 
from looking at that population on how we could improve access 
to care for elderly veterans or senior veterans for whom 
transportation may be much more of an issue?
    Senator Dole. You are exactly right. I mean, when you are 
80, 85 years old, you are not driving. You may not have a 
spouse. Your children may be somewhere. You know, how do I get 
to the VA hospital? We didn't deal with that because we are 
dealing with this younger generation.
    But the thing we did deal with, which should apply to any 
veteran, that if you have a facility say much, much closer to 
you than the VA hospital, that you ought to be able to use it. 
There ought to be authority to use it. That is happened in some 
cases in Afghan and Iraqi veterans.
    The National Rehabilitation Hospital here in Washington, 
DC, is one of the finest in America. They have treated, I 
think, about a dozen Iraq-Afghanistan veterans.
    The Rehab Institute of Chicago, they have had veterans 
who--because they get really excellent care.
    So, yes, the answer is that ought to be available to--you 
know, we don't want to forget these people just because they 
are getting older and say, ``Well, we don't really care about 
them. Let them figure it out.'' If we have to send a taxi, I 
guess that would be all right with me, too; maybe a limo. Why 
not a limo? Yes.
    Senator Collins. Thank you. Thank you for your excellent 
service and your testimony.
    Senator Dole. Thanks a lot.
    Senator Smith. Senator Dole, I just wanted to follow up.
    What are the veterans' groups objecting to so far in your 
commission's recommendations?
    Senator Dole. Well, I am hoping we are going to be able to 
work it out. But one group said we didn't go far enough. We 
didn't go back over the whole system.
    We only had 4 months. So we did limit it to Iraq and 
Afghanistan because that seemed to be where the focus was, 
based on, you know, different stories.
    There is a benefits commission going to report--I thought 
last week; maybe this week--but they pretty much agree with 
ours.
    I think it is when you start dealing with benefits and 
somebody thinks they are going to get a dollar less, that is 
not a good program. Our view was, we don't want anybody to get 
any less, but we also want to stress that we are dealing with 
outcomes where people can be prepared. We had these two young 
men on our commission, both Iraqi-wounded veterans, who worked 
on the benefits section.
    But hopefully we can work it out. We are meeting with all 
the different groups and----
    Senator Smith. So it is nothing we need to be alarmed about 
or----
    Senator Dole. No. But before you introduce a bill, I think 
I would----
    Senator Smith. OK.
    Senator Dole [continuing]. Read it carefully, so---- 
[Laughter.]
    Senator Smith. I apologize, Senator Lincoln. I didn't see 
you come back in. Do you have questions for Senator Dole?

          OPENING STATEMENT OF SENATOR BLANCHE LINCOLN

    Senator Lincoln. A special thanks to you, Chairman Smith, 
for having this discussion today. We do think it is so 
important.
    I am the daughter of an infantryman from the Korean War and 
was taught certainly at a young age how important it was to 
have the respect and appreciation for our servicemen and women.
    I want to thank you, Senator Dole, for coming to speak to 
Arkansans that were in town. What a treat that was when our 
World War II veterans were here and you came down and spoke. 
They had a wonderful----
    Senator Dole. Well, I was just bragging about that program. 
You have been there. You know how the veterans feel after they 
have been here.
    Senator Lincoln. Oh, they are just--it is incredible for 
them to be with one another and to be with fellow servicemen 
like you. It is a wonderful thing.
    Arkansans, and certainly brave men and women all across our 
country, they continue to make these tremendous sacrifices 
today. In my State, thousands, both active duty and reserve, 
have served honorably in Iraq and Afghanistan. Tragically, 74 
have given their lives. I received word of our latest fatality 
just 2 days ago.
    So it is ongoing, and it is heavy on the hearts of the 
families, and in States like Arkansas and all across this 
Nation. My heart grows heavier by the day as nearly 3,200 
Arkansans from our Guard and Reserve will deploy to Iraq 
probably December or right after the first of the year.
    So providing for our men and women in uniform is essential 
when they are in harm's way. But undoubtedly, when they return 
home, it is absolutely our responsibility to provide for them.
    So we thank the Chairman for having this hearing, and, 
Senator Dole, to you for your incredible service, not only 
serving our Nation honorably in uniform, but here in the U.S. 
Senate and yet again your work here with Secretary Shalala.
    My one question to you, sir, would be one of your 
recommendations was to shift more responsibility for awarding 
benefits from DOD to the VA. I share your belief in this that 
it would help streamline the process that has become so 
cumbersome in terms of the bureaucracy for our veterans who are 
applying for disability benefits.
    We are trying to do the same thing here in shifting that 
responsibility for the educational benefits of our Guard and 
Reservists because we are finding that when they come home they 
don't have the time to access.
    I noticed you mentioned that looking for benefits for 
spouse for educational purposes was another recommendation. But 
just making sure that they can get those benefits and having 
them delivered through the VA, as opposed to DOD, particularly 
I would think these disability benefits, but also the 
educational benefits, which we are.
    But as you also well know, in this place and in this city 
the battle for jurisdiction is a great one.
    Have you experienced any pushback on this recommendation? 
Do you have any advice for those of us that are trying to kind 
of circumvent some of that territorial bureaucracy?
    Senator Dole. What we do is get the DOD out of the 
disability business, and they do what they should do. They 
decide whether Gordon Smith is fit for duty.
    But we want to make certain whoever makes that examination 
also--because you can have certain things wrong with you and 
still be fit for duty, which might be compensable under a VA 
rating. So whoever examines Mr. Smith, once he finds he is 
unfit, we are going to have a little checklist to make sure 
that all those things he finds wrong is given to the VA so when 
they make the rating it is based on, you know, accurate 
information.
    There is not much pushback there. I think most veterans, I 
think, feel the VA is a little more generous in their rating 
system. Of course, you have the right of appeal and all the 
other things. But I don't think that is a difficult point.
    But you made another thing that made me realize, which 
probably doesn't come within the purview of this Committee. But 
the hardest thing for the younger generation, the seriously 
injured--and there are about 3,000 in that category, seriously 
injured--is when they leave the hospital and go back to 
Russell, KS, or wherever it is and there are no nurses around 
or doctors or somebody to do this.
    You know, it takes a while for, you know, to really 
understand what you are going to have the rest of your life. 
You can't compensate for that. But we have to do everything we 
can to make, you know, to make it as normal as possible.
    Senator Lincoln. Well, the rural centers that we are 
setting up with the VA are doing a good job at helping in that 
outreach. We just need a few more of them.
    But you are right. That transition is critical. When you 
are going back to rural America, it is hard. You have got to 
have somebody there to help you.
    Thank you.
    Senator Dole. Well, we do a lot more for the--when I was 
wounded and in the hospital, my mother came and nobody--we 
didn't have any money. But somehow she was able to stay there 
and take care of me day after day and even held cigarettes, 
which I shouldn't have been doing and she didn't think was a 
good idea, but I couldn't use my arm, so--but now we make 
certain that person gets there--the spouse or the mother--and 
we relocate them and we take care of them.
    You know, we really do a lot of good things. It is just 
those cases that fall through the cracks. I guess when 25 
million people are involved, that is going to happen. It just 
happens.
    I always tell people who send me emails, if everything else 
fails, and I say this very seriously, you need to contact your 
senator or your Member of Congress because they can sometimes 
work these things out. So----
    Senator Lincoln. Thank you.
    Senator Smith. Thank you, Senator Lincoln.
    Senator Dole. Thank you very much. I appreciate it.
    Senator Smith. Senator Whitehouse has rejoined us.
    Senator Dole. Oh, excuse me.
    Senator Smith. Do you have a question? Or do you have a 
statement you want us to put in the record?

        OPENING STATEMENT OF SENATOR SHELDON WHITEHOUSE

    Senator Whitehouse. One of the things that is notable about 
the Veterans Administration and that it often gets great credit 
for is the extent to which it has adopted modern technologies: 
electronic health records, internal electronic physician order 
entry, and other such technologies. Throughout the American 
health care system, we are way, way, way, way, way behind on 
the adoption of those technologies.
    Not too long ago, The Economist magazine reported that the 
American health care system is second only to the American 
mining industry in being at the bottom of adoption of these 
information technologies.
    It is a little bit peculiar because if you look at the 
diagnostic side, we have the best equipment in the world. We 
have the most astonishing radiology, MRI, other devices. Yet 
when you go to the information management side, we fall to the 
very bottom of all American industries.
    I am wondering if you have any comment on, first of all, 
how effective this investment has been for the Veterans 
Administration, and second, why you think the Veterans 
Administration has shown such leadership in this area and what 
we, as senators, might take from that experience in terms of 
trying to improve the adoption of health information technology 
in other areas.
    Senator Dole. Well, we recognize that IT electronic 
recordkeeping was--the VA probably has the best system in the 
country. I mean, it is the envy of all the private hospitals.
    We had a Dr. Harris in the Cleveland clinic who that is his 
sole responsibility. He came back there and met with Members of 
Congress, with the VA, with the DOD.
    So you can get these--at my age, I don't understand all the 
stuff like you do--but you can get these computers talking to 
each other. If you leave Walter Reed, you leave with a half a 
bushel of paper. If you leave the VA hospital, you have got a 
little tape, I guess.
    But the DOD is doing better. There is improvement. That is 
one of our 6 strong recommendations that we improve electronic 
recordkeeping because we are behind. It means so much if I am 
out in Phoenix somewhere and I get sick and somebody can just 
push a button and they have got everything.
    Yes. We have got a provision. We don't know what it costs. 
But that, again, that wasn't--we didn't have any restraints, so 
that, we think, will bring us up into this century.
    Senator Whitehouse. I thank you, Senator.
    I just want you to know, as a new Senator it is an honor to 
be with somebody who served this institution so proudly and so 
long as yourself.
    Thank you.
    Senator Dole. Thank you. I appreciate it.
    Senator Smith. Senator Dole, before we let you go, for my 
colleagues' benefit and for the record, I'd like to read a 
couple of statements, a couple of paragraphs, from your book, 
``One Soldier's Story.''
    Senator Dole. Oh, yes.
    Senator Smith. Senator Dole wrote:
    I once said that I was the most optimistic man in America. 
It was a phrase reminiscent of Franklin D. Roosevelt, who 
undoubtedly was the most optimistic man in America during his 
lifetime. Deprived of the use of his legs, he had been brought 
through his own personal hell yet continued to hope for the 
best. I could relate to that.
    Today, I am still an optimist. I believe that the greatest 
generation is today's generation. My optimism is based on the 
belief that anyone in America, whatever your race, age or 
status, whatever your strengths, weaknesses or disabilities, 
deserves an equal opportunity to succeed. You can find that 
opportunity in America.
    That is what we fought for in World War II. That is why I 
charged uphill 9-13. That is what some of my friends bled and 
died for. That is what I lived for ever since.
    Thank you, Senator Dole.
    Senator Dole. Thank you. Good luck.
    [The prepared statement of Senator Dole follows:]

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    Senator Smith. We will now call up our second panel.
    We are pleased to be joined by Dr. Michael Shepherd from 
the Office of Inspector General of the Department of Veterans 
Affairs. Today, Dr. Shepherd will discuss the Veterans Affairs 
Office of Inspector General's review of the VA's suicide 
prevention initiatives implementation.
    Also on the panel are Mr. Larry Reinkemeyer, who is the 
director of the Kansas City Audit Operations Division for the 
Office of Inspector General. Today, he will discuss with us the 
Veterans Affairs Office of Inspector General's report on 
outpatient waiting times for care through the Veterans Health 
Administration.
    Why don't we start with you, Doctor, and then we will go to 
Larry.

