[Senate Hearing 110-690]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-690

               HEARING ON PENDING HEALTH CARE LEGISLATION

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 21, 2008

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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



                                 -----



                   U.S. GOVERNMENT PRINTING OFFICE
42-808 PDF                  WASHINGTON : 2009
----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, 
Washington, DC 20402-0001





                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Larry E. Craig, Idaho
Bernard Sanders, (I) Vermont         Kay Bailey Hutchison, Texas
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Johnny Isakson, Georgia
Jon Tester, Montana                  Roger F. Wicker, Mississippi
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director














                            C O N T E N T S

                              ----------                              

                              May 21, 2008
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     8
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     3
Murray, Hon. Patty, U.S. Senator from Washington.................     1
Durbin, Hon. Richard, U.S. Senator from Illinois.................     5
Craig, Hon. Larry E., U.S. Senator from Idaho....................     7

                               WITNESSES

Cross, Gerald M., M.D., Principal Deputy Under Secretary for 
  Health, U.S. Department of Veterans Affairs; accompanied by 
  Walter Hall, Assistant General Counsel, U.S. Department of 
  Veterans Affairs; and Kathryn Enchelmayer, Director, Quality 
  Standards, Office of Quality and Performance, Veterans Health 
  Administration, U.S. Department of Veterans Affairs............    10
    Prepared statement...........................................    12
    Written views for the record submitted by VA after the 
      hearing....................................................    27
    Response to request arising during the hearing by Hon. Patty 
      Murray.....................................................    41
Carl Blake, National Legislative Director, Paralyzed Veterans of 
  America........................................................    54
    Prepared statement...........................................    56
Wilson, Joseph L., Deputy Director, Veterans Affairs and 
  Rehabilitation Commission, The American Legion.................    64
    Prepared statement...........................................    65
Ilem, Joy J., Assistant National Legislative Director, Disabled 
  American Veterans..............................................    69
    Prepared statement...........................................    70
Needham, Christopher, Senior Legislative Associate, National 
  Legislative Service, Veterans of Foreign Wars of The United 
  States.........................................................    84
    Prepared statement...........................................    86
Luke, Stan, Ph.D., Vice President for Programs, Helping Hands 
  Hawaii.........................................................    99
    Prepared statement...........................................   100
Cox, J. David, R.N., National Secretary-Treasurer, American 
  Federation of Government Employees, AFL-CIO....................   101
    Prepared statement...........................................   102
McVey, Cecilia, MHA, R.N., Former President, Nurses Organization 
  of Veterans Affairs............................................   107
    Prepared statement...........................................   109
McCartney, Donna, Chair, National Association of Veterans 
  Research and Education Foundations, and Executive Director, 
  Palo Alto Institute for Research and Education.................   110
    Prepared statement...........................................   112
Berger, Thomas J., Ph.D., Chair, National PTSD and Substance 
  Abuse Committee, on behalf of Vietnam Veterans of America......   115
    Prepared statement...........................................   116
Satel, Sally, M.D., Resident Scholar, American Enterprise 
  Institute, and Lecturer, Yale University School of Medicine....   132
    Prepared statement...........................................   133
    Response to written questions submitted by Hon. Richard Burr.   136

                                APPENDIX

Bulter, David A., Ph.D. and Frederick Erdtmann, M.D., M.P.H., on 
  behalf of the Institute of Medicine and National Research 
  Council, National Academy of Sciences; prepared statement......   141
Connors, Susan H., President/CEO, Brain Injury Association of 
  America; prepared statement....................................   143
National Coalition for Homeless Veterans; prepared statement.....   144

 
               HEARING ON PENDING HEALTH CARE LEGISLATION

                              ----------                              


                        WEDNESDAY, MAY 21, 2008

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:36 a.m., in 
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka, 
Chairman of the Committee, presiding.
    Present: Senators Akaka, Murray, Burr, and Craig.

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

    Senator Murray [presiding]. Good morning. This committee 
hearing will come to order. Our Chairman, Senator Akaka, will 
be here shortly. He has asked me to go ahead and begin the 
hearing, so I want to welcome Senator Burr and other Senators 
who will be joining us today.
    I think it is fitting that we are holding today's hearing 
so close to Memorial Day. Memorial Day is a day of remembrance 
and gratitude from a thankful Nation. Next week, we gather in 
communities throughout America among our friends and families 
and neighbors and all pause to give a quiet, humble thank you 
to those men and women who honorably gave themselves for a 
cause far greater than any one person.
    And now, as America finds itself fighting two wars, it is 
our even greater duty to not only honor those who made the 
ultimate sacrifice, but to also do everything we can to care 
for those who are still with us. These men and women deserve 
the fulfilled promises of a grateful Nation, and as a country, 
we need to work to honor these veterans' sacrifices when they 
return home.
    As everyone on this committee knows, we are charged with 
not only taking care of today's veterans, but also with 
preparing the VA for the needs of tomorrow, and one of the best 
ways I believe we can do that is to be proactive about the 
needs on the horizon, to pass the Women Veterans Health Care 
Improvement Act of 2008, which expands and improves health care 
services for women veterans in the VA system.
    Women have always played a role in our military, going back 
to the founding of our Nation. However, as we all know, in 
today's conflicts, women are playing a far different and far 
greater role. Women now make up 14 percent of our current 
active duty Guard and Reserve forces. Some units, including 
Military Police, are using an increased number of females to 
fill jobs that were traditionally held by male personnel. 
Because of the conflicts of today, we often have no clear front 
lines, but women, like all of our servicemembers, are always 
riding on dangerous patrols, guarding pivotal checkpoints, and 
witnessing the horrors of war firsthand.
    However, while women's numbers are rising on the 
battlefield, up until now, women have remained a small minority 
at the VA. According to the VA, there are more than 1.7 million 
women veterans, but only 255,000 of those women actually use 
the VA health care services. For too long, the reasons for this 
discrepancy have been elusive. But today, we are getting a 
clearer picture.
    In fact, when I first started holding roundtables around my 
home State of Washington to talk to veterans about their 
experiences with the VA, I heard almost exclusively from men. 
They would sit at the table with me. They would stand up. They 
would tell their stories and talk about their issues. But 
inevitably, as I was leaving the room, a woman would come up to 
me and whisper to me her experiences. Some told me they had 
been intimidated by the VA and viewed their local VA as a male-
only facility. Others simply told me that they couldn't find 
someone to watch their kids so they could attend a counseling 
session or find time for other care.
    But, as some Members of this Committee and those who will 
testify today know, the voices of women veterans are no longer 
whispers. Today, they are full-throated calls for equal access 
to care at the VA and I believe that now, as we sit on the 
brink of seeing more returning women veterans than ever before, 
it is time that we heed those calls. We simply cannot allow the 
attitudes of the past or the VA's lack of preparation for the 
influx of new women veterans to linger a minute longer.
    As the Independent Budget has noted, the number of women 
using VA health care services will double in less than 5 years 
if women veterans from Iraq and Afghanistan continue to enroll 
at the current enrollment rates. We need to make sure now that 
the VA is prepared to care for the needs of these honorable 
veterans today, and that is exactly why Senator Hutchinson and 
I introduced the Women Veterans Health Care Improvement Act of 
2008.
    This important legislation will increase the number of 
women accessing care at the VA by increasing the VA's 
understanding of the needs of women veterans and the practices 
that will best help them. It will do so by requiring the VA to 
study the health care needs of women who are serving or who 
have served in Iraq and Afghanistan, study the effectiveness of 
current services being provided to women veterans, study 
barriers to care for women veterans who are not accessing the 
VA system, and it will also help provide child care for the 
newborn children of a woman veteran who is receiving maternity 
care at the VA.
    This bill will implement a program to train, educate, and 
certify VA mental health professionals to care for women with 
military sexual trauma and Post Traumatic Stress Disorder. It 
will begin a pilot program that provides child care to women 
veterans that seek mental health care or other intensive health 
care services at the VA. It will begin a pilot program that 
provides readjustment counseling to women veterans in group 
retreat settings. It will make the position of Women Veterans 
Program Manager at all VA medical centers a full-time position. 
And finally, it will include on VA advisory boards women that 
are recently separated from service.
    Now, I know that the VA recognizes they need to improve 
service for our women veterans, and the Department has taken 
several steps to do that. But a lot more needs to be done if we 
are going to ensure that women get access to equal care at the 
VA for health care benefits and services, and that the VA 
health care system is tailored to meet the unique needs of our 
women veterans.
    Planning for the wave of new women veterans is going to be 
a difficult and complex task, but the effort has to start today 
and it has to start with this bill.
    Thank you very much. I see our Chairman has joined us, as 
well, and Mr. Chairman, I will turn to Senator Burr for his 
opening remarks and turn the gavel back over to you. Thank you 
very much.
    Chairman Akaka [presiding]. Thank you very much.

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

    Senator Burr. I thank my colleague and aloha, Mr. Chairman.
    Chairman Akaka. Aloha.
    Senator Burr. And aloha to our witnesses. We are grateful 
for your willingness to be here.
    Before I get started on the subject of today's hearing, I 
would like to address a recent incident at the Temple, Texas, 
VA Medical Center. I and the Chairman, as well as other 
Members, were disappointed to learn that someone at the 
facility suggested, and I quote, ``that we refrain from giving 
a diagnosis of Post Traumatic Stress Disorder straight out,'' 
unquote. Veterans trust the VA to give them the best care 
possible. Senator Akaka and I have called on the VA Inspector 
General to investigate this incident to make sure that no 
veteran was negatively impacted by this suggestion. I look 
forward to the IG's report and I look forward to hearing more 
from the VA in the coming weeks.
    In light of the extensive agenda before us today, I will 
focus my remarks on one particular bill on today's agenda, S. 
2573, the Veterans Mental Health Treatment First Act. I think 
everyone on this committee can agree that recovery and 
rehabilitation must be the focus of helping veterans with 
mental illness. Advances in proven therapies and medicines have 
given veterans more hope than ever that recovery is, in fact, 
possible. Our job is to figure out how we can best serve our 
veterans who are faced with the challenges of PTSD. The 
Treatment First Act is an effort to both provide early 
treatment and to put VA's emphasis where it belongs, on 
wellness and recovery.
    Let me outline some facts that lead me to believe that a 
new approach to the care for veterans with service-related 
mental illness is absolutely essential. One, there has been a 
150 percent increase in the number of veterans who are on 
disability for Post Traumatic Stress Disorder since the year 
2000. Two, the evidence indicates that disability ratings for 
those with PTSD get progressively worse over time.
    Three, the Veterans Disability Commission encouraged 
Congress to create a modern disability compensation system that 
used, and I quote, ``a new holistic approach to PTSD, coupling 
PTSD treatment, compensation, and vocational assessment,'' 
unquote. The Disability Commission also recommended that, and I 
quote, ``treatment should be required and its effectiveness 
assessed to promote wellness of the veteran,'' unquote. In 
other words, the Commission recommended that disability 
compensation go hand-in-hand with treatment.
    Research published in the American Journal of Public Health 
by Dr. Christopher Frueh from the University of Hawaii's 
Department of Psychology concluded, and I quote, ``an 
accumulating body of empirical data suggests that current VA 
psychiatric disability and rehabilitation policies for combat-
related Post Traumatic Stress Disorder are problematic. Current 
VA disability policies require fundamental reform to bring them 
into line with modern science and medicine.'' What a novel 
thing. That is a problem, Mr. Chairman. We have a system that 
results in our veterans who are diagnosed with service-related 
mental illness just getting worse and worse and never better.
    In the last few years, we have been investing in the health 
care side of the VA's ledger to improve the mental health 
system. I would like the VA to start tracking how well its 
treatment programs are doing in terms of getting our veterans 
better and not worse. I believe that treatment can and should 
work.
    Let me outline the promise that treatment holds. First, I 
will quote from a recently published RAND Corporation study on 
mental health, and I quote, ``Ongoing advances in treatment 
provide hope for a new generation of servicemembers suffering 
the psychological effects of warfare. Medical science provides 
a better understanding than ever before of how to treat the 
psychological effects of combat,'' unquote.
    Second, the RAND report also suggests that with evidence-
based intervention, and I quote, ``complete remission can be 
achieved in 30 to 50 percent of the cases of PTSD and partial 
improvement can be expected by most patients,'' clearly not the 
trend that we see within the system today. Moreover, the RAND 
report notes that there is a, and I quote, ``hopeful 
possibility that PTSD may be reversible if patients can be 
helped to cope with the stresses in their current life.''
    Our challenge, then, is to focus on treatment, wellness, 
and recovery as a first priority and not sentence veterans to a 
lifetime of permanent disability. We really owe it to them to 
do better than we do today.
    That is the concept behind Treatment First, S. 2573, which 
would allow veterans who have been diagnosed with service-
related mental illness to enter into a mental health treatment 
program and provide them with a wellness stipend of up to 
$11,000. A wellness stipend is important so that veterans with 
mental health problems can still provide for their families 
while on the road to recovery. All the veterans would have to 
do is participate fully in the treatment program and agree to a 
short delay on filing disability until treatment has ended. The 
hope with my bill is that treatment will work and the veterans 
can then resume a full and productive life. VA disability 
payments will still be there at the end of the treatment for 
those who need it. And because it is a voluntary program, 
veterans can, at any time, file disability if that is, in fact, 
their desire.
    Mr. Chairman, I said it on the floor when I introduced this 
bill, there is no catch to this legislation. I see a real 
problem when I see veterans who get steadily worse and not 
better. This is a horrible outcome for everybody, especially 
our veterans who are denied a full and productive life. That is 
why I think it is time that we look at new ideas for solving 
what I consider to be a real tragic problem.
    Mr. Chairman, when I visit our men and women at Walter Reed 
and back home in North Carolina, I see the fierce determination 
they have to succeed in life, to overcome adversity, and not to 
be defined as disabled. I believe our veterans want an 
integrated system of health and benefits to help each one of 
them reach their goals. All this committee has to do is give 
them the tools to get there.
    I thank my colleagues for once again hearing me 
passionately speak about this. I realize more than anybody that 
Veterans Service Organizations do not like change. This is real 
change. This committee cannot accept the status quo, and I 
don't believe the Department of Veterans Affairs wants to. But 
more importantly, our veterans don't want to. This is a real 
opportunity to change the lives of people who have different 
expectations than previous generations of veterans. Let us 
seize on this opportunity to do it.
    I thank the Chair.
    Chairman Akaka.  I thank you very, very much, Senator Burr, 
for your statement.
    I am going to introduce Senator Dick Durbin from the State 
of Illinois--my distinguished colleague who has just arrived--
and following him, I will ask for the remarks of Senator Craig. 
I will then make my statement.
    Senator Durbin has asked to be here to make remarks on 
legislation that he has introduced. I am glad to have you here, 
Senator Durbin.

               STATEMENT OF HON. RICHARD DURBIN, 
                   U.S. SENATOR FROM ILLINOIS

    Senator Durbin.  Thank you very much, Mr. Chairman, Senator 
Burr, Senator Craig, and Senator Murray. Thank you for allowing 
me to make a few remarks here at this hearing.
    This is the first time that I have appeared before the 
Senate Veterans' Affairs Committee and I come here today to 
speak to you about S. 2377, the Veterans Health Care Quality 
Improvement Act, which Senator Obama and I have introduced. We 
were drawn into this issue because of an extraordinary 
situation at one of our veterans facilities.
    In Marion, Illinois, in Southern Illinois, there is a VA 
facility that has been there for many years and serves the 
veterans of Southern Illinois and Kentucky and Missouri who 
really treasure it. The men and women who go to the Marion VA 
love it and speak very highly of it. I would visit there from 
time to time and just thank goodness that we have, in a rural 
area of Illinois, such a great VA facility.
    And then, in August of last year, there was a tragedy. 
Reports came out of the Marion VA facility that an 
extraordinary number of veterans were dying in surgery. Because 
of the number and because it was much larger than ever should 
have been anticipated, the Veterans Administration decided to 
suspend the surgery and surgical activities at the Marion VA to 
find out what was wrong.
    Their investigation came up with some information that was 
very troubling--troubling in terms of Marion VA and its great 
reputation, troubling in terms of the veterans who counted on 
it, and troubling, as well, as we reflect on the new pressures 
and demands on our Veterans Administration with wars in Iraq 
and Afghanistan. As it turned out, there was at least one 
doctor, and maybe more, who should not have been practicing 
medicine at that facility.
    Before I came to Congress, I was a practicing attorney. I 
used to defend doctors in medical malpractice cases and 
prosecute them, as well; so I have been on both sides of the 
table. And the VA came in and explained to me about this 
doctor, this controversial doctor, the surgeon who had been 
licensed to practice medicine in the State of Massachusetts. 
The VA said that they learned after he was on the VA staff that 
his license to practice medicine in Massachusetts had been 
surrendered by this doctor, and that the Massachusetts Medical 
Board told the VA there was no disciplinary action involved.
    Well, I can tell you as a cynical lawyer, I didn't believe 
it. It was clear he had cooked a deal, a deal which said, I 
will give up my license to practice in your State if you will 
just drop whatever charges you have against me. And that is 
what happened.
    This doctor had been involved in serious malpractice cases 
in Massachusetts. The VA didn't know it. They didn't know the 
circumstances for the surrender of his license. He then went to 
my State of Illinois and was involved in surgeries that took 
the lives of nine of our veterans. That is the reality. And the 
reality is that the surgical unit has not been fully restored--
even as of today--at that Marion facility.
    That is the reason why we introduced this bill. I want to 
make sure that we have the highest quality medical 
professionals--doctors and nurses and others--for our veterans. 
It is one thing to have a great building and to put in great 
technology, but we have to have the men and women there who can 
deliver the highest quality services. We failed in Marion. We 
failed with this doctor, and I don't want us to fail again.
    Senator Obama and I introduced this legislation. There are 
several points that I will just raise with you and I hope you 
will consider, either in this bill or as part of another bill.
    Vet the doctors who apply to work for the VA. We have to 
have a better vetting process. We make a recommendation in this 
bill that the VA doesn't like at all, which may be the reason 
they oppose it. It says that you have to be licensed in the 
State where you are practicing. If you are in a VA hospital in 
Illinois, you have to have medical privileges in Illinois. The 
reason is to make sure that there is a disciplinary board that 
is vetting each one of these doctors and looking closely at 
their backgrounds before they show up at a hospital in my 
State, North Carolina, Hawaii, Washington, or Idaho. I think 
that is the basics. That really is the minimum that we should 
expect.
    Second, we expand quality control programs in the VA health 
care system to create new Quality Assurance Officers to give VA 
employees more opportunities to raise concerns, whistleblowers 
who can speak out. When we went back into this Marion VA 
facility after they had suspended surgical privileges. I had a 
young man on my staff who was a doctor. He started talking to 
the nurses--the surgical nurses--at the Marion VA who said, 
``We saw this coming. This man was doing things far beyond his 
expertise. He was performing surgeries which we have never 
performed at the Marion VA.'' The nurses knew it. They were 
afraid to speak out. That has to change.
    Third, our legislation creates incentives to encourage 
high-quality doctors to practice at veterans hospitals. Doctors 
who agree to practice in hard-to-serve areas would benefit from 
student loan forgiveness and tuition reimbursement programs. 
They also have a chance to enroll in the Federal Employee 
Health Insurance Program.
    Medical facilities in the VA should be required to 
establish affiliations with nearby medical schools. These 
partnerships would expose young medical students to a possible 
career in VA. In return, the VA would benefit from the energy 
of these young students working in these facilities.
    Finally, the bill would instruct the VA to increase its 
recruitment of experienced doctors who are willing to practice 
part-time to care for our veterans.
    I hope what happened to Senator Obama and me at the Marion 
VA never happens to you. We have a special obligation to make 
sure it doesn't. I hope you will consider this bill as part of 
the solution.
    Thank you for allowing me to testify.
    Chairman Akaka. Thank you very much, Senator Durbin.
    And now we will hear from Senator Craig.