  STATEMENT OF MICHAEL SHEPHERD, SENIOR PHYSICIAN, OFFICE OF 
  HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL (OIG), 
         DEPARTMENT OF VETERANS AFFAIRS, WASHINGTON, DC

    Dr. Shepherd. Mr. Chairman and members of the Committee, 
thank you for the opportunity to testify today on the issue of 
suicide and veterans in our Nation. Thank you for the 
opportunity and the honor to hear Senator Dole testify today.
    Suicide is an unequivocally tragic and often 
incomprehensible event.
    CDC data indicate there were more than 30,000 known 
suicides in 2004, making suicide the 11th leading cause of 
death in the United States. Although older adults comprised 
roughly 12 percent of the population, those 65 years and older 
represented 16 percent of suicides, with men accounting for 3 
out of 4 suicides in this age range.
    Between 1 percent and 5 percent of older adults living in 
the community are estimated to have major depression. The 
incidence increases among those older adults requiring home 
health care or residing in long-term care settings.
    Although many older adults prefer treatment for depression 
in a primary care setting, geriatric depression is often 
inadequately treated in this setting. Between 50 percent and 75 
percent of older adults who die by suicide have had contact 
with a primary care provider within a month prior to their 
death.
    There are approximately 25 million veterans in the United 
States, and 5 million receive care within the VA. In 2005, 45 
percent of veteran enrollees were ages 65 or over.
    In November 2004, VA finalized the 5-year Mental Health 
Strategic Plan. Among the action items were a number 
specifically aimed at the prevention of suicide.
    In May of this year, the OIG published an assessment of the 
extent to which VA has implemented these suicide prevention 
initiatives. Although we found that most facilities reported 
availability of 24-hour mental health care in person or through 
a crisis hotline, this was not universal throughout the system.
    On July 25 of this year, VA subsequently began operation of 
a national suicide prevention hotline. Through the end of 
August, 56 veteran calls have resulted in emergency rescues, 
and 165 calls resulted in VA hospital admission.
    One of the more extensive efforts that began implementation 
during the last year is the Primary Care-Mental Health 
Integration Program. Two models for primary care-mental health 
integration include co-located collaborative care and a case 
management model.
    The program, in which implementation began last winter, was 
at a handful of sites at the start of our inspection and is now 
presently running at 92 sites. It is hoped that the program 
will reduce stigma and enhance continuity of mental health 
treatment, especially for older adult veterans.
    In terms of referral, although 95 percent of facilities 
reported that patients with moderate depression referred to 
Mental Health by primary care providers are evaluated within 4 
weeks, approximately 5 percent of facilities reported a 
significant 4- to 8-week wait.
    Prior suicide attempts are one of the better predictors of 
at-risk patients. An electronic registry of suicide attempts 
has been piloted in 2 VA health care networks. The aim of the 
registry is to enhance follow up for at-risk veterans and to 
help identify potential VA system issues.
    On a national level, VA has been in the process of 
implementing suicide prevention coordinators at all VA medical 
centers to case manage at-risk veterans. At present, dedicated 
staff are reportedly in place at approximately 85 percent of 
facilities.
    In terms of initiatives related to education, we found that 
half of facilities provide training for first contact 
nonclinical personnel about crisis situations involving at-risk 
veterans. But only one-fifth of these facilities include 
mandatory presentation of suicide response protocols. Likewise, 
though most facilities provide education to health providers on 
best practices for suicide, these programs were mandatory at 
only a small percentage of facilities.
    Included in the recommendations were that VA facilities 
should provide for 24-hour crisis and mental health care 
availability either in person or via a functioning crisis line; 
that all nonclinical staff who interact with veterans should 
receive mandatory training that includes suicide response 
protocols; three, that all health care providers should receive 
mandatory education on identifying and addressing suicide risk; 
and four, that VA should establish a centralized mechanism to 
select among the emerging best practices for screening, 
assessment, referral, and treatment.
    Preventing suicide is a complex, multifaceted challenge to 
which there is not one best practice but several promising but 
not proven approaches and methods.
    VA has made ongoing progress toward implementation of the 
strategic plan initiatives for suicide prevention. However, 
more work remains to ensure a coordinated effort in achieving 
system-wide implementation.
    Mr. Chairman, thank you again for this opportunity to 
testify. I would be pleased to answer any questions that you or 
other members of the Committee may have.
    [The prepared statement of Dr. Shepherd follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Senator Smith. Before we go to Larry, Doctor, I was 
curious. Your final comments there--there is no one specific 
treatment for someone susceptible to suicide.
    Dr. Shepherd. I think there are many determinants. For 
instance, an older adult with major depression may have a 
certain set of needs compared to a young female with borderline 
personality disorder.
    So, there is not one answer for everyone. But it is an 
issue of finding what is considered to be the best possible 
modes and initiatives out there.
    Senator Smith. There are many avenues that work, but for 
different people.
    Dr. Shepherd. Right.
    Senator Smith. Is the reason there isn't one is because we 
haven't discovered it or because people are just different?
    Dr. Shepherd. I think it is a mix of both. People are 
different and have different determinants in what ultimately 
leads to suicide.
    Also, for some of these things, what would be an ideal 
screening tool are in the process of being developed at the 
Rocky Mountain Network in the VA system. The researchers there 
are doing a lot of work developing innovative tools. So they 
are having to essentially come up with those things from the 
start.
    I think the next step is going from there to getting those 
things in place system-wide.
    Senator Smith. Very good.
    Larry.

STATEMENT OF LARRY REINKEMEYER, DIRECTOR, KANSAS CITY OFFICE OF 
  AUDIT, OFFICE OF INSPECTOR GENERAL, DEPARTMENT OF VETERANS 
                    AFFAIRS, WASHINGTON, DC