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

    Senator Craig. Thank you, Mr. Chairman. Senator Durbin, 
thank you for bringing us that message. This Committee has been 
and will always be focused on quality health care for our 
veterans, as is--and I have to say--as is the VA. That doesn't 
mean that it is perfect, and you have obviously found a 
glitch--a very critical one. Thank you.
    Mr. Chairman and Ranking Member Burr, thank you again for 
holding this hearing on a broad panoply of issues. I come 
primarily this morning to speak of my cosponsorship to the 
legislation that Senator Burr spoke so passionately about a few 
moments ago, S. 2573, the Veterans Mental Health Treatment 
First Act. I am here in support of it because it would begin 
the coordination of care that is needed when it comes to 
treating mental health.
    Currently--and I think the Senator has made this clear--
there is a lack of coordination between the treatment provided 
by VHA and the disability payments made by VBA. S. 2673 does 
not stop a veteran from filing a disability claim for PTSD, it 
merely pauses this process so the veteran can focus on trying 
to get healthy. We are all about health and restoring people at 
the VA. And in today's modern medicine, one trip to Walter Reed 
(as most of us have taken), we can clearly see that we are 
matching modern medicine with the desire of the modern veteran: 
to get whole, to get healthy, to go back to their communities, 
to be a part of their community in a full and productive way.
    It is naive to think that disability ratings by VA and the 
payments that come with those ratings have no impact on a 
person's health, particularly when the willingness of the 
patient to get well plays a significant part in the success of 
their recovery. When you tell someone that has been living an 
active, healthy life that they are permanently disabled and 
give them a lifetime payment to reflect that, I believe, has a 
tremendous impact on their psyche. It makes it all the more 
difficult to get to the state of mind that is, at least in my 
opinion, necessary to tackle the mental health problems that 
they may be experiencing.
    In the testimony submitted by VA, there are some valid 
concerns about S. 2573 that could be used to improve the 
legislation. But I do not agree with the VA's dismissal of the 
legislation because it is too difficult to implement. Mr. 
Chairman, there really isn't anything too difficult if it comes 
to bringing our veterans back to wholeness, both physically and 
mentally. Our focus needs to be on making veterans healthy 
again in all the ways we possibly can.
    Unfortunately, it is clear that the current strategy to 
treat PTSD isn't working as well as we would want it to. 
According to disability ratings, veterans who are diagnosed 
with PTSD don't get better. They, in many instances, get worse. 
According to the 2005 review of the VA Inspector General, the 
rating evaluations typically increase over time until the 
disability rating reaches a full 100 percent.
    VA is doing a tremendous job when it comes to treating the 
physical wounds of our veterans. While I don't pretend to have 
all the answers, I think VA needs to be willing to try new 
strategies when it comes to treating PTSD so that we can be as 
successful with the minds of our veterans as we are now with 
their bodies. That is the job of this Committee, to make sure 
that happens. I think the Senator has brought us a very 
instructive and creative piece of legislation that advances 
that; and, as he said and went into further detail, it takes 
nothing away from the veteran having what he or she deserves in 
the full process of time. But what they most deserve is our 
commitment to make them as whole as we possibly can for the 
work which they provided for this Nation.
    Thank you.
    Chairman Akaka. Thank you very much, Senator Craig.

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

    Let me add my welcome to the panel and to those who are 
here today.
    We have another lengthy agenda that reflects the work and 
commitment of many members on both sides of the aisle on this 
Committee. The health care bills before us today address 
crucial issues which seek to improve services to veterans. I 
anticipate that from today's hearing, we will be able to 
develop another strong package of veterans health legislation. 
I will briefly highlight a few of the bills on our agenda.
    The Veterans Medical Personnel Recruitment and Retention 
Act of 2008 is based on extensive committee oversight, 
including our recent hearing on personnel issues. In the face 
of competition from other health care systems, VA frequently 
has difficulty recruiting and retaining personnel, particularly 
nurses and senior executives. To make matters worse, a 
significant portion of the VA nursing workforce will be 
eligible to retire within the next decade. This bill would 
provide the tools and flexibility for VA to attract the best 
personnel and deliver the best care for veterans.
    Servicemembers and their families face many challenges as 
they return to civilian life. S. 2796 would establish pilot 
programs on the use of community-based organizations. The 
programs would assist transitioning veterans and their families 
as they access VA care and benefits and reintegrate into 
civilian life. VA has made significant strides in reaching out 
to provide these services; and I believe this legislation will 
provide further support to veterans.
    Other bills before us seek to address a wide range of 
pressing needs. There are bills to prevent homelessness, assist 
family caregivers, and improve mental health services. It is 
this last topic, improving mental health care for veterans, 
which continues to get attention from this Committee, as you 
have heard. For the information of Members and others with an 
interest in the Committee's work, we have just scheduled a 
hearing on the current public perception of how mental health, 
and PTSD specifically, is dealt with by VA. While there has 
been much attention to an e-mail from one VA clinician which 
raised questions for many about the possible suppression of 
PTSD as a diagnosis, I am concerned that the suppression of 
PTSD both in terms of compensation and treatment may be, in 
fact, much more widespread.
    The bipartisan veterans mental health care bill approved by 
this Committee last year, and now on the Senate calendar, is a 
comprehensive approach to improving PTSD and substance abuse 
care. Yet, there are objections to Senate action on this bill. 
Senator Burr and I are trying to address the pending objections 
now and hope this bill can pass the Senate before Memorial Day.
    Finally, I am well aware that there are a substantial 
number of bills under consideration today and that several of 
them have been added to the agenda only recently. As a result, 
not all witnesses have had the opportunity to review them and 
formulate positions. Therefore, the Committee will hold the 
record of this hearing open for 2 weeks so that witnesses can 
submit supplemental views on any legislative item. It is 
important that we have your input well in advance of markup 
that is tentatively scheduled for June.
    I thank the witnesses for being here today and look forward 
to hearing your testimony on legislation before the Committee.
    I want to welcome our principal witness from the VA, Dr. 
Gerald Cross, Principal Deputy Under Secretary for Health. He 
is accompanied by Walter Hall, Assistant General Counsel, and 
by Kathryn Enchelmayer, Director of Quality Standards for the 
VHA's Office of Quality and Performance. Again, I thank you for 
being here. VA's full testimony will appear in the record.
    Dr. Cross, will you begin.

  STATEMENT OF GERALD M. CROSS, M.D., PRINCIPAL DEPUTY UNDER 
  SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
  ACCOMPANIED BY WALTER HALL, ASSISTANT GENERAL COUNSEL, U.S. 
   DEPARTMENT OF VETERANS AFFAIRS; AND KATHRYN ENCHELMAYER, 
DIRECTOR, QUALITY STANDARDS, OFFICE OF QUALITY AND PERFORMANCE, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

    Dr. Cross. Good morning, Mr. Chairman and Members of the 
Committee, and thank you for inviting me to present the 
administration's views on a number of bills that would affect 
the Department of Veterans Affairs' benefits and services. I 
would also like to thank you for introducing four bills on 
behalf of the Department. Those are S. 2273, S. 2797, S. 2889, 
and S. 2984. Among the other bills, the Department is pleased 
to support in part S. 2799 and S. 2937. We are unable to 
provide views, however, on S. 2926, S. 2963, and S. 2969 at 
this time, but we will submit them for the record.
    Joining me today are Walt Hall, Assistant General Counsel, 
and Kathryn Enchelmayer, Director of Quality Standards from the 
Office of Quality and Performance; and sir, I would like to 
request that my written statement be submitted for the record.
    Chairman Akaka. It will be included in the record.
    Dr. Cross. Thank you, Mr. Chairman, for introducing S. 2797 
on our behalf. Since our last communication on this proposal, 
VA has developed a more effective plan for Denver veterans. My 
prepared statement details our new vision. In addition to 
constructing a new state-of-the-art VA health care center, we 
propose to partner with the nearby University of Colorado 
Hospital by leasing inpatient space in the new tower that they 
intend to build there. VA would have its own building entrance, 
its own lobby, and the VA floors would be staffed by VA health 
care professionals. This model allows the VA to adjust to 
changing demographics and treatment methods. Our overall plan 
for serving Rocky Mountain veterans also includes a large new 
outpatient clinic in Colorado Springs.
    VA strongly supports enhancements for the care of women 
veterans and we support several provisions of S. 2799, the 
Women Veterans Health Care Improvement Act of 2008. We 
generally support Section 201, which would permit us to care 
for newborns of women veterans under our maternity care. 
However, we believe that VA's obligation as a provider of 
neonatal or well baby care should be limited to care necessary 
immediately after delivery and until the mother and child are 
discharged, up to a maximum of 30 days.
    We also support Section 206, which would require VA to 
staff each medical center with a full-time Women Veterans 
Program Manager. As to the other provisions of S. 2799, we 
already have many efforts underway that we think satisfy these 
requirements of the bill. We would be happy to discuss those 
during the course of this testimony.
    S. 2377 shows the Committee's concern regarding the quality 
of care our veterans receive. We continually evaluate and 
improve our system to ensure VA standards for physician 
licensing not only meet, but also exceed, those in many outside 
health care organizations. VA, however, is a national health 
care system that uses progressive technology, such as 
telemedicine, to reach veterans in remote areas and across 
State boundaries. The requirement to mandate State licensure 
for physicians in a specific State of practice would have a 
serious negative impact on patient care. The bill would also 
severely limit VA's ability to respond during periods of 
emergency. VA's excellent performance during Hurricanes Katrina 
and Rita demonstrates the vital importance of flexibility 
during a crisis.
    VA strongly opposes S. 2824. The major provision of this 
bill would make direct patient care and the issues related to 
competence of health care providers subject to collective 
bargaining. Mr. Chairman, I do not exaggerate when I say this 
could jeopardize patient care. The Secretary and Under 
Secretary for Health are responsible for the care and safety of 
our veterans. They must be able to establish standards of 
professional conduct and competency. We believe the current 
restriction on collective bargaining rights is a sound 
compromise between VA's mission to serve America's veterans 
with the honor and care that they deserve and the interest of 
our Title 38 physicians, dentists, and nurses in bargaining 
over the conditions of their employment.
    Mr. Chairman, I agree with S. 2573's emphasis on early 
treatment intervention. I stand ready to work closely with the 
Committee to explore the full impact of this complex proposal. 
In general, the bill would establish a program under which 
veterans would receive wellness stipends for complying with 
their treatment plans and for agreeing not to pursue the 
disability claims process for those conditions until treatment 
is completed. The bill, however, only authorizes VA to treat 
specific mental health conditions under this program. VA 
believes our veterans receive the best possible care when they 
receive comprehensive care addressing all of their medical 
needs. Moreover, the bill may place physicians in a 
``Catch-22'' by requiring them to link the patient's clinical 
progress with the patient's financial interest.
    The Department of Veterans Affairs considers suicide an 
issue of great importance and we are committed to doing 
everything we can to reduce the risk to our veterans and to 
better understand this complex phenomenon. However, because VA 
relies on multiple external sources of data to create a clearer 
picture of veterans' suicide, we believe S. 2899 may not 
achieve our mutual goal of a broader and more detailed view of 
this challenging issue. To arrive at accurate figures for the 
rate of suicide, multiple data sources have to be used, 
including national data sources. As an example, in one national 
database, a non-VA database, the most current data available is 
from 2005. VA continues to develop new methods for improving 
the quality and accuracy of the data. Our experts are among the 
Nation's leaders in the study of veteran suicide and our staffs 
stand ready to work closely with your staff to better measure 
and prevent suicide.
    The Department appreciates the Committee's continued 
interest in the issues raised in the other bills under 
discussion today. We will welcome the opportunity to discuss 
VA's current efforts in these areas and proposals.
    Mr. Chairman, this concludes my prepared statement. I would 
be pleased to answer any questions you or the Members of the 
Committee may have.
    [The prepared statement of Dr. Cross follows:]
  Prepared Statement of Gerald M. Cross, MD, FAAFP, Principal Deputy, 
       Under Secretary for Health, Department of Veterans Affairs
    Good Morning Mr. Chairman and Members of the Committee: Thank you 
for inviting me here today to present the Administration's views on a 
number of bills that would affect Department of Veterans Affairs (VA) 
programs of benefits and services. With me today are Walter A. Hall, 
Assistant General Counsel, and Kathryn Enchelmayer, Director, Quality 
Standards, Office of Quality and Performance. I am pleased to provide 
the Department's views on 14 of the 17 bills under consideration by the 
Committee. Unfortunately, we received S. 2963 too late to include in 
our written statement, but we will provide views and costs for the 
record. In addition, the Administration's position is currently under 
review for S. 2969. Therefore, it is not included in our written 
statement and we will forward those views as they are available. 
Similarly, the Administration is still developing its position on S. 
2926 and we will provide those views for the record. I will now briefly 
describe the 14 bills, provide VA's comments on each measure and 
estimates of costs (to the extent cost information is available), and 
answer any questions you and the Committee members may have.
    Mr. Chairman, today's agenda includes four bills that consist of 
legislative proposals the Administration submitted to the Congress: S. 
2273; S. 2797; S. 2889, and S. 2984. Thank you for introducing these 
bills at our request. We believe each bill would significantly enhance 
the health care services we provide to veterans as well as our means of 
furnishing these benefits. I will begin my testimony by addressing the 
major health care related provisions in these important bills.
    s. 2273 ``enhanced opportunities for formerly homeless veterans 
              residing in permanent housing act of 2007''
    S. 2273 would authorize VA to conduct two 5-year pilot grant 
programs under which public and non-profit organizations (including 
faith-based and community organizations) would receive funds for 
coordinating the provision of local supportive services for very low 
income, formerly homeless veterans who reside in permanent housing. 
Under one of the pilot programs, VA would provide grants to 
organizations assisting veterans residing in permanent housing located 
on military property that the Secretary of Defense closed or slated for 
closure as part of the 2005 Base Realignment and Closure program and 
ultimately designated for use in assisting the homeless. The other 
pilot program would provide grants to organizations assisting veterans 
residing in permanent housing on any property across the country. Both 
programs would require the Secretary to promulgate regulations 
establishing criteria for receiving grants and the scope of supportive 
services covered by the grant program.
    In 1987, when VA began its specific assistance to veterans who were 
homeless, few recognized that long-term or permanent housing with 
supportive services was necessary to return these veterans to full 
function. It is now well understood that the provision of long-term 
housing coupled with needed supportive services is vital to enable them 
to lead independent lives in their communities. Although supportive 
services are widely available to these veterans through VA and local 
entities, most housing assistance that is available to them is limited 
to temporary or transitional housing. Generally sources of long-term 
housing for these veterans are lacking. Military facilities recently 
slated for closure or major mission changes may provide an excellent 
site for long-term or permanent housing for these vulnerable veterans 
who remain at risk of becoming homeless. Local redevelopment 
authorities could take these VA grant programs into account when 
designing their local plans to convert the property for use in 
assisting formerly homeless veterans. This would not only help the 
veterans but also enhance the community's efforts at economic 
revitalization. We estimate the costs associated with each of these 
pilots to be $375,000 in fiscal year (FY) 2009 and $11,251,000 over a 
5-year period.
   s. 2797 authorization of fiscal year 2009 major medical facility 
                                projects
    Section 1 would authorize the following four major medical 
construction projects:

     Construction of an 80-bed replacement facility in Palo 
Alto, California, in an amount not to exceed $54,000,000;
     Construction of an Outpatient Clinic in Lee County, 
Florida to meet the increased demand for diagnostic procedures, 
ambulatory surgery, and specialty care, in an amount not to exceed 
$131,800,000;
     Seismic Corrections on Building 1 in San Juan, Puerto 
Rico, in an amount not to exceed $225,900,000; and
     Construction of a state-of-the-art poly-trauma health care 
and rehabilitation center in San Antonio, Texas, in an amount not to 
exceed $66,000,000.

    Section 2 would authorize the following major medical facility 
projects:

     Replacement of the VA Medical Center in Denver, Colorado, 
in an amount not to exceed $769,200,000.
     Restoration, new construction or replacement of the 
medical center facility in New Orleans, Louisiana, in an amount not to 
exceed $625,000,000.

    VA received authorization for lesser sums under Public Law 109-461 
for these two major projects. In February 2008 we requested 
authorization in the amount of $769.2 million for the Denver-
replacement project. However, the Department has identified an 
alternative option to purchase land and construct the new Denver VA 
facility while also leasing beds from the University of Colorado 
Hospital. Since our fiscal year 2009 major-facility-authorization 
request was submitted in February, we met with officials of the 
University of Colorado and the new University of Colorado Hospital 
(UCH) to discuss how best to replace the services and improve the 
access now being provided by the aging VA Medical Center in Denver. We 
are still finalizing the details of this approach, but our preliminary 
analysis shows that it would be better, for several reasons, to lease 
space in the inpatient unit that UCH plans to build and to have VA's 
new state-of-the-art health care facility focus on the provision of 
primary and specialty care, outpatient surgery, and nursing home care. 
This proposed and innovative VA partnership with UCH would also extend 
to the sharing of certain adjunct inpatient resources, such as 
laboratory and medical-imaging services, and include VA's leasing 
research space from the University of Colorado Denver. The leased 
inpatient space would be staffed by VA health-care professionals and 
accessed via a separate VA entrance and lobby. In all respects to our 
patients, it would be a VA facility. This change in construction plans 
would more effectively increase and improve veterans' access to care 
throughout the Rocky Mountain region. As part of this strategy, we 
would need to additionally seek authority to enter into a contract for 
a lease for an outpatient clinic in Colorado Springs, Colorado; the 
revised amount for this lease would exceed the current request. We will 
provide Committee the final authorization amounts needed for these 
projects shortly.
    Section 3 would authorize VA to enter into leases for the following 
twelve facilities:

     Brandon, Florida, Outpatient Clinic, $4,326,000;
     Colorado Springs, Colorado, Community-Based Outpatient 
Clinic, $3,995,000; (the final amount needed for this project is 
pending)
     Eugene, Oregon, Outpatient Clinic, $5,826,000;
     Green Bay, Wisconsin, Expansion of Outpatient Clinic, 
$5,891,000;
     Greenville, South Carolina, Outpatient Clinic, $3,731,000;
     Mansfield, Ohio, Community-Based Outpatient Clinic, 
$2,212,000;
     Mayaguez, Puerto Rico, Satellite Outpatient Clinic, 
$6,276,000;
     Mesa, Arizona, Southeast Phoenix Community-Based 
Outpatient Clinic, $5,106,000;
     Palo Alto, California, Interim Research Space, $8,636,000;
     Savannah, Georgia, Expansion of Community-Based Outpatient 
Clinic, $3,168,000;
     Sun City, Arizona, Northwest Phoenix Community-Based 
Outpatient Clinic, $2,295,000; and
     Tampa, Florida, Primary Care Annex, $8,652,000.

    Section 4 would authorize for appropriation the sum of $477,700,000 
for fiscal year 2009 for construction of the four major medical 
projects listed in Section 1 and $1,394,200,000 for the two projects 
listed in Section 2. Section 4 would also authorize for appropriation 
for fiscal year 2009 $60,114,000 from the Medical Facilities account 
for the leases listed in Section 3. However, we will likely revise our 
request for both those Section 2 construction projects and the Section 
3 leases. Our final recommendation on the amounts will be provided to 
the Committee shortly.
              s. 2889 ``veterans health care act of 2008''
    Mr. Chairman, you have asked us to testify on sections 2, 3, 4, 5, 
and 6, of S. 2889. Section 2 would authorize VA to contract for 
specialized residential care and rehabilitation services for veterans 
of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) 
who: (1) suffer from Traumatic Brain Injury, (2) have an accumulation 
of deficits in activities of daily living and instrumental activities 
of daily living that affects their ability to care for themselves, and 
(3) would otherwise receive their care and rehabilitation in a nursing 
home. These veterans do not require nursing home care, but they 
generally lack the resources to remain at home and live independently. 
This legislation would enable VA to provide them with long-term 
rehabilitation services in a far more appropriate treatment setting 
than we are currently authorized to provide. VA estimates the 
discretionary cost of section 2 to be $1,427,000 in fiscal year 2009 
and $79,156,000 over a 10-year period.
    Section 3 would require VA to provide full-time VA physicians and 
dentists the opportunity to continue their professional education 
through VA-sponsored continuing education programs. It would also 
authorize VA to reimburse these employees up to $1000 per year for 
continuing professional education that is not available through VA-
sources. Currently, VA is required by statute to reimburse each of 
these individuals up to $1000 per year for expenses they incur in 
obtaining continuing education, even though VA has the capacity and 
resources to meet most of their professional continuing education needs 
in-house. Enactment of section 3 would result in cost-savings to VA, 
while serving as an effective recruitment and retention tool for the 
Veterans Health Administration. We estimate section 3 would result in 
discretionary savings of $8,700,000 in fiscal year 2009 and a total 
discretionary savings of $87,000,000 over a 10-year period.
    Section 4 would eliminate co-payment requirements for veterans 
receiving VA hospice care either in a VA hospital or at home on an 
outpatient basis. In 2004, Congress amended the law to eliminate 
copayment requirements for hospice care furnished in a VA nursing home. 
Section 4 would result in all VA hospice care being exempt from 
copayment requirements, regardless of setting. Projected discretionary 
revenue loss is estimated to be $149,000 in fiscal year 2009 and 
$1,400,000 over 10 years.
    Section 5 would repeal outdated statutory requirements that require 
VA to provide a veteran with pre-test counseling and to obtain the 
veteran's written informed consent prior to testing the veteran for HIV 
infection. Those requirements are not in line with current guidelines 
issued by the Centers for Disease Control and Prevention and other 
health care organizations, which, with respect to the issue of consent, 
consider HIV testing to be similar to other blood tests for which a 
patient need only give verbal informed consent. According to many VA 
providers, the requirements for pre-test counseling and prior written 
consent delay testing for HIV infection and, in turn, VA's ability to 
identify positive cases that would benefit from earlier medical 
intervention. As a result, many infected patients unknowingly spread 
the virus to their partners and are not even aware of the need to 
present for treatment until complications of the disease become 
clinically evident and, often, acute. Testing for HIV infection in 
routine clinical settings no longer merits extra measures that VA is 
now required by law to provide. Many providers now consider HIV to be a 
chronic disease for which continually improving therapies exist to 
manage it effectively. Repealing the 1988 statutory requirements would 
not erode the patient's rights, as VA would, just like with tests for 
all other serious conditions, still be legally required to obtain the 
patient's verbal informed consent prior to testing. VA estimates the 
discretionary costs associated with enactment of section 5 to be 
$73,680,000 for fiscal year 2009 and $301,401,000 over a 10-year 
period.
    Section 6 would amend sections 5701 and 7332 of title 38, United 
States Code, to authorize VA to disclose individually-identifiable 
patient medical information without the prior written consent of a 
patient to a third-party health plan to collect reasonable charges 
under VA collections authority for care or services provided for a non-
service-connected disability. The section 5701 amendment would 
specifically authorize disclosure of a patient's name and address 
information for this purpose. The section 7332 amendment would 
authorize disclosure of both individual identifier information and 
medical information for purposes of carrying out the Department's 
collection responsibilities. VA estimates that enactment of section 6 
will result in net discretionary savings of $9,025,000 in fiscal year 
2009 and $108,858,000 over 10 years.
         s. 2984 ``veterans benefits enhancement act of 2008''
    This bill includes several important program authority extensions, 
including VA's mandate to provide nursing home care to veterans with 
service-connected disabilities rated 70 percent or more and to veterans 
whose service-connected disabilities require such care; VA's authority 
to establish research corporations; and VA's mandate to conduct audits 
of payments made under fee basis agreements and other medical services 
contracts. We urge the Committee to take action on all of the expiring 
authorities contained in the bill. Costs associated with these 
extensions will be paid from future discretionary appropriations. In 
the case of the audit-recovery program, we estimate discretionary 
recoveries in the amount of $9 million for fiscal year 2008 and a 10-
year total in recoveries of $70 million.
    A significant provision of S. 2984 would permit VA health care 
practitioners to disclose the relevant portions of VA records of the 
treatment of drug abuse, alcoholism and alcohol abuse, infection with 
the human immunodeficiency virus, and sickle cell anemia to surrogate 
decisionmakers who are authorized to make decisions on behalf of 
patients who lack decisionmaking capacity, but to whom the patient had 
not specifically authorized release of that legally protected 
information prior to losing decisionmaking capacity. It would, however, 
allow for such disclosure only under circumstances when the 
practitioner deems such content necessary for the representative to 
make an informed decision regarding the patient's treatment. This 
provision is critical to ensure that a patient's surrogate has all the 
clinically relevant information needed to provide full and informed 
consent with respect to the treatment decisions that the surrogate is 
being asked to make.
    Another key provision would authorize VA to require that applicants 
for, and recipients of, VA medical care and services provide their 
health-plan contract information and social security numbers to the 
Secretary upon request. It would also authorize VA to require 
applicants for, or recipients of, VA medical care or services to 
provide their social security numbers and those of dependents or VA 
beneficiaries upon whom the applicant or recipient's eligibility is 
based. Recognizing that some individuals do not have social security 
numbers, the provision would not require an applicant or recipient to 
furnish the social security number of an individual for whom a social 
security number has not been issued. Under this provision, VA would 
deny the application for medical care or services, or terminate the 
provision of, medical care or services, to individuals who fail to 
provide the information requested under this section. However, the 
legislation provides for the Secretary to reconsider the application 
for, or reinstate the provision of, care or services once the 
information requested under this section has been provided. Of note, 
this provision makes clear that its terms may not be construed to deny 
medical care and treatment to an individual in a medical emergency.
    Although VA has authority under 38 U.S.C. Sec. 1729 to recover from 
health insurance carriers the reasonable charges for treatment of a 
veteran's nonservice-connected disabilities, there is no permanent 
provision in title 38 to require an applicant for, or recipient of, VA 
medical care to provide information concerning health insurance 
coverage. This provision would ensure that VA obtains the health-plan 
contract information from the applicant for, or recipient of, medical 
care or services.
    Moreover, social security numbers enable VHA to make accurate and 
efficient medical care eligibility determinations and to 
instantaneously associate medical information with the correct patient 
by matching those social security numbers against records of other 
entities. Medical care eligibility determinations may be based on such 
factors as qualifying military service, service-connected disabilities, 
and household income. VHA may obtain or verify such information from 
internal VA components such as the Veterans Benefits Administration 
(VBA) which currently has authority to require social security numbers 
for compensation and pension benefits purposes, and outside sources, 
such as the Department of Defense (DOD), Internal Revenue Service and 
Social Security Administration. The availability of social security 
numbers ensures accurate matches of an individual's information with 
both internal and external sources. The income verification match 
programs are wholly dependent on social security numbers.
    Be assured that VA will provide the same high degree of 
confidentiality for the beneficiaries' health plan information and 
social security numbers as it provides to patients' medical information 
in its records and information systems. There are no direct costs 
associated with this provision other than administrative costs 
associated with collecting revenue. Those costs will be paid from 
future discretionary appropriations.
    Mr. Chairman, I now move to address the other bills on the agenda 
today.
        s. 2377 ``veterans health care quality improvement act''
    S. 2377 is an excessively prescriptive bill that would impede the 
fundamental operations and structure of VHA. We have very recently 
provided the Committee with a copy of the Department's views on H.R. 
4463, the identical House companion bill. Our views letter provides our 
detailed discussion of every provision. We would like to take this 
opportunity to discuss the provisions that cause us the most concern.
    The requirement that within 1 year of appointment each physician 
practicing at a VA facility (whether through appointment or 
privileging) be licensed to practice medicine in the State where the 
facility is located is particularly troubling and we believe harmful to 
the VA system. VA strongly objects to enactment of this provision. VHA 
is a nationwide health care system. By current statute, to practice in 
the VA system, VA practitioners may be licensed in any State. If this 
requirement were enacted, it would impede the provision of health care 
across State borders and reduce VA's flexibility to hire, assign and 
transfer physicians. This requirement also would significantly 
undermine VA's capacity and flexibility to provide telemedicine across 
State borders. VA makes extensive use of telemedicine. In addition, 
VA's ability to participate in partnership with our other Federal 
health care providers would be adversely impacted in times such as the 
aftermath of Hurricanes Katrina and Rita, where we are required to 
mobilize members of our medical staff in order to meet regional crises.
    Currently, physicians who provide medical care elsewhere in the 
Federal sector (including the Army, Navy, Air Force, U.S. Public Health 
Service Commissioned Corps, U.S. Coast Guard, Federal Bureau of Prisons 
and Indian Health Service) need not be licensed where they actually 
practice, so long as they hold a valid State license. Requiring VA 
practitioners to be licensed in the State of practice would make VA's 
licensure requirements inconsistent with these other Federal health 
care providers and negatively impact VA's recruitment ability relative 
to those agencies. In addition, many VA physicians work in both 
hospitals and community-based outpatient clinics. Many of our 
physicians routinely provide care in both a hospital located in one 
State and a clinic located in another State. A requirement for multiple 
State licenses would place VA at a competitive disadvantage in 
recruitment of physicians relative to other health care providers.
    Although the provision would allow physicians 1 year to obtain 
licensure in the State of practice, many States have licensing 
requirements that are cumbersome and require more than 1 year to meet. 
Such a requirement could disrupt the provision of patient care services 
while VA physicians try to obtain licensure in the State where they 
practice or transfer to VA facilities in States where they are 
licensed. The potential costs of this disruption are unknown at this 
time.
    Further, we are not aware of any evidence of a link between 
differences in State licensing practices and quality of patient care. 
In 1999, the General Accounting Office reviewed the effect on VA's 
health care system that a requirement for licensure in the State of 
practice would have. The GAO report concluded, in part, that the 
potential costs to VA of requiring physicians to be licensed in the 
State where they practice would likely exceed any benefit, and that 
quality of care and differences in State licensing practices are not 
directly linked. See GAO/HEHS-99-106, ``Veterans' Affairs Potential 
Costs of Changes in Licensing Requirement Outweigh Benefit'' (May 
1999).
    Another provision would provide that physicians may not be 
appointed to VA unless they are board certified in the specialties of 
practice. However, this requirement could be waived (not to exceed 1 
year) by the Regional Director for individuals who complete a residency 
program within the prior 2 year period and provide satisfactory 
evidence of an intent to become board certified. VA strongly opposes 
this provision of S. 2377. Current law does not require board 
certification as a basic eligibility qualification for employment as a 
VA physician. VA policy currently provides that board certification is 
only one means of demonstrating recognized professional attainment in 
clinical, administrative or research areas, for purposes of 
advancement. However, we actively encourage our physicians to obtain 
board certification. Facility directors and Chiefs of Staff must ensure 
that any non-board certified physician, or physician not eligible for 
board certification, is otherwise well qualified and fully capable of 
providing high quality care for veteran patients. VA should be given 
considerable flexibility regarding the standards of professional 
competence that it requires of its medical staff, including the 
requirement for specialty certification. Were this measure enacted, it 
could have a serious chilling effect on our ability to recruit very 
qualified physicians. At this point in time, VA has physician standards 
that are in keeping with those of the local medical communities.
    Moreover, the bill would provide that the board certification and 
in-State licensure requirements would take effect 1 year after the date 
of the Act's enactment for physicians on VA rolls on the date of 
enactment. This would at least temporarily seriously disrupt VA's 
operations if physicians are unable to obtain board certification and 
in-State licensure within 1 year, or are unable to transfer to a State 
where they are licensed.
    Mr. Chairman, we want to emphasize that we support the intent of 
several provisions of S. 2377 and have already been taking actions to 
achieve many of the same goals. We would welcome the opportunity to 
meet with the Committee to discuss recent actions we have undertaken to 
improve the quality of care across the system, including program 
oversight related measures.
 s. 2383 pilot program providing mobile health care and other services
    S. 2383 would require the Secretary, acting through the Director of 
the Office of Rural Health (DORH), to conduct a pilot program to 
furnish outreach and health care services to veterans residing in rural 
areas through the use of a mobile system equipped with appropriate 
program staff and supplies. The mobile system would have to be capable 
of furnishing the following services:

     counseling and education services on how to access VA 
health care, educational, pension, and other VA benefits;
     assistance to veterans in completing paperwork needed to 
enroll in VA's health care system;
     prescriptions for, and delivery of, medications;
     mental health screenings to identify potential mental 
health disorders, particularly for veterans returning from deployment 
overseas in OEF/OIF;
     job placement assistance and information on employment or 
training opportunities;
     substance abuse counseling; and
     bereavement counseling for families of active duty 
servicemembers who were killed in the line of duty while on active 
service.