    Mr. Reinkemeyer. Mr. Chairman and members of the Committee, 
I also thank you for the opportunity to testify on our audit of 
the VHA's outpatient waiting times that we issued on September 
10, 2007.
    Within the Department of Veterans Affairs, the Veterans 
Health Administration, commonly known as the VHA, has the 
mission to provide quality medical care on a timely basis to 
all authorized veterans.
    We performed this audit at the request of the U.S. Senate 
Committee on Veterans' Affairs. Our objective was to follow up 
on our July 2005 audit, where we reported that VHA did not 
follow established procedures when scheduling medical 
appointments, resulting in waiting times and waiting lists that 
were not accurate.
    VHA agreed with the findings and the 8 recommendations 
contained in our July 2005 report.
    The objectives of this audit were to determine whether 
established scheduling procedures were followed and outpatient 
waiting times reported by VHA were accurate, whether waiting 
lists were complete, and whether prior OIG recommendations were 
fully implemented.
    Our results showed the schedulers were still not following 
established procedures for making and recording medical 
appointments. As a result, the accuracy of VHA's reported 
waiting times could not be relied on and the waiting lists at 
those medical facilities were not complete.
    Also, to date, VHA has not taken the necessary actions to 
implement five of the eight recommendations from our July 2005 
report.
    In the Department of Veterans Affairs Fiscal Year 2006 
Performance and Accountability Report, VHA reported that 
veterans were seen within 30 days of their requested 
appointment date for 96 percent of primary care and 95 percent 
of specialty care appointments.
    To test the accuracy of VHA's reported waiting times, we 
selected a nonrandom sample of 700 appointments where VHA 
reported the veteran waited 30 days or less. We found that only 
524 of the 700 veterans were seen within 30 days of their 
requested appointment date, for an error rate of 25 percent. 
This included 78 percent of veterans seeking primary care 
compared to VHA's reported 96 percent, and 73 percent of 
veterans seeking specialty care, compared to VHA's reported 95 
percent.
    These error rates occurred because schedulers were not 
following established procedures when scheduling appointments.
    For example, VHA calculates a veteran's waiting time from 
the requested appointment date, which could either be requested 
by the medical provider or by the patient, to the actual 
appointment date. We found that instead of recording the 
requested appointment date, some schedulers would identify the 
date of the first available appointment and then record that as 
the patient's requested appointment date. This resulted in a 
waiting time of zero days.
    We also found that some schedulers were not following 
procedures for placing veterans on the waiting list. The most 
significant underreporting we identified involved referrals 
from one clinic to another.
    For example, if a veteran's primary care doctor refers him 
to the eye clinic, the eye clinic scheduler has 7 days to act 
on that referral by either scheduling the appointment or 
placing the veteran on the waiting list. This 7-day requirement 
prevents schedulers from creating unofficial waiting lists by 
holding on to referrals for extended periods until an 
appointment slot becomes available.
    Although the 10 medical facilities we reviewed listed a 
little over 2,600 veterans on their specialty care waiting 
lists, we identified over 70,000 veterans who, according to 
VHA's records, had been waiting more than 7 days, did not have 
an appointment, and were not on the waiting list.
    Part of the cause for these error rates was that medical 
facility schedulers were still not getting the necessary 
training to fully perform their job.
    Although we did not investigate whether schedulers were 
intentionally gaming the system, we did find that schedulers at 
some facilities were interpreting guidance from their managers 
to reduce waiting times as instruction to never put the 
veterans on the waiting list.
    Had VHA taken timely action to implement recommendations 
from our July 2005 report, they may have precluded some of 
these same conditions from occurring again.
    The VHA agreed with four of our five recommendations on 
this audit, including routinely testing the accuracy of waiting 
times and the completeness of waiting lists; ensuring consult 
referrals are acted on timely; ensuring all schedulers receive 
required annual training; and assessing alternatives to the 
current process of scheduling appointments and reporting 
waiting times.
    The VHA did not agree to our recommendation to either 
create appointments within 7 days or use the desired date to 
calculate the waiting time for new patients.
    In closing, we maintain that full compliance with 
established scheduling procedures is critical to ensuring 
patients are seen in a timely manner and that no one falls 
through the cracks. In addition to compliance, VHA management 
needs to establish effective mechanisms to ensure data 
integrity. VA and Congress must have accurate, reliable, timely 
information for budgeting and other decisionmaking purposes.
    Mr. Chairman, I thank you again for the opportunity to 
testify. I would be pleased to answer any questions you may 
have.
    [The prepared statement of Mr. Reinkemeyer follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Senator Smith. Thank you, Mr. Reinkemeyer.
    Dr. Shepherd, in your testimony, you state that 
approximately 3 out of 4 veterans seeking mental health 
treatment are Vietnam veterans. Why?
    Dr. Shepherd. You know, everywhere I have gone in the last 
year in terms of VA facilities, I ask the clinicians their take 
on that. I have talked to the people at the National Center for 
PTSD.
    You get a list of theories, among which would be that one 
might be that since the VA instituted universal screening for 
depression and PTSD at primary care appointments, people are 
being picked up who would not have been picked up prior.
    Some people say that perhaps the present war has reawakened 
anxiety or stress that had been dormant.
    Some have mentioned emergence of symptoms in people who 
essentially were workaholics all their lives and just kind of 
lived with their symptoms, they now retire or slow down and the 
symptoms take on a lot more bothersome role in their lives.
    With many aging adults, the co-morbid effect of the onset 
of new physical problems and functional impairments also adds 
to the mental health burden.
    So that is 3 or 4 of among probably a list of 10 theories I 
have heard.
    Senator Smith. Interesting. OK.
    Mr. Reinkemeyer, I want to applaud part of your report 
which notes that approximately 85 percent of VA facilities now 
have an acting suicide prevention coordinator. Is that correct?
    Mr. Reinkemeyer. That wasn't my report. That might have 
been Dr. Shepherd's.
    Senator Smith. I am sorry. That is Dr. Shepherd's.
    Dr. Shepherd. Yes. As of a conversation I had last week, 
approximately 85 percent have suicide prevention coordinators 
in place.
    Senator Smith. What is the next step? How do we get 100? Do 
these coordinators--is it working?
    Dr. Shepherd. From what I understand, for the other 15 
percent of the facilities, they have acting coordinators in 
place. I think they have ongoing recruitment for those 
positions.
    In terms of people I have spoken to at the hotline, the 
coordinators are having an impact. The hotline staffers follow 
up with the suicide prevention coordinator at the facility to 
make sure that the veteran actually did get seen and evaluated. 
Then they are initiating and following up again at 2 weeks to 
see whether the patient got evaluated and then kind of was lost 
to further treatment or has stayed in treatment.
    So I think it is starting to show some benefit. I think 
time will tell.
    Senator Smith. Thank you very much.
    Senator Wyden.
    Senator Wyden. Thank you very much, Mr. Chairman.
    I think Senator McCaskill identified a real priority on 
this wait issue and the question of sort of gaming the numbers. 
I think what I want to do is take it in a little bit different 
direction, although I think what Senator McCaskill has 
contributed is extremely important.
    You IGs talk, has been my experience, Mr. Reinkemeyer. That 
IGs around the country talk. How widespread do you think this 
problem is based on the fact that you looked at a handful of 
facilities?
    Mr. Reinkemeyer. Within the VA----
    Senator Wyden. Yes.
    Mr. Reinkemeyer. I think it is probably pretty prevalent.
    This effort was a short-timeframe audit requested by the 
Senate Committee on Veterans' Affairs in January. So we did not 
do a lot of interviews and questioning on the intentional 
gaming part.
    Having said that, I can tell you that, back in July 2005 
when we did the first report, we did extensive work in this 
area. We sent out a questionnaire to 30,000 schedulers. We had 
15,000 responded. We asked questions such as, ``Have you ever 
been directed by your supervisor to do this?'' Or, ``How would 
you schedule an appointment this way?''
    The first question, if my memory serves me correctly, we 
had about 7 percent or 8 percent of schedulers nationwide that 
said that they were directed by their supervisors to circumvent 
the scheduling process to make sure that waiting times looked 
good.
    So, although I can't answer that now, just by the scope of 
the audit that we just did, I can tell you that procedures have 
not changed all that much. We still found problems with 
schedulers following procedures. So we have no indication that 
some of this is still not going on.
    Senator Wyden. So you find these problems. You think they 
are fairly prevalent. You bring them to the VA. They say what? 
We don't agree with you? What is their response when you bring 
it to them?
    Mr. Reinkemeyer. Well, on the first audit back in July 
2005, we made 8 recommendations. They agreed with the findings 
and all 8 recommendations.
    However, as I said in my statement, five of those have not 
been acted on or have not been implemented yet. You would have 
to talk to the department as to why.
    Senator Wyden. We are going to have to have some spirited 
discussions with them to make sure that they get those 5 done.
    Mr. Reinkemeyer. I can tell you, for this audit they did 
not agree with some of our findings, primarily having to do 
with the methodology. It was not a statistical sample we didn't 
do a nationwide sample for this audit intentionally because of 
the short timeframes.
    But, they have agreed with 4 of the recommendations.
    Senator Wyden. Let me ask you one other one.
    My understanding is that there aren't a lot of statistics 
or good information on some of the groups that have really lost 
services in the past, like priority eight and priority seven. 
Is that your understanding?
    Mr. Reinkemeyer. Yes. I really don't know, the extent of 
the number of priority eight veterans out there.
    Senator Wyden. Yes.
    My sense is that there isn't a lot of good information 
about priority eight and priority seven folks who are being 
turned away. The statistics we have that several million 
veterans, 2 million veterans, can't access care at all may not 
even be reflected in the VA statistics. We may not even have 
our arms around an accurate number of veterans who we ought to 
be thinking about.
    Is that generally a point that you would share?
    Mr. Reinkemeyer. I really couldn't speak to that. I think 
the department could probably address that.
    I know we have not done any work looking at----
    Senator Wyden. You have not done any work.
    Mr. Reinkemeyer. We have not done any work looking at the 
number of priority eights, for example, that are out there and 
not receiving treatment.
    Senator Wyden. Well, I am going to let Senator McCaskill 
continue to prosecute this cause of making sure the gaming 
issue gets addressed because my sense is one, it is pretty 
prevalent, and two, based on some issues relating to whether we 
are getting numbers on priority seven and priority eight. If 
anything, I think we are underestimating the number of folks 
that are getting lost and getting denied services.
    So I thank both of you for your good work.
    Doctor, we will spare you because I think Senator Smith 
covered it very well.
    We appreciate both of you and your professionalism.
    Senator Smith. Senator McCaskill.
    Senator McCaskill. Thank you, both, for being here. It 
doesn't get much better than an auditor from Kansas City, Mr. 
Reinkemeyer.
    Mr. Reinkemeyer. Especially one from Jefferson City, so I 
was a Tigers fan.
    Senator McCaskill. Two near and dear things to my heart.
    I have reviewed an awful lot of GAO reports in preparation 
for this hearing. I want to take a minute to reference one of 
them that really got my attention from both of your 
perspectives within the IG system, within Veterans. That is a 
GAO report dating back from 2001 concerning the VA nursing 