    Staffing for the mobile system would be required to include VA 
physicians; nurses; mental health specialists; casework officers; 
benefits counselors, and such other personnel deemed appropriate by the 
Secretary. To the extent practicable, personnel and resources from area 
community-based outpatient clinics could be used to assist in this 
effort. The bill sets forth a number of requirements related to the 
development and coordination of the pilot program as well as to the 
conduct of the mobile system (including the minimum frequency of visits 
to rural areas participating in the pilot programs).
    S. 2383 would also mandate that the Secretary act jointly with the 
Secretary of Defense to identify veterans not enrolled in, or otherwise 
being cared for by, VA's health care system. VA would be further 
required to coordinate efforts with county and local veterans service 
officers to inform those veterans of upcoming visits by the mobile unit 
and the concomitant opportunity to complete paperwork for VA benefits. 
The bill would authorize $10 million to be appropriated for the mobile 
system each of FYs 2008 through 2010.
    VA does not support S. 2383, because it is not necessary and is 
duplicative of ongoing efforts by the Department. VA's Office of Rural 
Health is already in the process of standing up a mobile system by 
which to provide medical care and services to veterans residing in 
rural areas, and VA's Vet Centers are already using mobile units to 
furnish readjustment counseling services. The Vet Centers and VBA also 
have in place extensive outreach program targeted at these veterans. VA 
has recently created a Task Force to review the adequacy of the assets 
and resources dedicated to these efforts thus far. Particularly with 
respect to the mobile system, we urge the Committee to refrain from 
taking action on the bill until we have sufficient experience with this 
model of delivery to ascertain its effectiveness and to identify and 
cure any deficiencies. We would be glad to brief the Committee on our 
activities to date.
    As a technical matter, the duration of the pilot program is 
unclear, but we assume it is 3 years based on the terms of the bill's 
provision authorizing appropriations for FYs 2008-2010. Additionally, 
medications are currently mailed to these veterans and so it is not 
necessary to provide those benefits through a mobile system.
         s. 2573 ``veterans mental health treatment first act''
    Mr. Chairman, S. 2573 is a very ambitious bill that would provide 
the Department with significant new tools to maximize and reward a 
veteran's therapeutic recovery from certain service-related mental 
health conditions, and, to the extent possible, reduce the veteran's 
level of permanent disability from any of the covered conditions. The 
goal of the legislation is to give the veteran the best opportunity to 
reintegrate successfully and productively into the civilian community.
    Specifically, S. 2573 would require the Secretary to carry out a 
mental health and rehabilitation program for a veteran who has been 
diagnosed by a VA physician with any of the following conditions:

     Post Traumatic Stress Disorder (PTSD);
     depression; or
     anxiety disorder

that is service-related, as defined by the bill. The bill would also 
cover a diagnosis of a substance use disorder related to service-
related PTSD, depression, or anxiety. For purposes of this program, a 
covered condition would be considered to be service-related if: (1) VA 
has previously adjudicated the disability to be service-connected; or 
(2) the VA physician making the diagnosis finds the condition plausibly 
related to the veteran's active service. S. 2573 would also require the 
Secretary to promulgate regulations identifying the standards to be 
used by VA physicians when determining whether a condition is plausibly 
related to the veteran's active military, naval, or air service.
    The bill sets forth conditions of participation for the veterans 
taking part in the program. If a veteran has not filed a VA claim for 
disability for the covered condition, the veteran would have to agree 
not to submit a VA claim for disability compensation for the covered 
condition for 1 year (beginning on the date the veteran starts the 
program) or until the date on which the veteran completes his or her 
treatment plan, whichever date is earlier.
    If the veteran has filed a disability claim but it has not yet been 
adjudicated by the Department, the veteran could elect either to 
suspend adjudication of the claim until he or she completes treatment 
or to continue with the claims adjudication process. As discussed 
below, the stipend amounts payable to the veteran under the program 
will depend on which election the veteran makes.
    If the veteran has a covered condition that has been adjudicated to 
be service-connected, then the individual would have to agree not to 
submit a claim for an increase in VA disability compensation for 1 year 
(beginning on the date the veteran starts the program) or until the 
date the veteran completes treatment, whichever is earlier.
    S. 2573 would establish a financial incentive in the form of 
``wellness'' stipends to encourage participating veterans to obtain VA 
care and rehabilitation before pursuing, or seeking additional, 
disability compensation for a covered condition. The amount of the 
stipend would depend on the status of the veteran's disability claim. 
If the veteran has not filed a VA disability claim, VA would pay the 
veteran $2000 upon commencement of the treatment plan, plus $1500 every 
90 days thereafter upon certification by the VA clinician that the 
veteran is in substantial compliance with the plan. This recurring 
stipend would be capped at $6000. The veteran would receive an 
additional $3000 at the conclusion of treatment or 1 year after the 
veteran begins treatment, whichever is earlier.
    If the veteran has filed a disability claim that has not yet been 
adjudicated, the participating veteran who elects to suspend 
adjudication of the claim until he or she completes treatment would 
receive ``wellness'' stipends in the same amounts payable to veterans 
who have not yet filed a disability claim. If the participating veteran 
elects instead to continue with the claims adjudication process, the 
veteran would receive ``wellness'' stipends in the same amounts payable 
to veterans whose covered disabilities have been adjudicated and found 
to be service-connected: $667 payable upon the veteran's commencement 
of treatment and $500 payable every 90 days thereafter upon 
certification by the veteran's clinician that the individual is in 
substantial compliance with the plan. Recurring payments would be 
capped at $2000, and the veteran would receive $1000 when treatment is 
completed or 1 year after beginning treatment, whichever is earlier.
    If the Secretary determines that a veteran participating in the 
program has failed to comply substantially with the treatment plan or 
any other agreed-upon conditions of the program, the bill would require 
VA to cease payment of future ``wellness'' stipends to the veteran.
    Finally, S. 2573 would limit a veteran's participation in this 
program to one time, unless the Secretary determines that additional 
participation in the program would assist in the remediation of the 
veteran's covered condition.
    VA does not support S. 2573. While philosophically we discern and 
appreciate the aims of the bill, particularly the holistic and 
integrated approach to the receipt of VA benefits, this is a very 
complex proposal that requires further in-depth study of all of the 
bill's implications, including those related to cost. In addition, we 
have numerous concerns with the bill as currently drafted.
    S. 2573 assumes that early treatment intervention by VA health care 
professionals for a covered condition would be effective in either 
reducing or stabilizing the veteran's level of permanent disability 
from the condition, thereby reducing the amount of VA disability 
benefits ultimately awarded for the condition. No data exist to support 
or refute that assumption.
    With the exception of substance abuse disorders, we are likewise 
unaware of any data to support or refute the bill's underlying 
assumption that paying a veteran a ``wellness stipend'' will ensure the 
patient's compliance with his or her treatment program. Although there 
is a growing trend among health insurance carriers or employers to 
provide short-term financial incentives for their enrollees or 
employees to participate in preventive health care programs (e.g., 
reducing premiums for an enrollee who participate in a fitness program, 
loses weight, or quits smoking), we are unaware of any data 
establishing that these and similar financial incentives produce long-
term cost-savings to the carrier or employer. It would be extremely 
difficult, if not impossible, to quantify savings or offsets because 
there is no way to know whether a particular patient's health status 
would have worsened without VA's intervention and whether the 
intervention directly resulted in a certain or predictable total amount 
in health care expenditure savings. We would experience the same 
difficulties trying to identify what would have been the level of 
disability and costs of care for a particular veteran had he or she not 
participated in the early clinical intervention program established by 
S. 2573.
    Providing these mental health care benefits independent of the 
medical benefits package provided to enrolled veterans gives rise to 
other concerns. A veteran's mental health and physical health are 
integral, and it would be very difficult to discern if certain 
conditions or physical manifestations that may result from or be 
related to a mental health condition are covered by S. 2573. As a 
provider, VA would need to assume that this bill would cover needed 
care for physical conditions that result from, or are associated with, 
the covered mental health condition under treatment. (Our approach 
would be similar to the approach taken under the Department's authority 
in 38 U.S.C. Sec. 1720D to provide both counseling and care needed to 
treat psychological conditions resulting from sexual trauma.) For 
instance, recent scientific literature has linked heart disease to 
stress. Heart disease might at some point be linked to depression, PTSD 
and/or anxiety disorder. We believe that unless the scientific 
literature conclusively rules out an association between a covered 
mental health condition and the veteran's physical condition, the 
veteran should receive the benefit of the doubt. This could expand the 
scope of S. 2573 beyond the drafter's intent, because the types of 
physical conditions considered by the scientific community to be 
associated with mental health conditions could expand over time. Should 
this happen, S. 2573 could lead to VA essentially operating two 
different health care systems based on separate sets of eligibility 
criteria, undermining the accomplishments achieved under VA health care 
reform.
    It is also troubling to us that S. 2573 would require VA to treat 
specific diseases and not the veteran as a whole. This approach places 
VA practitioners in the difficult and untenable position of being able 
to identify conditions they cannot treat. This creates a particularly 
serious ethical dilemma for the practitioner who knows that his or her 
veteran-patient has no other access to the needed health care services. 
In our view, authority to treat specific diseases--and not the person--
is counter to the principles of patient-centered and holistic medicine.
    The ``wellness'' stipends, themselves, raise several complex 
issues. None of VA's current benefits systems is equipped to administer 
such a novel benefit, and no current account appears to be an 
appropriate funding source from which to pay them. After much grappling 
with the issue, we have concluded that because the bill would amend 
only chapter 17 of title 38, United States Code, these stipends would 
have to be administered by VHA and paid from funds made available for 
medical care.
    There would be significant indirect costs as well. VHA currently 
lacks the IT infrastructure, expertise, and staff to administer 
monetary benefits. Administering the easiest of monetary benefits would 
be challenging for VHA, but it is nearly insurmountable in connection 
with this bill, which calls for a very complex, nationwide patient 
tracking and monitoring system that also has the capacity to administer 
payments at different points in time for veterans participating in the 
program. The fact that the duration of each veteran's treatment plan is 
highly individualized only complicates the requirements of such a 
system-design, as does the fact that the bill would permit some 
veterans to receive treatment (and payment) extensions.
    As a result, we do not believe that S. 2573 would be cost-effective 
as currently drafted. The maximum we could pay any veteran under the 
bill would be $11,000; however, it is reasonable to assume that the 
costs associated with designing, operating, and administering such a 
complex benefit program would far surpass the actual amounts we would 
pay out to the veterans (individually or collectively).
    S. 2573 also places our physicians and practitioners in the 
difficult position of determining whether their patients will receive 
wellness stipends available under the program. It is quite atypical for 
a VA physician's clinical determination to have direct financial 
implications or consequences for his or her patients. VA physicians and 
practitioners seek to help their veteran-patients attain maximum 
functioning as quickly as clinically possible. S. 2573 would create 
potential conflict for our health care practitioners. They should focus 
solely on issues of health care and not feel pressure to grant requests 
for extensions of treatment in order to maximize the amount of money 
patients receive under the program.
    It would also be difficult to define ``substantial compliance,'' 
for purposes of S. 2573, in a way that is measurable and objective as 
well as not easily amenable to fraud or abuse. For instance, 
substantial compliance could be defined in part by a veteran stating 
that he or she took prescribed medications as ordered by the physician 
and VA could confirm the veteran obtained refills in a timely manner. 
But that information does not actually verify that the patient in fact 
ingested the medication or did so as prescribed. There would 
unavoidably be some patients whose motivation for participating in this 
program is strictly financial, and they would invariably find ways to 
circumvent whatever criteria we establish in order to receive their 
stipends. Although these payments would not be sizable, they are 
sufficient to entice some patients who would not otherwise access VA's 
health care system to participate in the program. We fear these 
patients would cease their treatment and stop accessing needed VA 
services once their treatment and payments end.
    Finally, if the use of ``wellness'' stipends were able to produce 
reliable, positive results in terms of patients' compliance or 
outcomes, there would then be a demand to extend this reward system to 
other VA treatment programs. And once a benefit is provided, it is 
difficult to ever repeal it. We say this only to point out that the 
cost implications in the out-years could be very difficult to estimate 
accurately.
    Costing this bill is very complex, as there is no way for us to 
determine the total number of veterans who would participate in the 
pilot program, in which year they would enter the program, their 
ultimate disability status, and the amount of medical care they would 
each require. We estimate the increase in medical administrative costs 
for every 40,000 new veterans entering the VA system to be $280 million 
per year in addition to $293,340,000 per year in maximum stipend 
payments. The estimated one-time cost for eligible living veterans is 
$6,712,891,046. These costs do not factor in the costs of developing 
the IT infrastructure needed to administer the benefit. In light of 
these serious concerns and the bill's unknown total cost implications, 
we are unable to supports its enactment.
        s. 2639 ``assured funding for veterans health care act''
    S. 2639 would establish, by formula, the annual level of funding 
for all VHA programs, activities, and functions (excluding the 
construction, acquisition, and alteration of VA medical facilities and 
provision of grants to assist States in the construction or alteration 
of State home facilities).
    VHA funding for fiscal year 2008 (the first fiscal year covered by 
the bill) would be automatically established at 130 percent of the 
amounts obligated by VHA (for all its activities, programs, and 
functions) for fiscal year 2006. Thereafter, VHA funding would be 
automatically determined by a fixed formula. The formula would, 
generally speaking, be based on the number of enrollees each year and 
the number of other persons receiving VA care during the preceding year 
multiplied by a fixed per capita amount. The per capita amount would be 
adjusted annually in accordance with increases in the Consumer Price 
Index.
    It has been VA's long-standing position that we do not support the 
concept of using a fixed formula to determine VHA funding. We believe 
that it is inappropriate and unworkable to apply an inflexible formula 
to a health care system that, by its very nature, is dynamic. The 
provision of care evolves continually to reflect advances in state-of-
the-art technologies (including pharmaceuticals) and medical practices. 
It is not possible to estimate the concomitant costs or savings 
resulting from those evolving changes. Moreover, patients' health 
status, demographics, and usage rates are each subject to distinct 
trends that are difficult to predict. The proposed formula would not 
take into account any changes in these and other important trends. As 
such, there is no certainty that the amount of funding dictated by the 
proposed formula would be appropriate to the demands that will be 
placed on VA's health care system in the upcoming years.
    Use of an automatic funding mechanism would also eliminate the 
valuable opportunity that Members of the Congress and the executive 
branch have to carry out their responsibility to identify and directly 
address the health care needs of veterans through the budget process. 
It could also depress the Department's incentive to improve its 
operations and be more efficient. It is important to note that S. 2639 
would not ensure open enrollment, as the Department would still be 
required to make an annual enrollment decision. That decision would 
directly affect the number of enrolled veterans and thus the amount of 
funding calculated under the formula. Finally, references to 
``guaranteed funding'' in the legislation may give the public the false 
impression that VA is being provided full funding for VA health care. 
It is not possible to determine whether the amount determined by the 
formula would be adequate. Because of S. 2639's potential for all of 
these unanticipated and unintended serious consequences, we continue to 
favor the current discretionary funding process that uses actuarially-
based budget estimates to project the future health care needs of 
enrolled veterans.
 s. 2796 pilot program using community based organizations to increase 
       the coordination of va services to transitioning veterans
    S. 2796 would require the Secretary to carry out a 2-year pilot 
grant program (at five VA medical centers) to assess the feasibility of 
using community-based organizations to increase the coordination of VA 
benefits and services to veterans transitioning from military service 
to civilian life, to increase the availability of medical services 
available to these veterans, and to provide their families with their 
own readjustment services. Specifically, grantees could use grant funds 
to operate local telephone hotlines; organize veterans for networking 
purposes; assist veterans in preparing applications for VA benefits; 
provide readjustment assistance to families of veterans transitioning 
from military life to civilian life; provide outreach to veterans and 
their families about VA benefits; and coordinate the provision of 
health care and other benefits being furnished to transitioning 
veterans.
    VA does not support S. 2796, because it is duplicative of the 
Department's ongoing efforts. Vet Centers are already providing much of 
the outreach, readjustment counseling services, and family support 
services that would be required by this bill. Additionally, VA case 
managers and Federal recovery coordinators already coordinate the 
delivery of health care and other VA services available to veterans 
transitioning from military service to civilian life, including 
supportive services for their families. VA is committing ever 
increasing resources to these ends. Use of grant funds to establish 
local hotlines would duplicate and dilute the effectiveness of VA's 
central hotlines. The duplicated efforts required by the bill would 
likely create significant confusion for the beneficiary. Further, 
funding family readjustment services wholly unrelated to the veteran's 
readjustment needs would divert medical care funds needed for veterans' 
health care.
    To the extent the Secretary determines external resources are 
necessary to provide the services described in the bill, VA already has 
the necessary authority to contract for them. We favor using contracts 
instead of grants, as the former allow VA to respond to changing local 
needs. That approach also gives us an accurate way to project the cost 
of the services. S. 2796, on the other hand, would not. It would also 
not be cost-effective as it is likely that a grant awarded under the 
program would be for an amount significantly less than the cost VA 
incurs in administering the grant. We also note the bill would not 
include authority for VA to recapture unused grant funds in the event a 
grantee fails to provide the services described in the grant.
    We note further that when selecting pilot sites the Secretary would 
have to consider medical centers that have ``a high proportion of 
minority groups and individuals who have experienced significant 
disparities in the receipt of health care.'' We are uncertain what this 
language means and on what basis such a determination would be based.
    Although the proposed pilot project is limited to five VA medical 
centers, the scope of the uses for the grant funds is very broad, and 
the bill does not specify the number and amount of the grants to be 
awarded. We are unable to estimate the cost estimate of S. 2796 due to 
the bill's lack of specificity.
     s. 2799 ``women veterans health care improvement act of 2008''
    In general, title I of S. 2799 would require VA to conduct a number 
of studies related to health care benefits for women veterans. Section 
101 would require VA, in collaboration with VHA's War-Related Injury 
and Illness Study Centers, to contract for an epidemiologic cohort 
(longitudinal) study on the health consequences of combat service of 
women veterans who served in OEF/OIF. The study would need to include 
information on their general, mental, and reproductive health and 
mortality and include the provision of physical examinations and 
diagnostic testing to a representative sample of the cohort.
    The bill would require VA to use a sufficiently large cohort of 
women veterans and require a minimum follow-up period of 10 years. The 
bill also would require VA to enter into arrangements with the 
Department of Defense (DOD) for purposes of carrying out this study. 
For its part, DOD would be required to provide VA with relevant health 
care data, including pre-deployment health and health risk assessments, 
and to provide VA access to the cohort while they are serving in the 
Armed Forces.
    Mr. Chairman, we do not support section 101. It is not needed. A 
longitudinal study is already underway. In 2007, VA initiated its own 
10-year study, the ``Longitudinal Epidemiologic Surveillance on the 
Mortality and Morbidity of OEF/OIF Veterans including Women Veterans.'' 
Several portions of the study mandated by section 101 are already 
incorporated into this project and planning for the actual conduct of 
the study is underway. The study has already been approved to include 
12,000 women veterans. However, section 101 would require us to expand 
our study to include women active duty servicemembers. We estimate the 
additional cost of including these individuals in the study sample to 
be $1 million each year and $3 million over a 10-year period.
    Section 102 would require VA to conduct a comprehensive assessment 
of the barriers to the receipt of comprehensive VA health care faced by 
women veterans, particularly those experienced by veterans of OEF/OIF. 
The study would have to research the effects of 9 specified factors set 
forth in the bill that could prove to be barriers to access to care, 
such as the availability of child care and women veterans' perception 
of personal safety and comfort provided in VA facilities.
    Neither do we support section 102. It is not necessary because a 
similar comprehensive study is already underway. VA contracted for a 
``National Survey of Women veterans in FY 2007-2008,'' which is a 
structured survey based on a pilot survey conducted in VISN 21. This 
study is examining barriers to care (including access) and includes 
women veterans of all eras of service. Additionally, it includes women 
veterans who never used VA for their care and those who no longer 
continue to use VA for their health care needs. We estimate no 
additional costs for section 102 because VA's own comparable study is 
underway, with $975,000 in funding committed for fiscal years 2007 and 
2008.
    Section 103 would require VA to conduct, either directly or by 
contract, a comprehensive assessment of all VA programs intended to 
address the health of women veterans, including those related to PTSD, 
homelessness, substance abuse and mental health, and pregnancy care. As 
part of the study, the Secretary would have to determine whether the 
following programs are readily available and easily accessed by women 
veterans: health promotion programs, disease prevention programs, 
reproductive health programs, and such other programs the Secretary 
specifies. VA would also have to identify the frequency such services 
are provided; the demographics of the women veteran population seeking 
such services; the sites where the services are provided; and whether 
waiting lists, geographic distance, and other factors obstructed their 
receipt of any of these services.
    In response to the comprehensive assessment, section 103 would 
further require VA to develop a program to improve the provision of 
health care services to women veterans and to project their future 
health care needs. In so doing, VA would have to identify the services 
available under each program at each VA medical center and the 
projected resource and staffing requirements needed to meet the 
projected workload demands.
    Section 103 would require a very complex and costly study. While we 
maintain data on veteran populations receiving VA health care services 
that account for the types of clinical services offered by gender, VA's 
Strategic Health Care Group for Women Veterans already studies and uses 
available data and analyses to assess and project the needs of women 
veterans for the Under Secretary for Health. Furthermore, we lack 
current resources to carry out such a comprehensive study within the 
18-month time-frame. We would therefore have to contract for such a 
study with an entity having, among other things, significant expertise 
in evaluating large health care systems. This is not to say that 
further assessment is not needed. We recognize there may well be gaps 
in services for women veterans, especially given that VA designed its 
clinics and services based on data when women comprised a much smaller 
percentage of those serving in the Armed Forces. However, the study 
required by section 103 would unacceptably divert significant funding 
from direct medical care. Section 103 would have a cost of $4,354,000 
in fiscal year 2008.
    Section 104 would require VA to contract with the Institute of 
Medicine (IOM) for a study on the health consequences of women 
veterans' service in OEF/OIF. The study would need to include a review 
and analysis of the relevant scientific literature to ascertain 
environmental and occupational exposure experienced by women who served 
on active duty in OEF/OIF. It would then have to address whether any 
associations exist between those environmental and occupational 
exposures and the women veterans' general health, mental health, or 
reproductive health.
    We do not object to section 104. We suggest the language be 
modified to allow VA to decide which organization is best situated to 
carry out this study (taking into account the best contract bid). While 
IOM has done similar studies in the past, this provision would 
unnecessarily foreclose the possibility of using other organizations. 
We estimate the one-time cost of section 104 to be $1,250,000, which 
can be funded from existing resources.
    Section 201 would authorize VA to furnish care to a newborn child 
of a woman veteran who is receiving VA maternity care for up to 30 days 
after the birth of the child in a VA facility or a facility under 
contract for the delivery services. We can support this provision with 
modifications. As drafted, the provision is too broadly worded. We 
believe this section should be modified so that it applies only to 
cases where a covered newborn requires neonatal care services 
immediately after delivery. The bill language should also make clear 
that this authority would not extend to routine baby well-baby 
services.
    We are currently unable to estimate the costs associated with 
section 201 without data on projected health care workload demands and 
future utilization requirements. We have contracted for that data and 
we will forward the estimated costs for this section as soon as they 
are available.
    Section 202 would require the Secretary to establish a program for 
education, training, certification and continuing medical education for 
VA mental health professionals furnishing care and counseling services 
for military sexual trauma (MST). VA would also be required to 
determine the minimum qualifications necessary for mental health 
professionals certified under the program to provide evidence-based 
treatment. The provision would establish extremely detailed reporting 
requirements. VA would also have to establish education, training, 
certification, and staffing standards for VA health care facilities for 
full-time equivalent employees who are trained to provide MST services.
    We do not support the training-related requirements of section 202 
because they are duplicative of existing programs. In fiscal year 2007, 
VA funded a Military Sexual Trauma Support Team, whose mission is, in 
part, to enhance and expand MST-related training and education 
opportunities nationwide. VA also hosts an annual 4-day-long training 
session for 30 clinicians in conjunction with the National Center for 
PTSD, which focuses on treatment of the after-effects of MST. VA also 
conducts training through monthly teleconferences that attract 130 to 
170 attendees each month. VA has recently unveiled the MST Resource 
Homepage, a web page that serves as a clearinghouse for MST-related 
resources such as patient education materials, sample power point 
trainings, provider educational opportunities, reports of MST screening 
rates by facility, and descriptions of VA policies and benefits related 
to MST. It also hosts discussion forums for providers. In addition, VA 
primary care providers screen their veteran-patients, particularly 
recently returning veterans, for MST, using a screening tool developed 
by the Department. We are currently revising our training program to 
further underscore the importance of effective screening by primary 
care providers who provide clinical care for MST within primary care 
settings.
    We object strongly to the requirement for staffing standards. 
Staffing-related determinations must be made at the local level based 
on the identified needs of the facility's patient population, workload, 
staffing, and other capacity issues. Retaining this flexibility is 
essential to permit VA and individual facilities to respond to changing 
needs and available resources. Imposition of national staffing 
standards would be an utterly inefficient and ineffective way to manage 
a health care system that is dynamic and experiences continual changes 
in workload, utilization rates, etc.
    Section 203 would require the Secretary to establish, through the 
National Center for PTSD, a similar education, training, and 
certification program for health care professionals providing evidence-
based treatment of PTSD and other co-morbid conditions associated with 
MST to women veterans. It would require VA to provide these 
professionals with continuing medical education, regular competency 
evaluations, and mentoring.
    VA does not support section 203 because it is duplicative of, and 
would divert resources from, activities already underway by the 
Department. VA is strongly committed to making state-of-the-art, 
evidence-based psychological treatments widely available to veterans 
and this is a key component of VA's Mental Health Strategic Plan. We 
are currently working to disseminate evidence-based psychotherapies for 
a variety of mental health conditions throughout our health care 
system. There are also two programs underway to provide clinical 
training to VA mental health staff in the delivery of certain therapies 
shown to be effective for PTSD, which are also recommended in the VA/
DOD Clinical Practice Guidelines for PTSD. Each training program 
includes a component to train the professional who will train others in 
this area, to promote wider dissemination and sustainability over time.
    Section 204 would require the Secretary, commencing not later than 
6 months after the date of enactment, to carry out a 2-year pilot 
program, at no fewer than three VISN sites, to pay veterans the costs 
of child care they incur to travel to and from VA facilities for 
regular mental health services, intensive mental health services, or 
other intensive health care services specified by the Secretary. The 
provision is gender-neutral. Any veteran who is a child's primary 
caretaker and who is receiving covered health care services would be 
eligible to participate in the pilot program. VA does not support this 
provision. Although the inability to secure child care may be a barrier 
to access to care for some veterans, funding such care would divert 
those funds from direct patient care. We estimate the cost of section 
204 to be $3 million.
    Section 205 would require VA, not later than 6 months after the 
date of enactment, to conduct a pilot program to evaluate the 
feasibility of providing reintegration and readjustment services in a 
group retreat setting to women veterans recently separated from service 
after a prolonged deployment. Participation in the pilot would be at 
the election of the veteran. Services provided under the pilot would 
include, for instance, traditional VA readjustment counseling services, 
financial counseling, information on stress reduction, and information 
and counseling on conflict resolution.
    VA has no objection to section 205; however, we are unclear as to 
the purpose of and need for the bill. We note the term ``group retreat 
setting'' is not defined. We would not interpret that term to include a 
VA medical facility, as we do not believe that would meet the intent of 
the bill. We also assume this term would not include Vet Centers as we 
could not limit Vet Center access to any one group of veterans. 
Moreover, many Vet Centers, such as the one in Alexandria, Virginia, 
are already well designed to meet the individual and group needs of 
women veterans. Section 205 would have no costs.
    Section 206 would require the Secretary to ensure there is at least 
one full-time employee at each VA medical center serving as a women 
veterans program manager. We strongly support this provision. The 
position of the women veterans program manager has evolved from an 
overseer of local programs to ensure access to care for women veterans 
to a position requiring sophisticated management and administrative 
skills necessary to execute comprehensive planning for women's health 
issues and to ensure these veterans receive quality care as evidenced, 
in part, by performance measures and outcome measurements. The duties 
of this position will only continue to grow as we strive to expand 
services to women veterans. Thus, we believe there is support for the 
dedication of a full-time employee equivalent at every VA medical 
center. We estimate section 206 would result in additional costs of 
$7,131,975 for fiscal year 2010 and $86,025,382 over a 10-year period.
    Next, section 207 would require the Department's Advisory Committee 
on Women Veterans, created by statute, to include women veterans who 
are recently separated veterans. It would also require the Department's 
Advisory Committee on Minority Veterans to include recently separated 
veterans who are minority group members. These requirements would apply 
to committee appointments made on or after the bill's enactment. We 
support section 207. Given the expanded role of women and minority 
veterans serving in the Armed Forces, the Committees should address the 
needs of these cohorts in carrying out their reviews and making their 
recommendations to the Secretary. Having their perspective may help 
project both immediate and future needs.
   s. 2824 collective bargaining rights for review of adverse actions
    The major provision of S. 2824 would make matters relating to 
direct patient care and the clinical competence of clinical health care 
providers subject to collective bargaining. It would repeal the current 
restriction on collective bargaining, arbitrations, and grievances over 
matters that the Secretary determines concern the professional conduct 
or competence, peer review, or compensation of Title 38 employees. The 
Secretary would also be required to bargain over direct patient care 
and clinical competency issues, the processes VA uses to assess Title 
38 professionals' clinical skills, and the discretionary aspects of 
Title 38 compensation, including performance pay, locality pay, and 
market pay. Because they would be negotiable these matters would also 
be subject to nonclinical, non-VA third party review.
    VA strongly opposes this provision. Prior to 1991, Title 38 
professionals did not have the right to engage in collective bargaining 
at all. The current restriction on collective bargaining rights is a 
sound compromise between VA's mission--best serving the needs of our 
Nation's veterans--and the interest of Title 38 physicians, nurses, and 
other professionals in engaging in collective bargaining. Importantly, 
Congress recognized that the Secretary, as the head of the VA health 
care system, would be in the best position to decide when a particular 
proposal or grievance falls within one of the statutory areas excluded 
from bargaining. Such determinations should not be legislated. Neither 
should they be made by a non-clinical third party who is not 
accountable for assuring the health and safety of the veterans the 
Department is responsible for. If the Secretary and the Under Secretary 
for Health are going to be responsible and accountable for the quality 
of care provided to and the safety of veterans, they must be able to 
determine which matters affect that care. They must be able to 
establish standards of professional conduct by and competency of our 
clinical providers based on what is best for our veterans rather than 
what is the best that can be negotiated or what an arbitrator decides 
is appropriate. The Under Secretary for Health has been delegated the 
authority to make these discretionary determinations. VA has not abused 
this discretionary authority. Since 1992, there have been no more than 
13 decisions issued in a 1-year period and, in most cases, even far 
fewer decisions than that. This is particularly striking given the 
number of VA health care facilities and bargaining unit employees at 
those facilities. We are therefore at a loss to understand the need for 
this provision.
    S. 2824 would also transfer VA's Title 38 specific authorities, 
namely the right to make direct patient care and clinical competency 
decisions, assess Title 38 professionals' clinical skills, and 
determine discretionary compensation for Title 38 professionals, to 
independent third-party arbitrators and other non-VA non clinical labor 
third parties who lack clinical training and understanding of health 
care management to make such determinations. For instance, labor 
grievance arbitrators and the Federal Service Impasses Panel would have 
considerable discretion to impose a clinical or patient care resolution 
on the parties. VA would have limited, if any, recourse if such an 
external party erred in its consideration of the clinical or patient 
care issue. The exceptions to collective bargaining rights for Title 38 
employees identify areas that directly impact VA's ability to manage 
its health care facilities and monitor the professional conduct and 
competence of its employees; management actions concerning these areas 
must be reserved for VA professionals.
    This bill would allow unions to bargain over, grieve, and arbitrate 
subjects that are even exempted from collective bargaining under Title 
5, including the manner by which an employee is disciplined and the 
determination of the amount of an employee's compensation. That would 
be unprecedented in the Federal Government. Such a significant change 
in VA's collective bargaining obligations would adversely impact VA's 
budget and management rights; it would also skew the current balance 
maintained between providing beneficial working conditions for Title 38 
professionals and meeting patient care needs, jeopardizing the lives of 
our veterans. There would be no costs associated with this provision.
            s. 2921 caring for wounded warriors act of 2008
    Section 2 would require the Secretary to conduct up to three pilot 
programs, in collaboration with the Secretary of Defense, to assess the 
feasibility of training and certifying family caregivers to be personal 
care attendants for veterans and members of the of the Armed Forces 
suffering from TBI. VA would be required to determine the eligibility 
of a family member to participate in the pilot programs, and such a 
determination would have to be based on the needs of the veteran or 
servicemember as determined by the patient's physician. The training 
curricula would be developed by VA and include applicable standards and 
protocols used by certification programs of national brain injury care 
specialist organizations and best practices recognized by caregiver 
organizations. Training costs would be borne by VA, with DOD required 
to reimburse VA at TRICARE rates for the costs of training family 
members of servicemembers. Family caregivers certified under this 
program shall be eligible for VA compensation and may receive 
assessments of their needs in the role of caregiver and referrals to 
community resources to obtain needed services.
    VA does not support section 2. Currently, we are able to contract 
for caregiver services with home health and similar public and private 
agencies. The contractor trains and pays them, affords them liability 
protection, and oversees the quality of their care. This remains the 
preferable arrangement as it does not divert VA from its primary 
mission of treating veterans and training clinicians.
    Section 3 would require VA, in collaboration with DOD, to carry out 
a pilot program to assess the feasibility of providing respite care to 
family caregivers of servicemembers and veterans diagnosed with TBI, 
through the use of students enrolled in graduate education programs in 
the fields of mental health or rehabilitation. Students participating 
in the program would, in exchange for graduate course credit, provide 
respite relief to the servicemember's or veteran's family caregiver, 
while also providing socialization and cognitive skill development to 
the servicemember or veteran. VA would be required to recruit these 
students, train them in the provision of respite care, and work with 
the heads of their graduate programs to determine the amount of 
training and experience needed to participate in the pilot program.
    We do not support section 3, which we recognize is an effort to 
compel VA to use existing arrangements with affiliated academic 
institutions as a novel means of providing respite care to family 
caregivers of TBI patients. Individuals providing respite care do not 
require advanced degrees, only appropriate training. Respite care is an 
unskilled type of service that does not qualify for academic credit or 
serve to meet any curricula objectives in the graduate degree programs 
related to mental health or rehabilitation. Further, section 3 would 
require VA to use graduate students in roles that are not permissible 
under academic affiliation agreements, and we have serious doubts this 
proposal would be acceptable to graduate schools.
    Moreover, VA has a comprehensive respite care program. We also have 
specialized initiatives underway for TBI patients to reduce the strain 
on their caregivers, which overlap with this bill. Plus we provide 
respite care by placing the veteran in a local VA facility for the 
duration of the respite period. Veterans may receive up to 30 days of 
respite care per year. We estimate the costs of S. 2921 to be 
$39,929,000 for fiscal year 2010 and $790,374,000 over a 10-year 
period.
                 s. 2899 ``veterans suicide study act''
    S. 2899 would require the Secretary to conduct a study to determine 
the number of veterans who have committed suicide between January 1, 
1997, and the date of the bill's enactment. The study would have to be 
carried out in coordination with the Secretary of Defense, Veterans 
Service Organizations, the Centers for Disease Control and Prevention, 
and State public health offices and veterans agencies. The bill would 
require the Secretary to submit a report to Congress on his findings 
within 180 days of the bill's enactment.
    VA understands the intent of the Senate in proposing S. 2899. 
However, we would like to make the Senate aware of the difficulties in 
accomplishing the legislation's intent--and what VA is doing, and 
intends to do, to improve our ability to obtain and report on suicide 
numbers.
    At present, determining suicide rates among veterans is a 
challenging puzzle. Multiple data sources must be used, and data must 
be carefully checked and rechecked. Each system helps obtain a piece of 
the complicated puzzle that constitutes the process of accurately 
estimating rates of veteran suicides. These are time-consuming 
processes--but they are the best ways VA knows to obtain aggregate data 
on suicide.
    VA relies on multiple sources of information to identify deaths 
that are potentially due to suicide. This includes VA's own Beneficiary 
Identification and Records Locator Subsystem, called BIRLS; records 
from the Social Security Administration; and data compiled by the 
National Center for Health Statistics in its National Death Index 
(NDI).
    Calculating suicide rates specifically for veterans is made even 
more difficult by the fact that the National Death Index does not 
include information about whether a deceased individual is a veteran or 
not. NDI is simply a central computerized index of death record 
information on file in the vital statistics offices of every State. The 
Index is compiled from computer files submitted by State vital 
statistics offices. Death records are added to the file annually, about 
twelve months after the end of a calendar year.
    Given that the NDI does not indicate veteran status, VA regularly 
submits requests for information to NDI. VA sends NDI a list of all 
patients who have not been treated at any VA medical centers in the 
past twelve months and before, to see if they are still among the 
living. NDI checks this list against their records, and tells VA which 
veterans have died, and the cause of their death as listed on the 
veterans' death certificates. From this information, VA is able to 
learn the approximate number of veterans under its care who have died 
of suicide, and to use that information to make comparisons on rates of 
suicide among those veterans and all other Americans.
    This information tells VA about the suicide rates among veterans 
under its care, but says nothing about the rates of suicide among 
veterans who are not currently in the system. For those veterans, an 
even more complicated process has to be followed in order to estimate 
rates. VA obtains regular updates from the Department of Defense's 
Defense Manpower Data Center on soldiers separating from the military. 
Those new veterans immediately become part of total population and 
suicide calculations.
    Additionally, the Department will, among other things, also 
systematically assess its efforts to inform funeral directors about the 
importance of determining whether or not a person who has died of 
suicide is or is not a veteran, and what sorts of information to 
consider in making that determination. Finally, VA will investigate 
working directly with State vital records offices, as the NDI does, to 
obtain information on veteran suicides directly from them.
    VA asks that the Senate give us time to complete these actions 
before requiring any study of the numbers of suicides among veterans. 
We are ``pushing the envelope'' to get the most accurate data available 
on suicides in the shortest possible timeframe, and we commit to 
sharing that data with Congress as soon as it becomes available.
    We estimate the cost of this bill to be $1,580,006 in fiscal year 
2008 and $2,078,667 over a 10-year period.
s. 2937 permanent treatment authority for veterans who participated in 
                          certain dod testing
    Section 1 would make permanent the Secretary's authority to provide 
needed inpatient, outpatient, and nursing home care to a veteran who 
participated in a test conducted by the Department of Defense (DOD) 
Deseret Test Center as part of its chemical and biological warfare 
testing program conducted from 1962-1973, for any condition or illness 
possibly associated with such testing at no cost to the veteran. This 
authority will expire after December 31, 2008.
    VA supports section 1, which we note is identical to our own 
proposal in S. 2984. We estimate the discretionary cost of this 
provision to be $4,458,000 in fiscal year 2009 and $144,434,000 over a 
10-year period.
    Section 2 would require the Secretary, not later than 90 days after 
the date of the Act's enactment, to enter into a contract with IOM to 
conduct an expanded study on the health impact of participation in 
Project Shipboard Hazard and Defense (Project SHAD). Such a study 
should include, to the extent practicable, all veterans who 
participated in Project SHAD. VA does not support this provision, as we 
doubt that an expanded study could be conducted by IOM or any other 
organization because IOM has already thoroughly studied the health of 
SHAD veterans and made a concerted attempt to identify all involved 
veterans for its study.