homes and the reality that the nursing home inspections of the 
VA-operated nursing homes, unlike any other nursing home 
inspections done by CMS, are not available to the public.
    I wondered if you all were aware of that, and if that is 
something that internally has been discussed in the IG 
community.
    The interesting thing in this audit back in 2001, the VA 
said, oh, they had a plan to begin to look--you know, there are 
three different types of nursing homes that VA uses. One is the 
community nursing homes they contract with, one is the state-
owned nursing homes that are owned by the various states, and 
then the vast majority of the average daily census in these 
veterans' nursing homes are actually VA-operated nursing homes.
    Now, understanding that the community-based and the--in 
most instances--and the state-based are getting very thorough 
CMS inspections for quality of care issues, and all of those 
inspections are public records. The state facilities are also 
getting--and the community facilities--are also getting state 
surveys and inspections. Those are indeed public records.
    But for some reason, the VA nursing homes do not have any 
public review of the inspections of these homes.
    I know that there are waiting lists for them. I know the 
kind of pressure that is on health care workers in that 
particular segment: long-term care. That the quality issues are 
a real problem in terms of care.
    I was wondering, you know--and the thing that is really 
frustrating is, like so many of the GAO reports, you know, the 
response from the agency is, ``Oh, we are on it. We are 
planning that. We are fixing all that.'' Of course, here were 
are in 2007 and my staff made inquiry and nothing has changed. 
That, in fact, they still are not using the CM--and, by the 
way, they should be relying on these CMS inspections.
    They should allow--I mean, this system is very thorough, 
and it is, you know, public. People who are putting people in 
nursing homes, loved ones, can look at these reports and 
determine whether they believe this is a quality facility.
    I was curious if either one of you are aware of this or if 
there has been any discussion within the IG community to take a 
more in-depth look at this in the near future.
    Dr. Shepherd. I was unaware of that. If I may, I would like 
to respond in the record after I educate myself more on to what 
extent VA does look at its own nursing homes and not just the 
extent but with what quality.
    Senator McCaskill. Well, I would--Mr. Reinkemeyer?
    Mr. Reinkemeyer. Yes.
    From an audit perspective, we have looked at nursing homes 
in the past but typically it would have to do with rates. What 
are we paying? What are we getting? Those aspects.
    I know health care, which Dr. Shepherd is a part of, they 
will look at the quality of care aspect and maybe have looked 
in the past at why inspections are not visible. Certainly, as 
Dr. Shepherd indicated, he can, prepare a statement for the 
record later.
    I just have not been the--Office of Audit typically will 
look at the contract side of it.
    Senator McCaskill. Well, I would appreciate a response for 
the record.
    I will follow up with that, Mr. Chairman, because I think 
this Committee would be a good place to look at that issue, 
particularly if we look at why in the world will they not make 
these reports public? I can't imagine what a good answer would 
be.
    It seems to me that ought to be something--we are always 
looking for something we can actually get done around here. You 
know, because we can talk about things until we are blue in the 
face, but getting things done is a whole other matter.
    It seems to me this ought to be low-hanging fruit that we 
ought to get accomplished for the veterans and their families. 
They ought to be able to look at the quality of care in these 
homes based on thorough inspections that are done on an ongoing 
basis.
    I would hope that if you determine that what I have stated 
today is, in fact, accurate, that the IG's office would also 
take a look at this issue. Maybe between the IGs and this 
Committee, we can change that on behalf of the veterans and 
their families that are looking at nursing home care.
    Thank you, Mr. Chairman.
    Senator Smith. Thank you, Senator McCaskill.
    Senator Lincoln.
    Senator Lincoln. Thank you, Mr. Chairman.
    Dr. Shepherd, as I mentioned earlier with Mr. Dole, we have 
got about 3,200 Arkansas National Guard and Reservists which 
will be deploying for Iraq after the first of the year. It will 
be their second deployment in 3 years.
    One of the issues we have brought up in the debate under 
SCHIP is the kind of care that these Guard and Reservists look 
to for health care when they return home and after they have 
been home. We have a number that depend on SCHIP for their 
children. I was disappointed to see the president's veto of 
that.
    But given that the National Guard soldiers only have access 
to TRICARE for a limited time upon their return from service, 
and given that some of the symptoms of PTSD and TBI may not 
become apparent right away, maybe you can let us know what 
safeguards are in place to provide for the mental health care 
needs of our citizen soldiers, as well.
    Do you feel that our military and veterans' health care 
system are properly taking into account the increased service 
of our reserve components? we are seeing a tremendous number of 
our Guard and Reserve, and, of course, coming home, having had 
an experience in many instances very different than what they 
expected. Are there any unique challenges that we are 
confronted with in providing for them?
    Dr. Shepherd. In terms of Guard and Reservists, beside the 
window for TRICARE, I believe there is a 2-year window to 
enroll in VA care.
    One of the efforts I know that VA's making is that I think 
is one of the key things--is continuing to outreach to Guard 
and Reservists units to let people know that even if you are 
not having symptoms now, that with this type of problem, you 
can develop symptoms 6 months from now, 5 years from now, and 
the importance of when you are 22 or 24 of not thinking, ``I am 
fine today. I don't need anything.'' But really encouraging, 
through outreach at Guard and Reservists bases, returning 
veterans to enroll in VA in case they do need this care down 
the line.
    Senator Lincoln. So they are able to apply for the VA 
services early.
    Do they need detection? I mean, do they need to be tested, 
if it is going to be service connected, in order to get that 
benefit? I mean, is it something you would encourage them to do 
when they return before they have to--I mean, they have a 
limited window when they can apply for that, is that not right?
    Dr. Shepherd. Right.
    I know that the DOD and the VA do these post-deployment 
health assessment screenings and are supposed to do them, not 
just on deactivation but at 3 months and at 6 months, to try to 
capture some veterans who may not have been showing symptoms 
immediately post-deployment but are starting to show symptoms 
at 3 and 6 months.
    Again, I think it is very important that the word keeps 
getting out there that, even if you are not having symptoms 
now, you may develop them. To get in, get enrolled.
    If people do get in the system and do get seen during the 
window where they can be seen without having to have a service 
obligation connection, the primary care providers at their 
appointments should be mandatorily doing a PTSD and depression 
screen. So hopefully in that 2-year window some of these 
people, if they can be engaged to get into the system, will get 
picked up.
    Senator Lincoln. Are there recommendations of how we get 
that word out there in a better--or do you see us getting that 
word out in an efficient and effective way? Are we being 
effective about that? Or is there some recommendation of how we 
do a better job of getting that word out to these Guard and 
Reservists?
    Dr. Shepherd. I don't have a specific recommendation or a 
specific sense of how well that effort is.
    In terms of some vignettes that have been pointed out to 
me, one of the suicide prevention researchers goes out to Guard 
and Reservists bases pre-deployment and talks to Guard and 
Reservists about symptoms they may experience post-deployment.
    I think that is an important consideration because if I was 
returning home, I am a young guy, I want to get home to my 
family. I might not be listening too much and be interested in 
getting home. Whereas I might have a lot more attention to what 
I am hearing pre-deployment when someone, you know, discusses 
possible mental health issues I may develop later and also ways 
to access the system.
    I thought that was a very good initiative.
    Senator Lincoln. Well, that is a good suggestion. Doing it 
pre-deployment instead of, you are right, the anxiousness.
    Just last question, Mr. Chairman.
    We are certainly grateful to your work in the area of 
veterans' mental health and particularly the suicide 
prevention. It is such a crucial issue. You have done an 
important job in bringing about a greater awareness.
    Senator Snowe and I recently introduced legislation that, 
among other provisions, seeks to increase the number of 
mandatory mental health assessments. It would include 
comprehensive screenings for mild, moderate and severe cases of 
TBI.
    Kind of similar to my previous question, maybe you might 
briefly describe the way that we attempt to screen and detect 
those symptoms of PTSD and TBI in its early stages.
    What is the methodology there that is used? How do we 
address and detect the instances of later occurring symptoms? 
If they are going to go in for these screenings, or they are 
going to go in, what is the methodology or the questions that 
we are using to try and have that early detection?
    Dr. Shepherd. The screening questionnaires they use have 
about four or five questions about PTSD. So they are not 
extensive, comprehensive questionnaires or interviews.
    If someone scores I forgot whether the number is 3 or 4 
positives, then they are supposed to be referred for a more 
extensive evaluation. So that is the present methodology.
    I think in terms of trying to detect PTSD in the presence 
of TBI, it is a very clinically challenging situation. I think, 
again, keeping the awareness among the clinicians that these 
things can co-exist and that they are not mutually exclusive, 
and that people can have PTSD in the setting of TBI, and that 
the symptoms you see may not be ascribable to just one.
    So I think basically more disseminated education regarding 
that is needed.
    Senator Lincoln. How much early information do they go back 
to?
    I just remember reading an account in the news several 
months ago. A woman who was concerned that her husband--too 
much early background information, high school grades were 
used. She said, ``Well, you know, if he was competent enough 
for the military to take him and send him off, you know, then 
why is it now a question as to whether his capacity or his 
mental health is at risk or is a problem because of those early 
grades?''
    I thought that was interesting. How far back do they go?
    Dr. Shepherd. I really couldn't answer that.
    Senator Lincoln. No?
    Dr. Shepherd. I just don't know. That was not the focus of 
our review.
    Senator Lincoln. OK.
    Thank you, Mr. Chairman.
    Senator Smith. Gentlemen, thank you for the work you have 
done, the work you are doing, and for adding so much to our 
hearing this morning.
    We will now call up our third panel. They consist of Mr. 
Steven R. Berg. He is the vice president for programs and 
policy at National Alliance to End Homelessness. Today, Mr. 
Berg will testify on the unique needs of homeless veterans, 
including their complex health care needs.
    He will be joined by Mr. Fred Cowell, who is the senior 
associate director of the health analysis program at Paralyzed 
Veterans of America. He is a veteran of the U.S. Navy and 
served two tours of duty in Vietnam assigned to the Naval 
Security Group. Mr. Cowell will testify on the long-term care 
needs of our veterans.
    Finally, last but certainly not least, Dr. Mark Kaplan. He 
is a professor of community health at Portland State University 
and holds adjunct appointments in psychiatry and family 
medicine at the Oregon Health Sciences University and 
epidemiology and community medicine at the University of 
Ottawa. Today, Dr. Kaplan will testify on the study he 
published earlier this year on the rate of suicide for 
veterans, which garnered national attention.
    Gentlemen, a vote has just started. With your indulgence so 
as not to shortchange you, I will rush real quickly, vote, and 
be right back, so that we in no way lose what you have to 
present to us.
    So, if you have no objection, we will take a very brief 
recess and be right back. [Recess.]
    Thank you, gentlemen, for your understanding. I just simply 
note that the leaders on the Senate floor don't often check 
with the Aging Committee as to when they time the votes. But we 
do want to make sure we give full consideration to your 
testimony.
    So, Steven, why don't we start with you.

 STATEMENT OF STEVEN R. BERG, VICE PRESIDENT FOR PROGRAMS AND 
 POLICY, NATIONAL ALLIANCE TO END HOMELESSNESS, WASHINGTON, DC

    Mr. Berg. All right.
    Thank you, Senator Smith, for having us at this hearing. I 
am with the National Alliance to End Homelessness, as you know. 
Thank you, also, for the work you have done personally, I know, 
and your staff has done, on this issue in a whole range of 
different ways.
    Part of the homelessness issue that is particularly vexing, 
particularly infuriating, is the high rates of homelessness 
among veterans. We are in the middle of a major research 
project to try to put some numbers on that problem, look at 
some of the factors that go into it. That is research that will 
be released in early November, but I would like to share some 
of our preliminary findings today that I think are worth 
noting.
    First of all is just that it is a sizable problem. Our 
estimate is that over 195,000 veterans are homeless on any 
given night in the United States, which is--there are different 
ways to look at it. It is like a whole medium-sized city. You 
cleared everyone out and filled the whole city up with homeless 
veterans. That is the size of the problem.
    Of particular relevance to this Committee is that many 
homeless veterans are older and have disabilities. It is sort 
of a commonplace within the homeless services field that 
homeless veterans are older and sicker than homeless people 
generally. That is particularly seen among homeless veterans 
who are considered chronically homeless.
    That is a term the Federal Government uses to describe 
homeless people who are on their own, have severe disabilities, 
have been homeless for a long time, for a year or more. Our 
estimate is that between 44,000 and 64,000 veterans fit that 
definition of chronic homelessness, which makes this very much 
a health care issue because besides housing those are all 
people who need treatment, many times for mental health 
conditions accompanying substance abuse conditions and a whole 
range of physical ailments.
    Veterans are disproportionately represented among homeless 
people. In other words, veterans in the United States are more 
likely to be homeless than are Americans who are not veterans. 
There has been a whole range of theories put forward as to why 
that should be the case. We are trying to address some of those 
in this research that we are doing.
    One of the key contributors to homelessness among veterans 
and anyone else is housing affordability and high housing 
costs.
    Most veterans do pretty well in terms of incomes, in terms 
of their ability to afford housing. In fact, for veterans in 
general their incomes and their ability to afford housing are 
better than nonveterans.
    But there is a subset of veterans who don't do as well, who 
have high housing cost burdens, who are paying a 
disproportionate percentage of their income in rents. That is 
particularly the case among women veterans, among veterans who 
have a disability, and also among veterans who are older. The 
sort of World War II and Korea-era veterans are far more likely 
to have a high housing cost burden than veterans who are 
younger.
    So it is a sizable problem. But we view the problem of 
homelessness--and particularly homelessness for veterans--as a 
problem with a solution.
    Several years after sort of the Federal Government and 
Congress, we like to, you know, we hope we had some small part 
to play in this, announced new initiatives to try to get 
communities to work less at managing the problem of 
homelessness and more at ending homelessness.
    We see communities around the country who are undertaking 
local plans to end homelessness a lot of times with the 
participation of the VA. We have good models all around the 
country.
    You mentioned Central City Concern in Portland. There are 
similar kinds of programs all over the country that are doing 
similar kind of work.
    The most important thing is we are starting to see results. 
In a small handful of cities that have undertaken some of these 
best program models, we are seeing the number of homeless 
people decline.
    People in the homeless services field, I will say, talk 
about the Portland miracle, based on the reductions in the 
number of people who are homeless in Portland.
    I lived in Portland back in the 1970's, and even then there 
were lots of people living on the street and had been for a 
long time. In recent years, those numbers have really 
demonstrably declined because of work that people like Central 
City Concern, people with the city are doing to adopt a range 
of strategies that we know really work.
    Now, our feeling is that this should be easiest for 
veterans for a number of reasons. One, because one of the key 
components of the strategy that works is health care. Veterans 
have a system of health care that other Americans don't have 
access to that should work to deal with mental health problems, 
to deal with substance abuse problems.
    The VA keeps a lot of information about veterans. They do a 
good job of knowing which people that their health care system 
serves are homeless at the time they are being served. So it is 
a matter of identifying people who are experiencing the 
problem.
    Now, they have some tools there to deal with even things 
like the numbers.
    I mean, in Wisconsin, for example, the work the VA did to 
identify the number of homeless veterans came up with the 
number 828 veterans in the State of Wisconsin. You can fill 
this room pretty well with 828 people.
    But in a State that size, it gives people an understanding 
of what they are up against. That is the kind of number where 
sort of one big push could make a significant impact on that 
problem. Knowing that, having the VA able to tell you that 
number, I think, helps people on the ground adopt strategies 
that are going to work.
    Finally, the VA exists as a mechanism for ongoing support 
for veterans.
    I mean, Senator Dole and Senator Wyden talked about the 
idea of a care coordinator. The idea that there is a system in 
place that could adopt that kind of intervention is a big plus 
for veterans.
    Yet despite all these sort of advantages that veterans have 
in terms of dealing with homelessness, still it is a problem 
that disproportionately affects veterans. So there needs to 
be--we have a lot of work to do in this area.
    We have some recommendations for Federal policy. In my 
written testimony, I have gone through a number of those.
    The basic ideas are to provide funding and incentives for 
some of these key strategies that we know work: for discharge 
planning so that people have--the risks of homelessness are 
identified early on at the time people leave the military; 
emergency prevention; rapid re-housing so that when people do 
experience homelessness or are on the verge of experiencing 
homelessness, it is treated as a true emergency, intervention 
is in place.
    We know the kind of intervention that works. There just 
needs to be systems set up so that those interventions are 
applied to people who need it right at the time they need it.
    Another key element is permanent supportive housing, 
particularly for the older veterans who have the chronic health 
care problems and have been homeless a long time.
    Low-cost housing, combined with treatment, combined with 
case management, this is a very cost effective intervention 
that we know works. I know we have talked to you and your staff 
about this.
    There are a number of specific things that Congress could 
do that I have mentioned there. One thing I just want to 
mention, because it is sort of a hot item right now, is 
something called the HUD-VASH Program, HUD-VA Supportive 
Housing Program.
    This is a program that matches rent subsidies from HUD with 
supportive services, treatment, and sort of case coordination 
provided by the VA. It has been put into effect in the past.
    There haven't been new HUD-VASH vouchers put in place for a 
number of years. But in this year's appropriations bill for 
HUD, particularly the Senate bill, there is a substantial 
investment in the HUD bill for new HUD-VASH vouchers. In the 
Senate bill, there is probably enough to do 8,000 new vouchers.
    So two aspects of that. One, it is very important that as 
that bill goes through the process--I know the whole 
appropriations process is very uncertain this year--but as that 
bill goes through, it is important that the funding for HUD for 
those VASH vouchers stay in there.
    Two, it is incredibly important that the VA understand that 
it is Congress' intent and expectation that the VA will do 
their part in putting this program into effect.
    The VA services are paid for by the regular health care 
program. There isn't a need for a special appropriation for the 
VA share of this.
    But it is important--again, as Senator Wyden mentioned--
this is an organizational challenge issue to ensure that in 
every city where the Housing Authority gets funding for some of 
these VASH vouchers, that the VA hospital is coordinating with 
the Housing Authority, making sure that the veterans who need 
the help the most are referred for the vouchers, making sure 
that the case manager and that the VA is part of that is put 
into place.
    We can house thousands of veterans with what is in the 
appropriations bill now. But everybody needs to do their part.
    So thank you, once again, for inviting me. I am happy to 
answer any questions.
    [The prepared statement of Mr. Berg follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Senator Smith. Steven, for the record, I have your 
testimony here. But can you list 3 or 4, maybe 5 features of 
the best practices models? What is working?
    Mr. Berg. Right. I think----
    Senator Smith. It is affordable housing, access to health 
care, what else?
    Mr. Berg. Yes.
    I think that some of the key models--I mean, I mentioned 
permanent supportive housing, which is affordable housing 
combined with the health care, the case management, 
particularly treatment for mental health and substance abuse 
issues closely targeted to veterans with the worst health care 
needs and who have been on the street the longest, has very 
good results in terms of taking people who really are, you 
know, most people would have given up a long time ago, and 
getting them into housing. They tend to stay in the housing. 
They tend to get better, when they hadn't gotten better while 
they were living on the street.
    Senator Smith. So affordable and permanent housing.
    Mr. Berg. Permanent. Yes.
    Senator Smith. Any other feature?
    Mr. Berg. Other features that work well are the idea of 
sort of a rapid re-housing program, having people available who 
know the local rental market, who know landlords who are 
willing to rent to tenants who might not sort of on paper look 
like the best risks in the world, and who have sort of short-
term flexible resources available to deal with things like 
security deposits, deal with things like a bad credit history.
    These kind of programs have been very effective in a number 
of places and it is the kind of thing that, you know, if you 
had a care coordinator at the VA, that that kind of person 
could help make sure people have access to either as soon as 
they find out they are homeless or preferably before they ever 
become homeless but when they are experiencing a housing 
crisis.
    Those are some of the real best practices----
    Senator Smith. You know, I was struck, Steve, that 
according to your testimony, 2 percent of all Oregon veterans 
are homeless?
    Mr. Berg. Yes.
    Senator Smith. If this is accurate, Oregon appears to be 
fifth in the Nation for the percentage of veterans in a state 
who are homeless. That is pretty high.
    Mr. Berg. It is pretty high. I mean, and----
    Senator Smith. We don't have any active duty military 
bases, so why Oregon?
    Mr. Berg. Right.
    Senator Smith. Why Oregon?
    Mr. Berg. Right.
    Well, we are trying to figure--one of the reasons it is 
taking us so long to get this report out, as I was just 
speaking to someone else, is that we are trying to figure out 
what some of the factors are behind some of those differences.
    Some of it is just some people do--I mean, as you probably 
know, the VA is a fairly decentralized agency. These numbers 
are all based on local VA counts. Each local VA does it a 
little differently so some of it is just counting.
    But it is also the case we know that, for example, veterans 
in Oregon are more likely to have a higher housing cost burden. 
That we know based on census data that is done the same in 
every State. It is part of just a housing affordability issue 
that varies State to State.
    Senator Smith. Is that an unintended consequence of urban 
growth boundaries?
    Mr. Berg. That is something you would know more about than 
I would.
    Senator Smith. I know I shouldn't get into that. But, I 
mean, don't they, as part of land use planning, require certain 
amounts of affordable housing to go in to deal with that issue?
    Mr. Berg. That is a matter of State law.
    I know Oregon has been a leader in that for a long time. 
But it is, I mean, it is also the case housing costs--there are 
a whole range of factors behind housing costs.
    I think it is the case that Oregon has seen sort of rents 
grow faster than a lot of parts of the country just because of 
population changes. It is a good place to live and people want 
to live there.
    It is supply and demand. There are a lot----
    Senator Smith. Well, it is strange to me that, without an 
active military base, which you would think would be something 
of a magnet to veterans who are, you know, when they go home, 
that the homelessness would correlate to where those exist. But 
Oregon is obviously an exception to that.
    Mr. Berg. That is true. We are trying to get some answers 
to that. It is a range of different factors.
    Senator Smith. Well, when you get those answers, please 
share them with us.
    Mr. Berg. Absolutely.
    Senator Smith. I am very interested.
    Mr. Berg. Absolutely.
    Senator Smith. Thank you, Steve.
    Fred Cowell.

STATEMENT OF FRED COWELL, ASSOCIATE DIRECTOR OF HEALTH POLICY, 
         PARALYZED VETERANS OF AMERICA, WASHINGTON, DC

    Mr. Cowell. Thank you, Mr. Chairman.
    Before I begin my oral testimony, I would just like to take 
a second, with your indulgence, on behalf of the Paralyzed 
Veterans of America, I would like to express our sincere 
gratitude and profound respect that we have for Senator Dole 
for his service to our country, our Nation's veterans, and all 
Americans with disabilities.
    Senator Smith. Thank you.
    Mr. Cowell. It was a real honor to be on the same panel 
with him today.
    Mr. Chairman and members of the Committee, the Paralyzed 
Veterans of America is pleased to present its views concerning 
access to, and availability of, quality VA long-term care 
services for our Nation's veterans.
    In the interest of time, PVA's oral testimony will briefly 
focus on five long-term care issues of importance to America's 
veterans. More detailed information on these and additional 
topics is contained in our written testimony.
    The long-term care needs of younger OIF-OEF veterans.
    Mr. Chairman, PVA believes that age-appropriate VA 
institutional and non-institutional programming for younger 
OIF-OEF veterans must be a priority for VA and your Committee. 
New VA institutional and noninstitutional programs must come 
online and existing programs must be re-engineered to meet the 
various needs of a younger veteran population.
    Changes to VA's noninstitutional long-term care programs 
will be required to assist younger veterans with catastrophic 
disabilities who need a wide range of support services, such as 
personal attendant services, programs to train attendants, 
family caregiver training, peer support programs, assistive 
technology, and hospital-based home care teams which are 
trained to treat and monitor specific disabilities.
    VA's institutional programs must change direction, as well. 
Nursing home services created to meet the needs of aging 
veterans will not serve younger veterans well. VA must make 
every effort to create an environment that recognizes younger 
veterans have different needs.
    These younger veterans must be surrounded by forward-
thinking administrators and staff that can adapt and design 
programs to meet youthful needs and interests. For example, 
therapy programs, living units, meals, recreational programs 
and policies must be changed to accommodate younger veterans 
entering the VA long-term care system.
    Veterans with spinal cord injury or disease.
    PVA is concerned that many aging veterans with spinal 
injury and disease are not receiving the specialized long-term 
institutional care they require.
    Today, VA's SCI-D long-term care capacity cannot meet 
current or future demand. Waiting lists exist at the 4 existing 
designated SCI-D long-term care facilities, which only have a 
total of 125 beds nationwide and geographic accessibility is a 
major problem because none of these 4 existing facilities are 
located west of the Mississippi River.
    VA data projects an SCI-D long-term care bed gap of 705 
beds in 2012 and a larger bed gap of 1,358 for the year 2022.
    Currently, VA's construction budget submission for 2007 
includes provisions for new VA nursing homes in Denver, CO, Las 
Vegas, NV, and Des Moines, IA. A 15 percent bed allocation at 
each of these new facilities would be a good first step toward 
closing the looming long-term care bed gap for veterans with 
SCI-D.
    Mr. Chairman, PVA needs the Committee's support to ensure 
that new VA nursing home construction planning includes a 15 
percent bed allocation for SCD-D residents.
    Waiting lists for VA noninstitutional long-term care.
    PVA is concerned about reports from our members and from VA 
health care professionals that long waiting lists exist for 
aging veterans who need access to certain segments of VA's 
noninstitutional care program list. PVA calls upon Congress to 
review the demand, availability, and associated waiting times 
for care in VA's home-based primary care program. 
Recommendations for appropriate funding would then depend on 
the outcome of the program review.
    Assisted living.
    VA conducted an assisted living pilot project mandated by 
the Millennium Benefits and Health Care Act between January of 
2003 and June 2004. VA's subsequent report on the pilot project 
was forwarded to Congress by then-VA Secretary Principi in 
November 2004.
    The report revealed a number of positive findings, 
including information on cost, quality of care, and veteran 
satisfaction.
    The authors of the independent budget have called on VA's 
assisted living project to be replicated in at least three VA 
networks with high concentrations of elderly veterans to 
determine if the findings of the original pilot are valid.
    Finally, VA's strategic plan for long-term care.
    Mr. Chairman, Congress recently passed a comprehensive 
package of veteran proposals which became Public Law 109-461. 
Section 206 of the law mandated the secretary of Veterans 
Affairs to publish a strategic plan for the provision of long-
term care within 180 days of enactment. To date, VA has not 
complied with the law.
    The aging of the veteran population and the subsequent 
increasing demand for long-term care services has been well 
documented for over a decade by both VA and the General 
Accountability Office.
    Mr. Chairman, PVA calls upon members of this Committee to 
investigate VA's delay in publishing its urgently needed 
strategic plan for long-term care as soon as possible.
    Mr. Chairman, that concludes my remarks. I will be happy to 
answer any questions.
    [The prepared statement of Mr. Cowell follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Senator Smith. Thank you very much, Fred.
    In your testimony you mentioned that there are many 
veterans who are denied admission or care through the VA or 
through community nursing homes due to high acuity needs, 
spinal cord injuries specifically. What happens to them?
    Mr. Cowell. Well, many times they are not able to get the 
proper care they need. They are relegated to stay at home with 
caregivers that are also aging.
    This is probably the first time in our Nation's history 
that we have a generation of aging veterans that have survived 
with spinal cord injury. So they heavily depend on those 
specialized services the VA can provide.
    VA currently only has a current capacity of 125 beds for 
trained staff to meet the needs of this aging population.
    These veterans are staying home longer than they need to be 
or should be. They are not receiving the proper care they do. 
Many of them wind up in VA acute care hospitals for long 
periods of time because there are no nursing homes that can 
treat them.
    Senator Smith. Obviously, the point you are making is, in 
previous wars, those with these kinds of injuries would simply 
die.
    Mr. Cowell. That is right.
    Senator Smith. Clearly, they are performing miracles on the 
battlefield now. They are not dying. But I think you are 
highlighting a real shortcoming in our VA capacity.
    Mr. Cowell. Yes, sir. It is absolutely true.
    Senator Smith. In a nutshell, that is the problem. So we 
have got to ramp that up.
    Is this something you see a lot of or a growing amount of 
because of the survivability rates now?
    Mr. Cowell. It is an increasing issue for PVA.
    We are a member organization with an aging membership. More 
and more of our members are in their sixties, seventies, and 
some are reaching their eighties. They are just simply not able 
to live independent lives any longer.
    Senator Smith. Yes.
    Mr. Cowell. Even with the advent of many breakthrough 
programs in a noninstitutional care, they are designed to keep 
veterans at home as long as possible, and we certainly support 
all of those programs. There is just an increasing demand.
    VA's own data shows a lack of capacity to treat these aging 
veterans. There really needs to be more work done in this area.
    We have brought this attention to the Strategic Group of 
Spinal Cord Injury in the VA. We are trying to work to get new 
long-term care beds created that can meet the needs of this 
population. It has just been an uphill battle, to be quite 
frank.
    Senator Smith. So if I understand your other point about--I 
think you were speaking of authorizations and appropriations 
for new veterans nursing homes, you are saying they should have 
a 15 percent bed requirement----
    Mr. Cowell. Yes, sir.
    Senator Smith [continuing]. To deal with high acuity cases.
    Mr. Cowell. Most of these new facilities that are in VA's 
2007 construction budget were located west of the Mississippi. 
Currently, the 4 facilities the VA has for our members today 
are all on the East Coast. There is nothing west of the 
Mississippi for this membership.
    So they are relegated to nursing homes, community nursing 
homes, state veterans' homes, if they can get in. They don't 
have the trained staff to meet their needs. So it is a major 
problem.
    Senator Smith. Is 15 percent the right percentage, or is 
it----
    Mr. Cowell. We would be happy to talk about that with VA.
    When we look at only 125 beds being available nationwide, 
we think 15 percent is a good first step. We could step back 
from these original facilities, these new proposed facilities 
and see how that is working and try to get a handle on, ``Is it 
meeting the demand or is there a greater need for a higher 
percentage?'' Senator Smith. Thank you very much, Fred.
    Mr. Cowell. Absolutely.
    Senator Smith. Dr. Kaplan, thank you for your patience.