    Mr. Chairman, this concludes my prepared statement. I would be 
pleased to answer any questions you or any of the Members of the 
Committee may have.
                                 ______
                                 
  Written Views Submitted After the Hearing by James B. Peake, M.D., 
            Secretary of the Department of Veterans Affairs
                       U.S. Department of Veterans Affairs,
                                      Washington, DC, July 8, 2008.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: We are pleased to provide the Department of 
Veterans Affairs' (VA) views on S. 2969, the ``Veterans' Medical 
Personnel Recruitment and Retention Act of 2008.'' We stated at the 
Committee's hearing on May 21, 2008, that VA would provide written 
views for the record.
    S. 2969 contains several provisions intended to enhance VA's 
ability to recruit and retain nurses and other health-care 
professionals. Many of these provisions would be helpful, and we can 
support them. However, several of the provisions would not be helpful 
or are otherwise flawed. We appreciate the opportunity to work with 
Committee staff on this bill and to provide technical comments and 
operational observations.
        section 2. enhancement of authorities for retention of 
                         medical professionals.
Authority to Extend Hybrid Status to Additional Occupations
    Subsection (a) would amend section 7401(3) to add ``nurse 
assistants'' to the list of so-called hybrid occupations for which the 
Secretary is authorized to appoint and to determine qualifications and 
rates of pay under title 38. In addition, it would authorize the 
Secretary to extend hybrid status to ``such other classes of health 
care occupations as the Secretary considers necessary for the 
recruitment and retention needs of the Department'' subject to a 
requirement to provide 45 days' advance notice to the Veterans' Affairs 
Committees and OMB. Before providing such notice, VA would be required 
to solicit comments from unions representing employees in such 
occupations.
    VA favors such a provision. Nursing Assistants are critical to the 
Veterans Health Administration's (VHA) ability to provide care for a 
growing population of older veterans, who are high-acuity patients and/
or frail elderly requiring 24-hour nursing care. Turnover data, 10.5 
percent for 2006 and 11.1 percent for 2007, illustrate the great 
difficulty VA experiences in retaining this occupation. It is 
increasingly critical for VHA to be able to quickly and easily employ 
these nurse extenders. The same holds true for other hard-to-recruit 
health care occupations. This bill would give the Secretary the ability 
to react quickly when it is determined that these authorities would be 
useful in helping in recruiting and retaining a critical occupation 
without seeking additional legislative authority. However, the bill 
language should be modified to specifically apply to occupations that 
clearly involve the delivery of health care. In addition, because this 
authority involves the conversion of title 5 occupations to title 38 
hybrid, the 45-day notice requirement should be modified to add OPM. 
Thus, we recommend modifying subsection 2(a) of the bill to read:

        (a) SECRETARIAL AUTHORITY TO EXTEND TITLE 38 STATUS TO 
        ADDITIONAL POSITIONS.--
        (1) IN GENERAL.--Paragraph (3) of section 7401 of title 38, 
        United States Code, is amended by striking ``and blind 
        rehabilitation outpatient specialists.'' and inserting in its 
        place the following: ``blind rehabilitation outpatient 
        specialists, and such other classes of health care occupations 
        who
        (A) are employed in the Administration (other than 
        administrative, clerical, and physical plant maintenance and 
        protective services employees);
        (B) are paid under the General Schedule pursuant to section 
        5332 of title 5;
        (C) are determined by the Secretary to be providing either 
        direct patient-care services or services incident to direct 
        patient-care services; and
        (D) would not otherwise be available to provide medical care 
        and treatment for veterans;
        (E) as the Secretary considers necessary for the recruitment 
        and retention needs of the Department.
        (2) The Secretary's authority provided in paragraph (1) is 
        subject to the following requirements:
                ``(A) Not later than 45 days before the Secretary 
                appoints any personnel for a class of health care 
                occupations that is not specifically listed in this 
                paragraph, the Secretary shall submit to the Committee 
                on Veterans' Affairs of the Senate, the Committee on 
                Veterans' Affairs of the House of Representatives, the 
                Office of Management and Budget and the Office of 
                Personnel Management notice of such appointment.
                ``(B) Before submitting notice under subparagraph (A), 
                the Secretary shall solicit comments from any labor 
                organization representing employees in such class and 
                include such comments in such notice.''
Probationary Periods for Part-Time Nurses
    Subsection (b) provides for probationary periods for part-time (PT) 
Registered Nurses (RN) and revises the probationary period for RNs, 
both full-time (FT) and PT, from 2 years to its equivalency in hours, 
4180. It also provides that a PT appointment of a person who previously 
served on a FT basis in a ``pure'' title 38 position (7401(1)), and 
completed a probationary period in the FT position would not have to 
serve a probationary period in the PT ``pure'' title 38 position. VA 
opposes this provision. We believe this provision is technically flawed 
and would not be helpful.
    Part-time title 38 employees, including RNs, do not serve 
probationary periods. Probationary periods apply to full-time, 
permanent employees. We see no benefit to creating a probationary 
period for part-time nurses. Moreover, a probationary period for PT RNs 
would not make them the equivalent of tenured employees, for example 
for purposes of discipline or discharge.
Prohibition on Temporary Part-Time Nurse Appointments In Excess of 
        4,180 Hours
    Subsection (c) would amend section 7405(f)(2) to limit temporary 
part-time appointments of hybrid (Licensed Practical Nurse (LPN) and 
Licensed Vocational Nurse (LVN)) nurses to no more than 4180 hours. VA 
opposes this provision. Currently, all part-time hybrid appointments 
may be for periods exceeding 1 year. The purpose of this restriction on 
LPNs and LVNs is not apparent. Operationally, it could hamstring VHA 
when it determines that part-time LPNs and LVNs best serve patient care 
needs. The result could be to deprive VA of highly qualified LPNs and 
LVNs wishing to work only on a part-time basis, for example, for 
personal and family reasons.
Reemployed Annuitant Offset Waiver
    Subsection (d) generally provides that annuitants may be 
temporarily reemployed in a title 38 position without being subject to 
having their salary offset by the amount of their annuity.
    VA instead favors a Government-wide policy on waivers of this 
offset. Under current law, VA must obtain a waiver for individuals on a 
case-by-case basis, or obtain delegated waiver authority from the 
Office of Personnel Management (OPM). VA has done so for some critical 
occupations. The Administration has submitted a bill, which VA favors, 
to provide agencies with the authority to grant offset waivers to 
facilitate the temporary part-time reemployment of annuitants, which 
has been introduced as S. 2003. With many VA employees at or near 
retirement eligibility the potential for significant losses of mission-
critical leaders and technical experts is a significant threat to VA's 
capability to deliver high quality health care to our Nation's 
veterans. VA access to retired title 38 health care providers, without 
financial penalty, would enhance our ability to meet these challenges 
and maintain the continuity of quality patient care, including support 
in times of disaster. As explained by OPM, S. 2003 ``would allow 
Federal agencies to rehire recently retired employees to assist with 
short-term projects, fill critical skill gaps and train the next 
generation of Federal employees.''
Minimum Rate of Basic Pay for Section 7306 Appointees Set to Lowest 
        Rate of Basic Pay for SES
    Subsection (e) would amend section 7404(a) to add a provision 
setting the basic pay of non-physician/dentist section 7306 employees 
at not less than the lowest rate of basic pay for the Senior Executive 
Service (SES). This amendment would be effective the first pay period 
that is 180 days after enactment.
    VA supports the principle of pay equity with SES rates for its 
section 7306 non-physician/dentist executives as a tool needed to meet 
the challenge of recruitment and retention. However, we recommend some 
modifications in the bill's language.
    Equity in pay for executive level managers and consultants is 
essential to attracting and retaining candidates for key positions. The 
pay schedule for 38 U.S.C. Sec. 7306 appointees is capped at the pay 
rate for Level V of the Executive Schedule (currently $139,600). 
Locality pay is paid up to the rate for Level III (currently $158,500).
    Individuals appointed under 38 U.S.C. Sec. 7306 serve in executive 
level positions that are equivalent in scope and responsibility to 
positions in the SES. By comparison, employees in the SES receive a 
significantly higher rate of basic pay. The maximum SES pay limitation 
is the rate for Level II (currently $172,200) pending OPM certification 
that the agency meets all regulatory criteria for certified performance 
appraisal systems, including the employing agency makes meaningful 
distinctions based on performance. We estimate the costs of this 
provision to be $225,290 in fiscal year 2009 and $2,466,862 over a 10-
year period.
    We recommend modifying this proposal to state that the basic pay of 
non-physician/dentist section 7306 employees be set at the rates of pay 
for SES employees under section 5382 of title 5. This modification 
would allow VA executive pay to track the full range of SES pay. The 
SES pay system conditions pay up to EL II on OPM certification that an 
agency's SES rating system meets all regulatory criteria for certified 
performance appraisal systems. In this regard we note that VHA uses the 
same rating system for its section 7306 executives as it uses for its 
SES members. OPM has certified this system in the past, and is 
finalizing certification for this year. For consistency, we also 
recommend that the bill be modified to require that the Secretary make 
the same certification for the rating system covering section 7306 
employees. Thus, we suggest that section 2(e)(3) be modified to read as 
follows:

        ``(3) Positions to which an Executive order applies under 
        paragraph (1) and are not described by paragraph (2) shall be 
        paid basic rates of pay in accordance with section 5382 of 
        title 5 for Senior Executive Service positions and not greater 
        than the rate of basic pay payable for level III of the 
        Executive Schedule; or if the Secretary certifies that the 
        employees are covered by a performance appraisal system meeting 
        the certification criteria established by regulation under 
        section 5307(d), level II of the Executive Schedule.''
Comparability Pay Program for Section 7306 Appointees
    Subsection (f) would amend section 7410 to add a new subsection to 
establish ``comparability pay'' for non-physician/dentist section 7306 
employees of not more than $100,000 per employee in order to achieve 
annual pay levels comparable to the private sector. Similar to 
provisions for RN Executive Pay in section 7452(g), it would provide 
that ``comparability pay'' would be in addition to other pay, awards 
and bonuses; would be considered base pay for retirement purposes; 
would not be base pay for adverse action purposes; and could not result 
in aggregate pay exceeding the annual pay of the President.
    VA supports the concept of comparability pay for its non-physician/
dentist executives. However, at this time we cannot support this 
proposal because it is a potentially precedent-setting departure from 
the unitary approach to government-wide SES pay. The Department is 
evaluating alternative proposals that may be more appropriate in 
addressing the comparability pay issues of these executives.
    VA is working on a cost estimate for this provision and will 
provide it at a later time.
Special Incentive Pay for Department Pharmacist Executives
    Subsection (g) would further amend section 7410 to authorize 
recruitment and retention special incentive pay for pharmacist 
executives of up to $40,000. VA's determination of whether to provide 
and the amount of such incentive pay would be based on: grade and step, 
scope and complexity of the position, personal qualifications, 
characteristics of the labor market concerned, and such other factors 
as the Secretary considers appropriate. As with RN Executive Pay and 
comparability pay added by subsection (f), it would provide that 
``comparability pay'' would be in addition to other pay, awards and 
bonuses; would be considered base pay for retirement purposes; would 
not be base pay for adverse action purposes; and could not result in 
aggregate pay exceeding the annual pay of the President.
    This provision will provide a retention incentive to about 40 
positions: pharmacy benefit managers (PBM), consolidated mail 
outpatient pharmacy (CMOP) directors and VISN formulary leaders (VFL). 
While VA is facing worsening pay compression issues within the ranks of 
senior pharmacy program managers in the VHA, we cannot support this 
provision because it will not address the Department's retention needs 
in the long-term. The Department is evaluating alternative proposals 
that will be more appropriate in addressing the recruitment and 
retention needs of our pharmacy executives.
    We estimate the cost of this provision to be $1,391,500 for fiscal 
year 2009 and $16,324,220 over a 10-year period.
Physician/Dentist Pay
    Subsection (h) concerns physician/dentist pay. VA supports this 
provision.
    Paragraph (1) would provide that the title 5 non-foreign cost of 
living adjustment allowance for physicians and dentists would be 
determined as a percentage of base pay only. This would clarify the 
application of the title 5 non-foreign cost of living adjustment 
allowance to VHA physicians and dentists. The VA physician/dentist pay 
statute, 38 U.S.C. Sec. 7431, does not address how the allowance is 
determined for physicians and dentists. We recommend that this 
provision be amended to clarify that it is applicable only to these 
physicians and dentists employed at Department facilities in Alaska, 
Hawaii, and Puerto Rico. These are the only Department facilities to 
which the title 5 non-foreign cost of living adjustment allowance is 
applicable.
    Paragraph (2) would amend section 7431(c)(4)(B)(i) to exempt 
physicians and dentists in executive leadership provisions from the 
panel process in determining the amount of market pay and tiers for 
such physicians and dentists. In situations where physicians or 
dentists occupy executive leadership positions such as chief officers, 
network directors, and medical center directors, the consultation of a 
panel has some limitations. The small number of physicians and dentists 
who would qualify as peers for the executive leaders results in their 
serving on each other's compensation panels and, in some cases, on 
their supervisor's panel. Providing the Secretary with discretion to 
identify executive physician/dentists positions that do not require 
that panel process would resolve these issues.
    Paragraph (3) would provide an exception to the prohibition on the 
reduction of market pay for changes in board certification or reduction 
of privileges correcting an oversight in the recent revision of the 
physician/dentist pay statute. This modification would allow VA to 
address situations where there is a loss of board certification or an 
adverse reduction in clinical privileges. No costs are associated with 
this provision.
RN and CRNA Pay
    Subsections (i) and (j), relate to RN and Certified Registered 
Nurse Anesthetist (CRNA) Pay
    Subsection (i) would amend the cap for registered nurse to maximum 
rate of EL V or GS-15, whichever is greater. The current cap is the 
rate for EL V. Subsection (j) would amend section 7451(c)(2) to exempt 
CRNAs from the current cap of EL V.
    It is important for pay caps to be both fiscally responsible and 
sufficient to promote employee recruitment and retention. These 
proposals are not consistent with these principles. We note the 
alternative GS-15 cap would be meaningless inasmuch as it already is 
lower than the existing cap that is set at EL V, with a difference of 
about $15,000. Moreover, it is unclear whether this alternative cap 
would be at the GS-15 rate before locality pay or after locality pay. 
The CRNA cap would leave CRNA pay rates completely uncapped, which 
would allow rates to potentially exceed those of physicians and 
dentists, the title Executive Schedule (Levels I-V), or the VA 7306 
Schedule.
    We would support this provision if the bill were amended to modify 
section 7451(c)(2) to read: ``The maximum rate of basic pay for any 
grade for a covered position may not exceed the rate of basic pay 
established for positions in level IV of the Executive Schedule under 
section 5315 of title 5.'' This would increase the cap from level V to 
level IV for both RNs and CRNAs, consistent with the pay cap that 
applies to the GS locality pay system. We estimate the cost of this 
provision to be $4,803,964 for fiscal year 2009 and $56,357,188 over a 
10-year period.
    Subsection (k) would make amendments to the RN locality pay system 
(LPS). These provisions are not helpful and unnecessary. No costs are 
associated with this provision.
    Paragraph (1) would require the Under Secretary for Health to 
provide education, training, and support to VAMC directors in the 
``conduct and use'' of LPS surveys. We are concerned that this 
provision's focus on facility-conducted surveys is at odds with Public 
Law 106-419, which enabled VAMCs to use third-party salary surveys 
whenever possible rather than VA-conducted surveys. The use of third-
party surveys is in fact the preference of the Department. We recommend 
modifying this provision to read: ``The Under Secretary for Health 
shall ensure appropriate education and training are available with 
regard to the conduct and use of surveys, including third-party 
surveys, under this paragraph.'' This would cover both types of 
surveys. Paragraph (2) would require the annual report VAMCs must 
provide to VA Central Office to include the methodology for every 
schedule adjustment. These reports form the basis for the annual VA 
report to Congress. We are concerned that this provision, especially in 
conjunction with proposed paragraph 3, could result in the 
inappropriate disclosure of confidential salary survey data, contrary 
to current section 7451(d)(5). It also would impose an onerous burden 
inasmuch as VHA has nearly 800 nurse locality pay schedules. We do note 
that VA policy does provide for how these surveys are to be obtained or 
conducted.
    Paragraph (3) would require the most recent VAMC report on nurse 
staffing to be provided to any covered employee or employee's union 
representative upon request. This provision should be modified to 
specify at what point the report must be provided. It would not be 
appropriate to provide an individual a copy of the VAMC report before 
Congress receives the VA report.
    Subsection (l) would increase the maximum payable for nurse 
executive special pay to $100,000. This provision would make the amount 
of nurse executive pay consistent with the Executive Comparability Pay 
in section 2f. We do not support this proposal. We estimate the cost of 
this provision to be $316,250 for fiscal year 2009 and $3,710,053 over 
a 10-year period.
    The caption for subsection (m) suggests it provides for eligibility 
of part-time nurses for certain nurse premium pay. However, many of the 
substantive amendments are not limited to part-time nurses, or to all 
registered nurses.
    VA opposes subsection (m) as seriously flawed, unnecessary, and 
costly.
    Subparagraph (1)(A) would amend section 7453(a) to make part-time 
nurses eligible for premium pay under that section. However, part-time 
nurses already are eligible for section 7453 premium pay where they 
meet the criteria for such pay.
    Subparagraphs (1)(B) and (1)(C) would require evening tour 
differential to be paid to all nurses performing any service between 6 
pm and 6 am, and any service on a weekend, instead of just those 
performing service on a tour of duty established for those times to 
meet on-going patient care needs. Under current law, these 
differentials are limited to the RN's normal tour of duty and any 
additional time worked on an established tour.
    The ``tour of duty'' in the current law reflects the requirement of 
ensuring adequate professional care and treatment to patients during 
off and undesirable tours. The limitation of tour differential and 
weekend pay only for service on a ``tour of duty'' rewards those 
employees who are subject to regular and recurring night and weekend 
work requirements. If that is changed to ``period of service,'' any 
employees performing night or weekend work on an occasional or ad-hoc 
basis would also be entitled to this premium pay in addition to 
overtime pay, providing an inappropriate windfall for performing 
occasional work.
    Subparagraph (2) would authorize title 5 VHA employees to receive 
25 percent premium pay for performing weekend work on Saturday and 
Sunday. We understand the purpose of this provision is to limit the 
expansion of week-end premium pay to non-tour hours to registered 
nurses. However, it does not fully achieve that purpose. Pursuant to 
section 7454(a) and (b)(2), physician assistants, expanded-function 
dental auxiliaries, and hybrids are also entitled to week-end pay under 
section 7453. The expansion of week-end pay would apply to them as 
well. In addition, because physician assistants and expanded-function 
dental auxiliaries are entitled to all forms of registered nurse 
premium pay under section 7453, the expansion of the night differential 
premium pay would also apply to them. Furthermore, where VA has 
authorized section 7453 night differential for hybrids, the expansion 
of the night differential premium pay would apply to them as well.
    Subsection (n) would add additional occupations to the exemption to 
the 28th step cap on title 38 special salary rates: LPNs, LVNs, and 
unspecified ``other nursing positions otherwise covered by title 5.'' 
Notwithstanding the exemption, under current statute, title 38 special 
salary rates cannot exceed the rate for EL V. The language ``nursing 
positions otherwise covered by title 5'' is unclear as to what 
positions it would include. RNs are appointed under title 38, LPNs/LVNs 
are hybrids, and section 2(a)(2) of the bill would convert nursing 
assistants to hybrid. Moreover, it is not apparent why only these 
positions and not all positions authorized title 38 special rates would 
be exempted. Using the same formula for the cap on title 5 special 
rates would afford VA the most flexibility in establishing maximum 
rates for title 38 special rates. Adopting the title 5 fixed percentage 
formula would render the section 7455(c)(2) report for exceeding 94 
percent of the grade maximum unnecessary, so we propose deleting it. 
Thus we recommend amending section 7455 to read as follows:

        (a)(1) Subject to subsections (b), (c), and (d), when the 
        Secretary determines it to be necessary in order to obtain or 
        retain the services of persons described in paragraph (2), the 
        Secretary may increase the minimum rates of basic pay 
        authorized under applicable statutes and regulations, and may 
        make corresponding increases in all rates of the pay range for 
        each grade. Any increase in such rates of basic pay--
          * * * * * * *
        (c) The amount of any increase under subsection (a) in the 
        minimum rate for any grade may not exceed the maximum rate of 
        basic pay (excluding any locality-based comparability payment 
        under section 5304 of title 5 or similar provision of law) for 
        the grade or level by more than 30 percent, and no rate may be 
        established under this section in excess of the rate of basic 
        pay payable for level IV of the Executive Schedule.

    Section 3(a)(1) would add new section 7459, imposing restrictions 
on nurse overtime.
    Section 7459 generally would prohibit mandatory overtime for nurses 
(RNs, LPNs, LVNs, nursing assistants, and any other nurse position 
designated by the Secretary). It would permit mandatory overtime by 
nurses under certain conditions: an emergency that could not have been 
reasonably anticipated; the emergency is non-recurring and not due to 
inattention or lack of reasonable contingency planning; VA exhausted 
all good faith, reasonable attempts to obtain voluntary workers; the 
affected nurses have critical skills and expertise; and the patient 
work requires continuity of care through completion of a case, 
treatment, or procedure. VA could not penalize nurses for refusing to 
work prohibited mandatory overtime. Section 7459 provides that nurses 
may work overtime hours on a voluntary basis.
    VA favors this mandatory overtime restriction with the caveat that 
first and foremost, VA needs to be able to mandate overtime where 
issues of patient safety are identified by facility leadership. We note 
VAMCs currently have policies preventing RNs from working more than 12 
consecutive hours and 60 hours in a 7-day period pursuant to section 
4(b) of Pub. L. 108-445.
    Section 3(b) would amend 38 U.S.C. 7456 (the ``Baylor Plan''), 
which authorizes VA to allow nurses who perform two 12-hour regularly 
scheduled tours of duty on a weekend to be paid for 40 hours. This 
work-scheduling practice typically would be used when facilities 
encounter significant staffing difficulties caused by similar work 
scheduling practices in the local community. Currently, VA has no 
nurses working on the Baylor Plan. The proposed revision would 
substitute scheduled ``periods of service'' for ``regularly scheduled 
12-hour tour of duty.'' The purpose and effect of this amendment are 
unclear. VA would oppose a revision of this authority if it were to 
mandate that all work on 12 hour regular weekend tours of duty 
automatically be considered Baylor Plan tours such that it would 
mandate that any nurse who works two 12-hour shifts on a weekend in 
addition to their regular tour of duty to get paid for 40 hours, in 
addition to premium pay for the extra work, such as overtime; and to 
mandate that nurses are not on the Baylor Plan but who routinely work 
12-hour shifts under compressed work schedules that fall on weekends 
are entitled to 40 hours of pay for the 24 hours worked on the weekend 
in addition to pay for the remaining 16 hours.
    Section 3(b)(2)(A), in eliminating the requirement that service be 
on a ``tour of duty'' appears to make the Baylor 1,248 hourly rate 
divisor apply to all service on the weekend instead of just non-
overtime hours. It is not appropriate for non-Baylor weekend work 
hours, and VA opposes this provision.
    Section 3(b)(3) would delete section 7456(c), the current Baylor 
Plan requirement, which provides for a 5-hour leave charge for each 3 
hours of absence that reflects the relative value of the truncated 
Baylor tour, in effect increasing the value of leave for affected 
employees. VA opposes this provision as providing an unwarranted 
windfall.
    Section 3(c) would amend section 7456A to change the 36/40 
alternate work schedule to a 72/80 alternate work schedule, so that 
under the schedule six 12-hour ``periods of service'' anytime in a pay 
period would substitute for three ``12-hour tours of duty'' in each 
week of the pay period. Similar changes would be made to section 
7456A's overtime, premium pay and leave provisions.
    VA is experiencing planning problems with the use of the current 
36/40 schedule. That problem stems from the 36/40 language requiring 
three 12-hour tours in a work week and because VA defines ``work week'' 
as Sunday-Saturday. Changing ``work week'' to ``pay period'' only makes 
the problem occur every 2 weeks instead of every week, so we do not 
view that as helpful. We do support changing the 36/40 alternate work 
schedule to a 72/80 alternate work schedule, so that the six 12-hour 
tours can occur anytime in a pay period, providing more work 
scheduling/planning flexibility. VA will soon undertake a pilot in 
which all hours worked on tours of duty that begin in a work week (even 
if they end in the following work week) will be considered part of the 
work week for the purpose of the 36/40 alternate work schedule. We 
think this may help resolve the problem.
    Section 4 would make amendments to VA's Education Assistance 
Programs. VA supports these proposals.
    Section 4(a) would amend section 7618 to reinstate the Health 
Professionals Educational Assistance Scholarship Program through the 
end of 2013. The program expired in 1998. The Health Professional 
Scholarship Program would help reduce the nursing shortage in VA by 
obligating scholarship recipients to work for 2 years at a VA health 
care facility after graduation and licensure.
    This proposal would also expand eligibility for the scholarship 
program to all hybrid occupations. This would be helpful in recruiting 
and retaining employees in the several hard-to-fill hybrid occupations. 
We estimate the cost of this provision to be $725,000 in fiscal year 
2010 with a 5-year total of $21,380,000.
    Section 4(b) would make certain amendments to the Education Debt 
Reduction Program. It would amend section 7681(a)(2) to add retention 
as a purpose of the program and amend section 7682(a)(1) to make it 
available to ``an'' employee, in lieu of ``recently appointed.'' It 
would also increase the authorized statutory amounts in section 7683 to 
$60,000 and $12,000, respectively.
    The ``recently appointed'' requirement limits eligibility to 
employees who have been appointed within 6 months. VA's experience has 
been that this is not a sufficient period. In several instances, 
employees applying just missed the 6-month deadline. In many cases it 
takes more than 6 months for employees to become aware of this very 
helpful recruitment and retention program. VA also supports the 
increased amounts in light of increased education costs since the 
program was enacted. We estimate the cost of this provision to be 
$5,400,000 for fiscal year 2010 and $77,352,000 over a 10-year period.
    Section 4(c) would authorize VA researchers from ``disadvantaged 
backgrounds'' to use authorities in the Public Health Service Loan 
Repayment Program (LRP). This program presently is not available to 
Federal employees other than those working for the National Institutes 
of Health (NIH). Clinicians with medical specialization and research 
interests who might otherwise consider career clinical care or clinical 
research opportunities with VHA are therefore less likely to do so 
because VA employees are not eligible for the LRP. These same research-
focused, entry-level professionals have historically been the highest 
caliber and most sought-after candidates. VA researchers should be able 
to participate in this much sought-after program. VHA's Education Debt 
Reduction Program (EDRP) is only available for employees hired for 
permanent title 38 positions. Those in time-limited clinical research 
training positions such as the Research Career Development Awards 
(which historically have served as entryways to VA careers in clinical 
care and research) are not eligible. There are no costs associated with 
this proposal; it would not increase the funding of this program, but 
simply authorize VA researchers to participate in it.
    The Office of Management and Budget advises that there is no 
objection to the submission of this report from the standpoint of the 
Administration's programs.
            Sincerely yours,
                                      James B. Peake, M.D.,
                                                         Secretary.
                                 ______
                                 
                       U.S. Department of Veterans Affairs,
                                     Washington, DC, July 21, 2008.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: On May 21, 2008, you chaired a hearing to 
receive comments on 17 health care-related bills that were before the 
Committee. At the hearing, the Department testified on 14 of the bills. 
We stated that we needed additional time to coordinate the 
Administration's positions on S. 2926, S. 2963, and S. 2969. With this 
letter, we are providing views for the record on S. 2926 and S. 2963. 
The Administration's views on S. 2969 are being transmitted to you by 
separate letter.
         s. 2926, veterans research and education corporations
                        enhancement act of 2008
    S. 2926 contains many clarifying and technical provisions; however, 
we will discuss only the substantive provisions of the bill. The most 
important change to be accomplished by S. 2926 is contained in Section 
2. It would amend 38 U.S.C. Sec.  7361 to allow two or more medical 
centers, with the concurrence of the Secretary, to form a Multi-Medical 
Center Research Corporation (MMCRC). The MMCRC would be authorized to 
support research and education projects at the two or more medical 
centers that had formed it. This section would also allow an existing 
non-profit research corporation (NPC), with the approval of the medical 
centers involved and the Secretary, to expand into a MMCRC. Under 
current law, a VA medical center may establish an NPC that is 
authorized to facilitate approved research and education projects at 
that medical center.
    This provision of section 2 would not change the requirement that 
four members of senior management of one medical center, the Director, 
the Chief of Staff and, as appropriate, the Assistant Chiefs of Staff 
for Research and for Education, will serve on the board of the NPC. 
Rather, it would provide that this core group be augmented by the 
medical center director from each of the other facilities to be served 
by that NPC. This would provide VA with one official from each facility 
served by the MMCRC who may be held accountable by VA. It would require 
the NPC boards to decide whether their NPCs should evolve into MMCRCs 
and require them to obtain VA approval. This would ensure that the 
board has accepted the responsibilities that an MMCRC entails and that 
VA has considered whether the arrangement is reasonable and in the best 
interests of the Department.
    Section 2(c) would make clear that NPCs are subject to VA oversight 
and regulation, but not under the direct control of the Department. It 
would also expressly provide that the NPCs are not ``owned or 
controlled by the United States'' or ``an agency or instrumentality of 
the United States.'' This is currently made clear only in the 
legislative history of the statute.
    Section 3 would clarify that NPCs may support VA research and 
education generally. More specifically, it would amend 38 U.S.C. 
Sec. 7362 to state that NPCs may support ``functions related to the 
conduct of'' VA research and education--but still only VA research and 
education--not just administer approved research or education projects. 
Currently, the corporations may facilitate only VA-approved research 
and education projects.
    Section 4 would broaden the qualifications for the non-VA board 
members to include business, legal and financial backgrounds, thus 
allowing NPCs to use these board positions to acquire the legal and 
financial expertise needed to ensure sound governance and financial 
management. Currently, the law requires that there be members of the 
board of directors of an NPC who are not Federal employees and who 
``are familiar with issues involving medical and scientific research or 
education.''
    Section 4 would also update the conflict of interest provision 
currently in section 7363(c) of title 38, United States Code, which 
prevents individuals from serving on the board if they are ``affiliated 
with, employed by, or have any other financial relationship with'' a 
for-profit entity that is a source of funding for VA research.
    Section 5 would enhance several powers of the NPCs. Section 5(a) 
collects in one place all discussion of NPC powers and makes several 
important clarifications. First, it would provide NPCs with authority 
to retain fees charged to non-VA attendees for educational programs in 
order to cover the costs of attendance by such participants. Current 
law authorizes NPCs to facilitate education, but does not authorize 
them to retain fees charged to non-VA attendees for educational 
programs they administer.
    Second, it would permit the NPCs to reimburse the VA Office of 
General Counsel (OGC) for resources necessary for prompt review of 
Cooperative Research and Development Agreements (CRADAs). This would 
permit Regional Counsel offices to address the growing volume of 
CRADAs, the form of agreement mandated by VA to establish terms and 
conditions for industry-sponsored studies performed at VA medical 
centers and administered by NPCs. Under the bill, any such 
reimbursements would be used by OGC for only staffing and training in 
connection with such legal services.
    Third, section 5(a) of the bill would permit NPCs to expend funds 
for necessary planning purposes, prior to approval of a research 
project or education program by VA, such as the expenses of preparing a 
grant proposal. Currently, the NPCs can assist VA with funding only for 
research or education projects that have already been approved by VA.
    Section 5(b) would continue the proscription on VA transfer of 
appropriated funds to NPCs, but would make explicit the authority of a 
medical center to ``reimburse the corporation for all or a portion of 
the pay, benefits, or both of an employee of the corporation who is 
assigned to the Department medical center if the assignment is carried 
out pursuant to subchapter VI of chapter 33 of title 5.'' This would 
codify that reimbursements from VA to NPCs pursuant to 
Intergovernmental Personnel Act (IPA) assignments are allowable.
    Section 7 would increase NPC reporting requirements to include IRS 
Form 990, which contains a wealth of information about revenues and 
expenditures as well as major programmatic accomplishments. Section 8 
would eliminate the sunset clause on establishing new NPCs.
    We support the provision in section 2 of S. 2926 that would 
authorize the establishment of new multi-center non-profit research 
corporations (NPCs) and the consolidation of existing single facility 
NPCs into multi-facility NPCs. This would offer the prospect of NPC-
assistance in funding research projects to VA medical centers (VAMCs) 
that are unable to support their own dedicated corporation. This 
provision would also provide the system with the tools needed to 
consolidate or close NPCs that are too small to institute proper 
internal controls without the loss of the funding support for VA 
research and education programs that the NPCs provide. By requiring the 
Director of all VAMCs supported by an NPC to sit on its board of 
directors, the provision would provide this beneficial increased 
flexibility without sacrificing VA oversight.
    With respect to the draft bill's remaining provisions, however, we 
ask the Committee to defer further action on this draft bill in order 
to give the Department an opportunity to address underlying structural 
issues and to formulate policy related to the governance and finance of 
the VA affiliated non-profit research corporations. A steering 
committee has been chartered by the Veterans Health Administration 
Office of Research and Development to provide recommendations regarding 
governance, oversight, and finance issues related to the corporations 
by the end of the fiscal year. We will be happy to provide you with a 
copy of their final report and recommendations.
       s. 2963, va mental health and other benefits extended to 
                      members of the armed forces
    Section 1 of the bill would require the Secretary of the Department 
of Veterans Affairs (VA), acting through the Under Secretary for 
Health, to carry out a program to provide scholarships to individuals 
pursuing education or training in behavioral health care specialties 
critical to the operations of the Department's Vet Centers. Individuals 
eligible for the program would include those pursing education or 
training leading to licensure or certification in behavioral health 
care specialties, which the Secretary deems are critical to the 
operation of the Vet Centers and who otherwise meet other criteria or 
requirements established by the Secretary. The amount of any 
scholarship provided under the program would be determined by the 
Secretary; however, the total amount available for all the scholarships 
provided under the program in any fiscal year could not exceed $2 
million.
    In exchange for the scholarship, an individual participating in the 
program would be required to enter into an agreement with the Secretary 
and fulfill a service obligation in a Vet Center, as specified in the 
agreement. Section 1 would also require these agreements to include 
repayment provisions in the event the individual does not fulfill the 
service obligation. The bill would also specify that these scholarships 
are to be paid from amounts made available to VA for the provision of 
readjustment benefits.
    VA supports the concept of using scholarships for this purpose; 
however, this provision is unnecessary. Under existing authority, we 
could establish by regulation a special scholarship program for 
individuals pursuing degrees in mental health specialties and require 
those individuals to agree to serve for a specified period in VA's Vet 
Centers. The current program is used very successfully to recruit 
individuals for difficult-to-recruit and difficult-to-retain health 
care positions throughout the country. We believe it is essential to 
target scholarships to difficult-to-recruit and difficult-to-retain 
occupations across the Veterans Health Administration system, rather 
than limiting scholarships to specific facilities.
    We note that current law provides express terms governing a 
participant's service obligation and liability if a breach occurs at 
any phase in the program. These statutory provisions help ensure that 
VA is able to reap the benefits of tangible and intangible investments 
made by the Department. In addition, current law imposes treble damages 
for a scholarship participant who fails to complete the service 
obligation. In sharp contrast, section 1 would require VA to promulgate 
regulations relating to repayment of the amount of a scholarship 
provided under this section. Imposing significant penalties for those 
who breach their service obligations helps VA to deter individuals from 
using VA as an interest-free, tax-free educational loan program. 
Section 1 provides no effective means of ensuring that VA will receive 
the benefit of the participants' professional services as VA employees. 
Finally, because Vet Centers are currently funded through the medical 
care appropriations we believe the cost of such scholarship program 
shall be funded from the same appropriations, rather than the 
readjustment benefits program.
    We estimate the cost of section 1 to be $2,313,938 for fiscal year 
2009 and $24,483,918 over a 10-year period.
    Section 2 of S. 2963 would extend eligibility for VA's readjustment 
counseling and related services provided through the Department's Vet 
Centers to members of the Armed Forces, including members of the 
National Guard or Reserve, who serve on active duty in Operation 
Enduring Freedom or Operation Iraqi Freedom (OEF/OIF). Servicemembers 
would be eligible for the readjustment counseling services even if they 
are on active duty at the time they receive them. They would have to 
also meet eligibility requirements prescribed jointly by the Secretary 
of Veterans Affairs and the Secretary of Defense.
    VA supports section 2. We can most effectively address the 
readjustment needs of former combat-theater servicemembers who are 
still on active duty through early intervention--even before they are 
discharged. With our expertise, we can help prepare them for many of 
the common readjustment problems experienced by veterans with combat 
service. Extending readjustment counseling and related services to this 
population may also help to resolve problems that otherwise might 
prevent some of them from pursuing long-term military careers. We note 
that VA provides these services in a confidential setting and in a 
manner that helps to reduce any concern that an active-duty military 
member may have about any stigma related to seeking counseling or other 
mental health services. Thus, we see significant benefits to this 
section.
    We also note that, by operation of law, these servicemembers' 
immediate family members would remain eligible for certain family-
support services while the servicemember is on active duty. These 
services would be provided only to the extent that they are needed for, 
or in furtherance of, the active-duty member's successful readjustment 
to civilian life.
    The Department estimates the cost of section 2 to be $14,791,000 
for fiscal year 2009 and $178,418,309 over a 10-year period. The 
increased fiscal year 2009 workload resulting from this proposal can be 
absorbed within the fiscal year 2009 President's Budget request, which 
includes funding for the establishment of 39 new Vet Centers.
    Section 3 would require the Secretary to provide referral services 
at Vet Centers to individuals who have been discharged or released from 
active military, naval, or air service but who are not eligible to 
receive readjustment counseling and related services. It would also 
require VA to advise these individuals of their right to apply to the 
appropriate military, naval, or air service for review and upgrade of 
their discharge status.
    VA does not support section 3. Vet Centers provide readjustment 
counseling and related services to veterans who: (1) meet the title 38 
definition of veteran (i.e., ``a person who served in the active 
military, naval, or air service, and who was discharged or released 
therefore under conditions other than dishonorable''); and (2) served 
in a combat theater. It is unclear whether this provision is intended 
to address all of those with ``less than honorable'' discharges. If so, 
the language of this section is exceptionally broad and would broaden 
eligibility for these referral services to non-combat veterans. These 
clarifications need to be made before VA can develop a position and 
cost estimate for the provision.
    Section 4 would require that the suicide by certain former members 
of the Armed Forces that occurs during the 2-year period beginning on 
the date of separation or retirement from the Armed Forces be treated 
as a death in the line of duty for purposes of survivors' eligibility 
for certain benefits. The former Armed Forces members who would be 
covered are those ``with a medical history of a combat-related mental 
health condition or Post Traumatic Stress Disorder (PTSD) or Traumatic 
Brain Injury (TBI).'' The benefits that would be covered under section 
4 are ``[b]urial benefits,'' Survivor Benefit Plan benefits under title 
10, United States Code, ``[b]enefits under the laws administered by the 
Secretary of Veterans Affairs,'' and Social Security Act benefits. 
Furthermore, for purposes of benefits under section 4, the date of 
death would be considered to be the date of separation or retirement 
from the Armed Forces, except that, for purposes of determining ``the 
scope and nature of the entitlement,'' the date of death would be 
considered to be the date of the suicide. We believe this last 
provision would provide the date of death for purposes of determining 
the effective date of an award or amount of benefits, although this is 
not clear from the bill's language. Essentially, under section 4, the 
suicide of a covered individual would be treated as a service-connected 
death for VA benefit purposes.
    Although VA supports the concept of section 4 and recognizes its 
compassionate intent, we cannot support this provision because it may 
have a negative impact. In some cases, the veterans' combat-related 
mental health conditions may make them susceptible to considering 
suicide. Knowing survivor benefits would be awarded to their spouses 
and children might exacerbate their conditions, making them even more 
susceptible to acting on their suicide ideations. Their illnesses may 
cause them to reject any opportunity to obtain medical assistance, 
believing instead that their families will benefit more from their 
suicide. This might especially be the case for those who feel 
overwhelmed by their obligation to provide for their families.
    We also have several technical concerns with section 4. Subsection 
(b) identifies the covered former Armed Forces members as those ``with 
a medical history of a combat-related mental health condition or [PTSD] 
or [TBI].'' It is unclear from the language whether the adjective 
``combat-related'' is meant to modify PTSD and TBI as well as mental 
health condition. The statement of the bill's sponsor upon introducing 
the bill suggests so. ``This legislation guarantees benefits . . . 
provided they have a documented medical history of a combat-related 
mental-health condition, including PTSD or TBI.'' 154 Cong. Rec. S3716 
(daily ed. May 1, 2008). However, the bill language should be 
clarified.
    Subsection (c)(1) identifies ``[b]urial benefits'' as one of the 
covered benefits, but fails to specify from which Federal department or 
agency. We note that subsection (c)(3) identifies as covered benefits 
``[b]enefits under the laws administered by [VA],'' which would cover 
VA burial benefits and therefore implies that subsection (c)(1) refers 
to another agency. Again, the introductory statement of the bill's 
sponsor suggests a solution to this interpretive question. ``The 
Service Member's survivor will be entitled to the same . . . active 
duty burial benefits that they would have received'' had the former 
servicemember died on active duty, id., but clarification of the bill 
language may be in order.
    VA is still in the process of developing costs for section 4.
    Section 5 would require DOD to carry out a grant program for non-
profit organizations furnishing support services to survivors of 
deceased servicemembers and veterans. As to this section, VA defers to 
the views of the Secretary of Defense.
    The Office of Management and Budget advises that there is no 
objection to the submission of this report from the standpoint of the 
Administration's program.
            Sincerely yours,
                                      James B. Peake, M.D.,
                                                         Secretary.