  STATEMENT OF MARK S. KAPLAN, PROFESSOR OF COMMUNITY HEALTH, 
            PORTLAND STATE UNIVERSITY, PORTLAND, OR

    Dr. Kaplan. Thank you.
    Good afternoon, Mr. Chairman. I am Mark Kaplan, professor 
of community health at Portland State University.
    I want to thank you and the Committee for the invitation to 
testify before this Committee on this critical public health 
issue affecting the aging veteran population.
    I should note, interms of the demographics that today 
approximately 70 percent of older males are veterans.
    I applaud the Committee for embracing the critical issue of 
veterans' mental health and particularly the emphasis on 
suicide risk and prevention.
    I should point out here that I have been an active suicide 
researcher since 1992. Most of my work has focused on late life 
suicide. I am an elected member of the American Association of 
Suicidology Council of Delegates, as well as a member of SPAN 
USA National Scientific Advisory Council.
    Before I move on to my presentation, let me just take this 
opportunity to thank you, Senator Smith, for your leadership on 
these important issues.
    Senator Smith. Oh, you are welcome.
    Dr. Kaplan. As you know, Mr. Chairman, suicide remains a 
serious public health problem. Reducing suicide is a national 
imperative.
    To the best of our knowledge, more than 30,000 people in 
the United States take their lives every year. Approximately 1 
million make an attempt on their lives, as well. Veterans are 
particularly vulnerable to suicide compared to their civilian 
counterparts.
    So what I want to do in my testimony today is review some 
of the research that I have done with my colleagues back in 
Oregon and highlight some of the key findings and then end with 
some policy-oriented recommendations for the Committee.
    To start, in Oregon veterans are more than twice as likely 
to die of suicide than their nonveteran peers. The age-adjusted 
suicide rates among male veterans was 46.05 per 100,000 and for 
nonveteran males, the rate was 22.09 per 100,000. So the rate 
is twice as high as the nonveteran population.
    Senator Smith. Mark, can I stop you there----
    Dr. Kaplan. Sure.
    Senator Smith [continuing]. Can I ask you this question? It 
sort of relates to what I was asking Steven.
    Dr. Kaplan. Of course.
    Senator Smith. Because they are veterans and they have 
access to other resources, why is the suicide rate higher?
    Dr. Kaplan. Well, I don't think anyone really has an answer 
on that. As we noted in the publication that you alluded to, 
that the risk of suicide was twice as high as their non veteran 
peers.
    We did a slightly different analysis where we looked at 
vets who use and don't use VA facilities. There is not a whole 
lot of information out there on the vets who are not part of 
the VA system.
    According to a veteran survey done in 2001, only about one 
out of every five uses the VA. Most don't. So there is a gap in 
our knowledge in our understanding of why veterans might be at 
risk.
    But the fact is that independent of the era they served in, 
veteran status alone is an independent predictor of suicide.
    Senator Smith. Does it relate to combat experience?
    Dr. Kaplan. We don't really know. It might relate to 
combat. In studies that have been done within the VA system, 
obviously combat experience is a key factor. PTSD, depression, 
and a whole host of other forms of psychiatric morbidity have 
been linked to suicidal behavior.
    Senator Smith. Does combat experience increase the 
likelihood of substance abuse, alcohol----
    Dr. Kaplan. The two are correlated.
    Senator Smith. They are correlated. OK.
    Dr. Kaplan. Absolutely; substance abuse and co-morbid 
conditions. Rarely do you find a case of somebody simply having 
a substance abuse but it often goes hand in hand with a variety 
of other psychiatric conditions.
    Senator Smith. It may or may not be triggered--that 
substance abuse may or may not be triggered by combat 
experience, but combat experience does seem to have some 
linkage----
    Dr. Kaplan. Exactly.
    Senator Smith [continuing]. Then, of course, substance 
abuse leads to suicide.
    Dr. Kaplan. Exactly.
    Well, we already heard about the risk for homelessness that 
is a big factor. So people who experience downward mobility, 
unemployment, a breakup in their relationships, and a whole 
host of other circumstances that may trigger suicidal behavior. 
So it is a very complex problem--remarkably, we know very 
little.
    Senator Smith. Yes. Sorry for the interruption----
    Dr. Kaplan. That is fine.
    Senator Smith [continuing]. But I am trying to learn from 
you.
    Dr. Kaplan. That is fine.
    Veterans tend to have--along with what has already been 
said--veterans tend to have more disabilities that limit their 
ability to function, which in turn may lead to social isolation 
and depression. Disabilities that limit functioning are an 
important suicide risk factor among veterans compared to 
nonveterans in the general population.
    Again, referring to the study that we published over the 
summer, one of the key predictors of suicide over a 12-year 
period was disability. That is, in male veterans who reported 
at baseline some form of disability were at an elevated risk of 
completing suicide.
    Veterans are also more likely than their civilian 
counterparts to use firearms as their primary mode of suicide. 
This is also an important factor. I will say a little bit more 
about this. I will also address this in my recommendations.
    The National Violent Death Reporting System data reveals 
that the proportion of suicides involving firearms was 
significantly higher among veterans than their nonveteran 
peers. This is remarkable.
    Seventy-two percent of veterans use guns to complete 
suicide, while their nonveteran peers, the percentage there was 
only 56 percent. Equally ominous, female veteran suicide 
decedents were also significantly more likely than other 
nonveteran counterparts to use guns. Here again, female 
veterans, nearly 50 percent of them used guns to complete 
suicide, while their nonveteran counterparts, the rate there 
was only 33 percent.
    I should note here, and this might surprise you, we 
reported some years ago that the most common method used among 
elderly women happens to be firearms, 40 percent. More elderly 
women use guns than poison.
    Senator Smith. Is it generational or what is----
    Dr. Kaplan. Well, it might--I have often looked at that as 
sort of the masculinization of suicidal behavior. We are seeing 
that crossing generations. It is becoming the most common 
method across ages. But remarkably, we found that to be the 
case among elderly women.
    Male and female veteran suicide decedents are respectively 
47 percent and 76 percent more likely than their nonveteran 
peers to use guns. These statistics are important because what 
we did, we tried to statistically control for confounding 
factors. So, again, it seems to be a little higher for females.
    Similarly, older male and female veterans were also 
significantly more likely than their younger veterans to use 
firearms. This is based on the National Violent Death Reporting 
System.
    So we did some analysis where we tried to address some 
factors and found that the older vets, male and female, were 
more likely to use guns than their younger counterparts.
    So, again, one can look at guns as not just a method of 
completing suicide, but it also sends a message that there is a 
determination to end their lives and that there is very little 
that one can do. That window of opportunity to intervene, to 
prevent, is almost shut.
    So we need to begin thinking about ways of intervening with 
people who are going to attempt suicide with a gun as opposed 
to what some might characterize as a cry for help with some 
other less lethal methods.
    The rate of lethality is extremely high with guns. Ninety-
five percent plus, maybe close to 99 percent.
    I would like to conclude my testimony today with several 
policy-oriented recommendations. The first one is--and I think 
this touches on what some of the other witnesses have said 
today--No. 1, clinical and community interventions directed 
toward patients in both VA and non-VA care facilities will be 
needed. I want to underscore the word both here because I think 
we know a lot more about those users of VA than we do about the 
nonusers.
    Second, Congress should direct the Department of Veterans 
Affairs to provide reimbursement for primary care depression 
detection and management for veterans unable to be served 
within the Veterans Affairs system for a variety of reasons 
that we have discussed today, including geographic issues.
    I remember being on call-in shows during the summer in 
response to my piece. Many veterans called in and were--very 
dissatisfied with the quality of care in the VA system. Many 
thought of it as just an extension of the military and did not 
feel very comfortable in that culture.
    So there were a lot of reasons, but I heard that a lot. As 
I said, there is a survey of veterans done in 2001 that showed 
that only one out of every five was using the VA. Others were 
not for many different reasons.
    Another recommendation is training primary care physicians 
in suicide assessment, management and referral within the VA 
and outside.
    An interesting statistic here is that there has been a 
declining rate of primary care physicians in this country. 
Unlike other advanced industrialized countries, we are seeing a 
rise in specialists and a decline in primary care physicians.
    Senator Smith. Isn't that about compensation and all of 
that?
    Dr. Kaplan. Excuse me? Compensation. Right. Right. 
Absolutely.
    I spent some time in Canada as a Fulbright Scholar a few 
years ago. I studied the Canadian public health system. But 
what impressed me was the fact that over 50 percent of their 
physicians are primary care providers.
    Senator Smith. When you go to medical school--and I am not 
a medical doctor--but is there a real hierarchy of specialties 
and the social pressure to go into one of those as opposed to 
somehow a primary physician being a lesser professional?
    Dr. Kaplan. I am not a physician, but I have studied 
physicians. I must say that, at least anecdotally, you do hear 
that.
    Senator Smith. Yes. That is what I figured. That is how it 
is in----
    Dr. Kaplan. That would be an interesting project, actually. 
Medical sociologists do that kind of thing.
    Another recommendation is that there is a critical need to 
collect more comprehensive epidemiological information on the 
proximal and distal circumstances surrounding suicide morbidity 
and mortality.
    Here I want to make the point that I think we have looked 
at suicide in very narrow ways. We tend to focus on the 
immediate risk factors. But sometimes these are more distal, 
both in time and in space, such as homelessness.
    I mean, I am listening here and I am thinking we need to 
develop a more holistic, more proactive approach to suicide 
prevention, a more community-oriented approach as opposed to 
the reactive.
    Quite often the system is geared up to respond to people 
who call in, for instance. An interesting side note here is 
that most elderly people who are suicidal don't call up, do not 
use crisis lines.
    Another recommendation is that currently there are only 
funds to operate the National Violent Death Reporting System, 
run by the Centers for Disease Control, in 17 states. This is 
important in terms of developing a better database.
    At least $20 million is required to fully implement and 
maintain the NVDRS in all 50 states. It is now running in just 
a handful and, as I said, in 17 states. Oregon happens to be 
one of those.
    However, congressional funding has remained flat at about 
$3.3 million. So there is a real need to increase that budget, 
as I see it.
    Senator Smith. We are going to do that.
    Dr. Kaplan. Thank you.
    Another recommendation: Firearms are responsible for 
significant suicide mortality in the older veteran population. 
Many studies offer evidence linking accessibility of firearms 
to suicide with guns.
    More research is needed to study the interaction between 
firearm usage and suicidal behavior in the older adult 
population. We know so little about that.
    I had this conversation earlier today. Quite often we refer 
to it as suicide, but in many cases with older adults, 80 
percent of older men, men over the age of 65, white men in 
particular use guns to complete suicide. The firearm issue, and 
I know it is a highly charged question, but it is the elephant 
in the room when we talk about reducing suicide in the U.S.
    Senator Smith. It is actually something that, while I 
haven't seen legislation, it is one of the first issues after 
Virginia Tech that actually has gotten the NRA and gun 
opponents or mental health advocates actually talking 
constructively because I think even the gun advocates----
    Dr. Kaplan. Right.
    Senator Smith [continuing]. NRA and others----
    Dr. Kaplan. Right.
    Senator Smith [continuing]. Understand that gun ownership 
comes with gun responsibility. When people have diminished 
capacity, there needs to be some kind of a standard whereby we 
help them by removing guns from their proximity.
    Dr. Kaplan. One additional recommendation related to that 
is that unfortunately for too long we have looked at the gun 
issue, gun violence as a criminal justice, as opposed to a 
public health problem.
    Senator Smith. Yes.
    Dr. Kaplan. I think we need a paradigm shift in that 
regard.
    A couple of other points that I just want to run through 
quickly.
    I would like to see a congressional mandate for studies on 
the role of firearms in suicide specifically. Funding should be 
increased at the Centers for Disease Control and Prevention and 
other Federal agencies, such as NIMH, for research involving 
this type of firearm violence.
    Health care providers--another recommendation--need to be 
more attentive to the critical role that firearms play in 
suicidal behavior among veterans. Many physicians find it 
difficult to ask patients directly about suicide, fearing that 
they might prompt a case of suicide.
    Some years ago, my colleagues and I studied primary care 
physicians and found that only half of primary care physicians 
who identified an elderly patient as suicidal would inquire 
about their access to firearms. However, 70 percent asked about 
their misuse of medications.
    So there is an unwillingness or reluctance to probe with 
patients who are at risk about their access to guns.
    Another point: It is very important for medical providers 
to ask people if they have been in the military and then screen 
for health problems, mental health issues, and suicide in this 
population. This relates to this question of veterans who are 
not using the VA.
    There is also a need--and this is important--to incorporate 
more geriatric and gender-specific content into the programs in 
the VA. By that I mean, quite often we don't--when we look at 
suicide prevention programs, we haven't incorporated male-
specific content, even though most individuals who complete 
suicide are males, particularly older males.
    Finally, according to the American Psychiatric Association, 
men in psychological distress face appreciable stigma and 
barriers and are less likely to seek help than are equally 
distressed women.
    Thank you for the opportunity to testify before you today. 
I would be happy to respond to any questions you may have and 
look forward to working with you in the future.
    [The prepared statement of Mr. Kaplan follows:]

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    Senator Smith. Thank you very much, Mark.
    We will leave the Senate record open for a period.
    I apologize. My colleagues are gone. It is not any 
reflection on you. That is how life is around here.
    You have all contributed importantly to the Senate record 
and to our understanding. There may be written questions 
submitted. If there are, if you can answer them, great. We 
appreciate that.
    But you have come a long way. We value your work. That is 
why it was important to me that we not in any way shortchange 
your testimony and the contribution you have made here today.
    So thank you. I don't know how to say it better than just 
thank you.
    Keep it up. We need you to keep succeeding at what you do.
    With that, we are adjourned.
    [Whereupon, at 12:40 p.m., the Committee was adjourned.]
                            A P P E N D I X

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             Prepared Statement of Senator Robert P. Casey

    I want to thank my colleague, Senator Gordon Smith, for 
chairing this important hearing to address health care for 
aging veterans. I look forward to continuing our work through 
this committee to meet their needs and ensure that the services 
this nation promised them are delivered.
    The 110th Congress is focusing a good deal of attention to 
veterans' health care and with good reason. Those who have 
sacrificed so much for America's security and freedom deserve 
the most advanced medical care and comprehensive benefits our 
country has to offer, and the government is obligated to 
guarantee them. It is troubling, however, that it takes events 
like those of the past year at Walter Reed and throughout the 
Department of Defense and the Veterans' Administration health 
care systems to propel this issue to the forefront of our 
concerns in Washington.
    As the wars in Iraq and Afghanistan continue, we can only 
expect more casualties. Thanks to brilliant medical advances, 
many of these casualties will be survivors returning home to 
cope with debilitating physical and mental injuries and 
illness. The VA will face the challenge of caring for these 
veterans. Modern medicine has found a way to keep them alive, 
but our government bureaucracy has not kept pace with serving 
their increased needs.
    While our efforts to expand our health care system to 
accommodate these young men and women are crucial, it is 
equally imperative that we not neglect our older veterans who 
have fought valiantly in combat in previous wars. In addition 
to the problem of obtaining their health care and other 
benefits, older veterans also confront the issues of long term 
care and, in the most tragic cases, homelessness. Combat 
veterans from World War II and the Korean War are now in the 
ranks of our older citizens. Many of those who served in 
Vietnam have retired, adding thousands to the Veteran 
Administration's health care rolls. Men and women who fought in 
the Gulf War of 1991 have unique physical and mental health 
care concerns, the evidence of which has appeared in the years 
following the end of that war. With a quarter of the nation's 
population potentially eligible for VA benefits and services, 
we cannot cast our older veterans aside in our urgency to 
devote health care resources to veterans of the wars in 
Afghanistan and Iraq.
    I have met with members of the Pennsylvania chapter of the 
American Legion twice this year. I asked these distinguished 
gentlemen about their experiences with the VA hospitals in 
Pennsylvania. The response was almost unanimous: the VA 
hospital consistently offers the finest health care they could 
hope for--if they could manage to get an appointment. While 
this evidence is anecdotal, it illustrates the greatest problem 
the VA faces: its own bureaucracy. The numbers are staggering: 
the VA operates 155 medical centers, over 1,400 sites of care, 
including 872 ambulatory care and community-based outpatient 
clinics, 135 nursing homes, 45 residential rehabilitation 
treatment programs, 209 Veterans Centers and 108 comprehensive 
home-care programs. Despite the challenges of managing such a 
sprawling system, technology and good planning would streamline 
VA health care and benefits administration and deliver 
comprehensive services to our aging veterans promptly.
    In fiscal year 2006, the VA reported that nearly 1.1 
million veterans reside in Pennsylvania. Over 480,000 were 65 
or older. In 2004, the VA spent $2.5 billion on health care for 
veterans in Pennsylvania, and that number continues to increase 
year by year.
    I am grateful to Senator Smith for calling attention to 
these critical issues and I look forward to the testimony of 
our witnesses. We must do whatever is necessary to meet the 
physical, psychological and emotional needs of our veterans and 
ensure that America keeps its promise to our aging heroes. We 
owe them our services, as we still enjoy the freedoms that they 
served to protect many decades ago.
                                ------                                


        Reponses to Senator Smith's Questions from Dr. Shepherd

    Question. In your testimony you mention that approximately 
three out of four veterans seeking mental health treatment for 
the first time through the VA are Vietnam era veterans; many of 
whom are in the 55-64 year-old age group. Why do you think this 
is the case, and are these numbers growing from years past?
    Answer. There are many hypotheses offered to explain the 
influx if aging veterans into the VA mental health system over 
the past few years. All of the following rationales can account 
for some portion of increase in the numbers of these veterans:
     Universal screening for depression and PTSD by 
primary care physicians.
     As a result of educational initiatives, media 
coverage, and mental health outreach efforts following the 
attacks of September 11, 2001, and/or related to the current 
Global War on Terror, veterans have gained a heightened 
awareness of PTSD and have recognized symptoms described in the 
media as akin to their own experience.
     Some veterans in this group successfully 
suppressed and avoided their PTSD symptoms through the years by 
overachievement and sublimation to their work identity. As the 
specter of retirement and idle time becomes more apparent, they 
experience a decreased ability to evade symptoms, which then 
begin to impair their quality of life.
     Veterans experience subsequent traumas, such as 
death of a spouse, career change, criminal victimization, etc., 
which causes emergence or reemergence of mental health 
symptoms.
     Veterans progressing in the life cycle may begin 
to experience physical decline, functional impairments, and 
illness which, in turn, diminish their overall reserve and 
capacity to function. This co-morbid effect may impact 
vulnerability to onset of mental health problems or may 
decrease resiliency and coping with mental health symptoms that 
were already present at a sub-clinical level.
     There are a small, but reported number of cases of 
patients experiencing PTSD symptoms for the first time years 
after the military exposure event.
     Ongoing changes and reductions in employer 
provided health care benefit plans and/or the specter of having 
to provide for one's own health care coverage upon retirement 
may contribute to a decision by eligible veterans to shift to 
VA care.
    Follow up a. We know that overall, older males have 
increased risk for depression and suicide. We also know that 
being a veteran increases those risks. What do you think this 
means for the VA Mental Health system as these veterans 
continue to age and increase in number?
    Answer. In light of the ongoing Global War on Terror, the 
mental health needs of Operation Iraqi Freedom/Operation 
Enduring Freedom (OIF/OEF) veterans are in the forefront of our 
public consciousness. At present, the number of OIF/OEF 
veterans seeking mental health treatment is approximately 15 
percent. Over time, we do not know whether this rate will 
remain steady, whether and when it will change, and if so, at 
what velocity this change will occur. Simultaneously, 
increasing numbers of aging veterans are seeking mental health 
treatment in VA, and other aging veterans represent potential 
influx. We also do not know whether this trend will plateau, 
continues at present rate, or accelerate. I believe that the 
ability to adequately assess, plan for, and make ongoing 
adjustments to meet the access and programmatic needs at both 
ends of the age spectrum will be a primary challenge facing the 
VA mental health system.
    Follow up b. Is the VA prepared to adequately respond to 
the needs of these veterans?
    Answer. This will, in part, depend on VA's ability to 
simultaneously meet the needs that may arise from the increase 
in veteran utilization at both ends of the age spectrum 
described in the response to part A. Recruitment of mental 
health professionals, especially in rural areas, is a challenge 
in all sectors, public and private. I believe that a related 
consideration will be the ability for VA to recruit and/or 
efficiently match clinician skill sets with regional patient 
sub-populations. For example, it will be an advantage to have a 
higher density of clinicians particularly skilled and adept at 
treating geriatric depression and dementia related issues at VA 
facilities where there are a high concentration of patients 
with these mental health problems; likewise, having an 
increased density of clinicians adept at cognitive behavioral 
therapy such as prolonged exposure therapy is especially 
important in areas with high concentrations of returning OIF/
OEF veterans.
    Question. In your testimony you discuss the recent effort 
by the VA Office of Mental Health Services to ensure each VA 
medical center had a suicide prevention coordinator. You also 
mention that approximately 85 percent of facilities have at 
least an ``acting'' suicide prevention coordinator at this 
point--which I applaud. However, I am wondering about the next 
step--do you think that once a problem is identified that there 
are appropriate numbers of mental health care professionals in 
the VA system or affiliated with to ensure timely follow-up and 
treatment?
    Answer. In our work, we have found that over the past year, 
VA efforts at systematic suicide prevention have been more 
aggressive. VA Clinician researchers, especially in the Rocky 
Mountain Network, VA Stars and Stripes Network (Pennsylvania 
region), and New York/New Jersey Network have piloted or 
implemented some innovative programs. In our report, we 
encouraged VA to choose among emerging best practices for 
identifying, assessing, referring, tracking, and treating 
veterans at risk and for system-wide implementation with 
ongoing evaluation and modification. In our inspection, we did 
not look at access to mental health care. Access can be thought 
of in terms of multiple domains including waiting times, 
geographic location, patient eligibility, provider 
availability, and programmatic availability, among others. This 
would be a relevant topic for future examination by VA and our 
office.
    Question. In your testimony you talk about the 
implementation of a new hotline through the VA, and in 
cooperation with SAMSHA, to help respond to the emergency 
mental health needs of veterans. I applaud the VA and SAMSHA 
for their efforts and hear that since the end of July when the 
hotline went into effect; more than 170 Oregon veterans have 
been helped. Do you know how the training for those who answer 
the calls from veterans differs from the training for those who 
help on the nationwide hotline that SAMSHA runs for the general 
population?
    Answer. The primary difference between training for the VA 
suicide hotline and training for other major suicide hotlines 
is the specific focus on veterans and their issues. VA hotline 
officials reported that the phones are staffed with 9 social 
workers, 7 psychiatrically focused registered nurses, and 4 
addiction therapists. Prior to taking calls, clinical staffers 
receive approximately 40 hours of suicide prevention training, 
which initially is general in nature but then moves to veteran 
specific issues with role plays based on actual calls from 
veterans.
    Question. In your testimony you mention that the VA does 
not adequately tap into the linkages in communities that serve 
older veterans such as the aging network, including senior 
centers, as well as faith-based organizations and other groups 
that work with or serve seniors who are veterans. Why do you 
think this is the case and how can we encourage the VA to reach 
out more frequently and consistently to groups we know can help 
identify needs for aging veterans?
    Answer. One of the initiatives in the Veterans Health 
Administration Strategic Plan concerns using the VA Chaplaincy 
service to facilitate community outreach. As of the time of our 
inspection, no central action had taken place on this 
initiative, although some individuals facilities had 
implemented innovative outreach programs on a local level. I do 
not know why VA has not optimized community linkages for 
reaching out to aging veterans. I believe that it would benefit 
VA to look at and evaluate the more promising of these pockets 
of innovation and community outreach as applicable to aging 
veterans and to consider implementing similar efforts on a 
system wide basis.
                                ------                                


     Responses to Senator Smith's Questions from Larry Reinkemeyer

    Question. In your testimony you mention that more than 
70,000 veterans in the 10 VA medical facilities you audited had 
consult referrals from their doctors that were more than seven 
days old and that, according to VA policy, they should have 
been included on the VA wait list. However, you later mention 
that these facilities actually had a combined wait list of only 
2,600. Does this mean that these 10 facilities alone are 
excluding more than 67,000 veterans from their wait list and 
therefore vastly under-reporting need?
    Answer. The facilities were under-reporting the number of 
veterans on their waiting lists but the exact number is unknown 
and because our review was based on a non-random sample, we 
cannot project our conclusion across the entire 70,000 
consults. VHA's data (consult tracking report) identified over 
70,000 consults for veterans who did not have an appointment 
and were not on the facilities waiting list. According to 
medical facility personnel, the consult tracking report did not 
always reflect the actual consult status because clinic 
personnel did not always update the consult after action was 
taken. To substantiate VHA's data, we reviewed a non-random 
sample of 300 consult referrals and found that 61 percent of 
the associated veterans should have been on the waiting list 
and more than half of those had been waiting more then 30 days. 
The remaining referrals had already been acted on but facility 
personnel had not updated the records to reflect the true 
status (for example, completed or discontinued).
    Follow up a: What impact do these huge discrepancies have 
on the VA's budgeting and planning processes?
    Answer. A basic premise to budgeting and planning is that 
budgeting should meet demand. If the demand is under-reported, 
then information relied upon for budgeting and planning 
decisions are potentially flawed and could result in 
insufficient allocation of staff and other resources.
    Follow up b: Is Congress getting accurate information with 
which to make decision?
    Answer. No, our report clearly shows that waiting times and 
waiting lists are not reliable.
    Question. In your testimony you discuss your audit findings 
that many of the veterans who were waiting on a consult request 
to actually be scheduled, had no action on that request by 
schedulers for more than 30 days. You mention many factors that 
could contribute to this, including a shortage of scheduling 
staff, but one you don't really mention is physician 
availability. Did you look into the possibility that they are 
not putting veterans on waiting lists or even attempting to 
schedule appointments because of a lack of time for existing 
physicians to see them?
    Answer. We did not determine the impact of physician 
availability on waiting lists during this review.
    Follo up: Does the VA need more medical professionals?
    Answer. The focus of our audit was on waiting times and not 
on staff resources.
    Question. Your testimony mentions the fact that schedulers 
may have been incorrectly interpreting the guidance from their 
managers to reduce wait times and therefore were essentially 
gaming the scheduling process. Do you think that this gaming 
was unintentional or do you think there are incentives for 
managers and facilities in place that would encourage some of 
these practices?
    Answer. Because of the audit's short timeframe, we did not 
address the intentional gaming of the system on this audit. 
However, we did find indications that this was happening in our 
July 2005 audit and, based on results of this audit, it is 
possible that it is still occurring.
    In 2005 we conducted a nation-wide survey of schedulers 
where over 15,000 schedulers responded and found that:
     7 percent were directed by their supervisors or 
managers to schedule appointments contrary to policy.
     41 percent were directed to find the first 
available appointment slot and then use that as the desired 
date of care effectively reducing the waiting time to 0 days.
     10 percent felt pressure from leadership to keep 
waiting lists short which caused them to circumvent established 
scheduling procedures.
    The visibility and the emphasis to reduce waiting times and 
waiting list would certainly provide an incentive to some 
managers to manipulate the system in order to show better 
performance.
                                ------                                


        Responses to Senator Smith's Questions from Mark Kaplan

    Question. What do you feel are the most important 
characteristics of veterans that make more at risk for suicide 
than the general population?
    Do you feel that there are other factors that are unique or 
more acute for veterans that put them at greater risk for 
suicide such as the fact that they served in a war, that there 
is greater stigma in the military, or perhaps there is a 
difference between access to treatment through the VA system 
versus other community-based mental health systems?
    Answer. Indeed, there are several factors that put veterans 
at a higher risk for suicide compared to their nonveteran 
counterparts. In a national study of more than 320,000 men, we 
showed that those who served in the military, regardless of age 
or era of service, were twice as likely as their nonveterans to 
complete suicide. Although we did not draw firm conclusions 
about what makes veterans more at risk for suicide than the 
general population, we did find that that veterans with 
disabilities that limited their ability to function in their 
daily activities was one of the highest suicide risk factors. 
With the projected increase in veterans with disabilities among 
those who served in the Afghanistan and Iraq conflicts, there 
will be a need for more interventions by both VA and community-
based mental systems. Furthermore, I noted in my testimony that 
men in psychological distress face stigma and barriers and are 
less likely to seek treatment than equally distressed women.
    Question. What do you feel is the best way to help these 
veterans and to ensure that the doctors who are seeing them, 
whether they are mental health specialists or their general 
physician, are appropriately trained on the specific needs of 
veterans?
    Answer. According to my colleague and co-author, Dr. 
Bentson McFarland, Professor of Psychiatry at the Oregon Health 
and Science University, primary care physician assessment and 
management of depression and suicide prevention for veterans 
could be encouraged by expanding reimbursement so that primary 
care providers can implement and sustain evidence-based 
procedures aimed at detection and treatment of veterans with 
major depressive disorder. Federally funded research projects 
over the past twenty years have shown that primary care 
providers can do an excellent job at detecting and treating 
people with major depressive disorder. The key to success is 
inclusion in primary care practices of ``care managers'' who 
have expertise in mental health. Care managers are nurses or 
counselors (usually with masters degrees) who follow protocols 
for detection and treatment of people with depression. Primary 
care providers facilitate treatment by prescribing medication 
as needed. This care management approach has been well studied 
and shown to be effective. Unfortunately, this model has rarely 
been sustained owing to lack of reimbursement. Primary care 
providers nowadays are notinfrequently in financial difficulty 
and are unable to sustain evidence-based practices such as care 
management. Congress should direct the Department of Veterans 
Affairs to provide reimbursement for primary care depression 
detection and management for veterans unable to be served 
within the Veterans Affairs system.

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