    Chairman Akaka. Thank you very much, Dr. Cross.
    I would like to ask for questions, first, from Senator 
Murray.
    Senator Murray. Thank you very much, Mr. Chairman. Thank 
you all for your testimony.
    Dr. Cross, let me start with a subject all of us have 
referenced here today. Secretary Peake, speaking at the 
National Press Club yesterday, said that trust and confidence 
is important and that we need to earn them. I couldn't agree 
more. But, time and time again, actions taken by senior VA 
officials have undermined that trust, as you know, and last 
week we learned about the e-mail that has been referenced, sent 
by a VA mental health professional in Texas which suggested 
that the VA staff should stop diagnosing veterans with PTSD in 
order to save time and money.
    Well, thankfully, Secretary Peake strongly condemned that 
e-mail and I thank him for that. He said that it was an 
isolated case, however, by a single practitioner, which leads 
me to my question. How do we know that this is an isolated 
case?
    Dr. Cross. Well, thank you for mentioning that. First of 
all, the individual in question was not a senior VA employee 
but a new employee--relatively new--without supervisory 
responsibility. But let me say this very, very clearly: the 
contents of that e-mail--the 
e-mail in question--were absolutely contrary to VA policy. The 
VA is committed to absolute accuracy in all of our diagnoses, 
including those for PTSD.
    Now, we treat about 400,000 patients a year as of 2007 for 
PTSD. The message that I must get out today and that we must--I 
need your help with is this--to veterans and their families, we 
are concerned. We are the experts on this. Treatment is 
available and treatment works. Please come and see us if this 
is a problem. We are ready to help.
    Senator Murray. Well, I appreciate that statement from you 
and I appreciate what Dr. Peake said, but I would like to know 
what mechanism you have in place to ensure that the policies 
that you do establish in the central office are being followed 
out in the field. Do you have any classes or additional 
training or periodic assessments of how these policies are 
implemented so that we won't hear about this again?
    Dr. Cross. Yes, Senator, we absolutely do. Not only do we 
put out policies, we pursue the policies to see that they are 
being implemented. Our staff at that facility--our staff at the 
VISN--support the policy, and do not support this e-mail, and 
do not think it applies elsewhere within the organization. We 
will continue to pursue this and to make sure that it does not 
carry further.
    Senator Murray. OK, and I am sure this Committee will 
follow up on that, so thank you. I appreciate that and I hope 
that you keep sending that message through every mechanism that 
you have.
    Dr. Cross. Thank you.
    Senator Murray. Dr. Cross, in your testimony, you recognize 
that the inability to get child care is a barrier to some of 
our veterans, so I was surprised that you opposed Section 204 
of the women veterans bill that I have introduced, which would 
require the VA to simply conduct a pilot program to pay for the 
cost of child care for veterans receiving care at our VA 
facilities for mental health or for other intensive services. 
So, you identify the lack of child care as a barrier to care 
for these women, yet you are unwilling to do anything about it. 
So, why are you even looking at barriers for veterans if once 
you assess that they are barriers you are not willing to do 
what needs to be done to decrease those barriers?
    Dr. Cross. Senator, there is so much in your bill that we 
really appreciate and support and so many things that we have 
to work together on that we are exactly on the same sheet of 
music. It was only in regard to Section 204 that we found that 
the funding--our concern was that the funding would simply 
divert funds from direct patient care.
    Senator Murray. It would divert funds from----
    Dr. Cross. Direct patient care.
    Senator Murray. Well, if----
    Dr. Cross. Also, we have other means in place where we 
supplement individuals driving some distance, but----
    Senator Murray. Well, I find it troubling that that is the 
opinion--the way you look at it--because what we are finding is 
that women are not getting care, particularly mental health 
care, because they can't get child care. So, if we want to 
encourage these women to get in and to get the mental health 
care they need and not sit at home, reducing that barrier is a 
critical part of their care.
    Dr. Cross. We agree, too, that we want to make sure if 
there are any barriers that we can reduce, we do so. I think 
the only real objection we had to this was it would come out of 
direct patient care and we have other mechanisms in place to 
help supplement people for their travel----
    Senator Murray. Well, it is certainly not our intent to 
divert care. It certainly is our intent to make sure they get 
access to care, so I disagree on the premise, but we will keep 
working.
    In your testimony, you also stated that the VA is opposed 
to the longitudinal study on the health consequences for women 
veterans who have served in Iraq and Afghanistan because, you 
say, a similar study involving 12,000 women veterans has 
already been approved. Can you tell me what approved means?
    Dr. Cross. Underway.
    Senator Murray. Underway?
    Dr. Cross. Beginning.
    Senator Murray. Is it funded?
    Dr. Cross. In 2007, the VA initiated its own 10-year 
study--a longitudinal epidemiological surveillance on the 
mortality and morbidity of OEF/OIF veterans, including women 
veterans.
    Senator Murray. Including women veterans, but not 
particular to women veterans.
    Dr. Cross. Yes, Senator, including. And the staff, looking 
at both parts of the bill and what we are doing, felt that we 
certainly met that requirement.
    May I say something else about research?
    Senator Murray. Yes.
    Dr. Cross. This is very important to us and there is a 
point that very few people know. Over the past 7 years, we have 
published 46,000 articles in the medical literature--the VA, VA 
providers--896 of those were in Science,the New England Journal 
of Medicine, or JAMA. Many of those were related to women's 
health. I have a number here that I can share with you----
    Senator Murray. I actually would like it if you could, for 
the record, give me a list of all of the studies that you have 
ongoing for women veterans right now; conclusions; how long 
they are going to take; and what the process is.
    But in my time, let me ask you, I am also having trouble 
understanding why you are opposed to including active duty 
women servicemembers as part of the longitudinal study on 
health consequences. I would think that the VA would want to 
know what the needs are for current as well as future patients. 
So, if you exclude current active duty women, are you not going 
to lose some of the information that you need?
    Dr. Cross. I believe that the only objection that we would 
have in that regard is the logistics of trying to work with 
that group along with the veteran group. Of course, our focus 
as the VA is on the veterans, and so that is why we directed 
our study in that direction.
    Senator Murray. Well, OK. We will have further discussions 
about that. But you also object to assessing the existing 
health care programs for women veterans and reporting those 
findings to Congress. In your statement, you recognize that 
there are gaps in the care for women veterans--you say that to 
us--especially since the system was obviously designed when 
there weren't as many women in the VA. But, you oppose the 
assessment, and I find that very troubling.
    Dr. Cross. There is so much we can talk about on this and I 
think it is very important. I think there have been gaps, and 
continue to be, that we are addressing right now with a number 
of initiatives we have underway: everything from training to 
equipping, to the location of treatment, and to the way that 
women are welcomed into our system. We are absolutely committed 
to making them welcome. They make up 6 percent of our enrollees 
at this time and they are about 5.2 percent----
    Senator Murray. Well, making them welcome and making sure 
that they have the services available are two different ways of 
looking at it.
    Let me ask you particularly about the military sexual 
trauma (MST) provisions, because those are especially important 
to women today. It is a difficult topic and one that we believe 
we have got to address much stronger. In your testimony, you 
say you are strongly opposed to the MST staffing standards that 
we are putting in place. There has got to be today some sort of 
accepted norm for providing care for veterans who have MST. Can 
you tell me what the appropriate patient workload for an MST 
provider is today?
    Dr. Cross. I don't have that information, Senator. I will 
be happy to get it for you, but I can explain why----
    Senator Murray. Before you do that, can you tell me what 
acceptable time a provider should spend with someone who has 
MST?
    Dr. Cross. As much time as necessary.
    Senator Murray. OK. You wanted to respond further. I mean, 
it seems to me that we need to put in place norms, particularly 
for military sexual trauma, that we don't know much about. It 
is an issue that women are reluctant to talk about, and 
establishing some staffing standards is a realistic way of 
making sure that we are dealing with that issue adequately.
    Dr. Cross. We support the focus on MST. It is, in fact, 
very important and that is why we made it a screening test, to 
make sure that even if the patient themselves don't bring it 
up, that we raise the issue and ask them directly about this, 
and that if there is a positive screen, that we get them in 
treatment. What we are doing is developing a number of 
outpatient/inpatient capabilities to provide the best treatment 
in the United States for these individuals.
    Senator Murray. Do you believe that you have an adequate 
number of people today to train and educate people--your 
clinicians--about MST within the VA today?
    Dr. Cross. I think that we are doing an adequate job on 
training our primary care providers and also our specialty 
providers. That doesn't mean I am satisfied.
    I have a group called the Strategic Health Group for Women 
Veterans that reports to me and has to inform me how we are 
doing; and I rely on them to keep me informed and to modify our 
programs as time goes along.
    I think our concern about staffing standards was the 
``cookie cutter'' approach, that we don't accept, really, on 
any of our programs. We think that they have to be individually 
tailored at the facility. Our facilities have different 
organizations and different places and different capabilities 
and providers, different patient populations. We tailor our 
approach in those places to put together our resources in the 
most effective way possible.
    Senator Murray. Well, I would just say, Mr. Chairman--and 
my time is way over--that because this issue is so important, 
because there are so many women not accessing the VA today, 
because there is an increasing number of veterans, I think it 
is imperative that we focus like a laser on this and really 
show that we are following a set standard and have very 
explicit policies in place to make sure these women do get in; 
because just hoping it is going to happen or saying it is there 
today is not making it happen.
    But thank you, Dr. Cross. We will look forward to working 
with you on this.
    Dr. Cross. Thank you, Senator.
    [The response from VA follows:]
Response to Request Arising During the Hearing by Hon. Patty Murray to 
   Department of Veterans Affairs regarding Women's Health Research 
                                Projects
    Request: Please provide a list of all active and recently completed 
women's health research studies, along with a short description of the 
studies, the number of women veterans involved in the studies, the 
expected completion dates of studies still underway and the amount of 
funding either requested or provided for each study during its 
duration. Also, provide a list of proposals that have been made for 
women veterans' health research studies since January 1, 2003, that 
were not approved for awards, with a short description of the reason 
for disapproval, and the estimated cost of those proposed studies. In 
addition, please provide a description of how the Department of 
Veterans Affairs (VA) selects research projects.
    Response: Attached is a list of active and recently completed 
women's health research projects supported by VA's Office of Research 
and Development (ORD). VA's women's health research includes studies on 
diseases prevalent solely or predominantly in women, such as certain 
types of cancer (e.g., breast, cervical, ovarian), lupus, human 
papillomavirus (HPV), and hormonal effects on diseases in post-
menopausal women; studies focusing on women subjects, for example, Post 
Traumatic Stress Disorder (PTSD) in women, osteoporosis in women, and 
multiple sclerosis in women; and studies on the health care needs and 
service utilization of women at VA, as well as the structures and 
organizations for the delivery of quality care. Current research 
examines the complex interaction of physical and mental health; the 
unique risks and outcomes of military service, particularly related to 
sexual and combat trauma and PTSD; and the impact of VA's organization 
and structures of health care delivery for women veterans on access, 
barriers to care, service availability, utilization, satisfaction, and 
quality of care. Reflecting the increasing numbers of women in the 
military, research is also directed at analyzing the needs and 
experiences of the new generation of Operation Enduring Freedom and 
Operation Iraqi Freedom (OEF/OIF) women veterans. In some of these OEF/
OIF studies, such as the women veterans' cohort study, potential gender 
disparities in utilization and outcomes are being assessed. Studies are 
also aimed at better understanding special concerns of reintegration 
for women veteran mothers.
    The broad scope of VA women's health research is also mirrored in 
recent research findings. Recent research has identified possible 
factors affecting treatment decisions such as hormone therapy 
discontinuation; explored gender differences in health care use and 
costs, health-related quality-of-life, VA health care utilization and 
mortality, and colorectal cancer screening barriers and information 
needs; suggested that gender is a factor explaining the use of mental 
health and substance abuse services among at-risk drinkers; and 
evaluated strategies to increase regular mammography screening among 
women veterans. Women veterans' perceptions about and experiences with 
VA health care have been documented, and VA and non-VA health care 
outcomes for vascular surgery operations in women have been compared. 
VA's efforts to identify and treat military sexual trauma have also 
been evaluated, and knowledge about the impacts of military trauma on 
women veterans--sexual and combat--has been reviewed in order to inform 
future research and treatment. In the largest randomized clinical trial 
to date involving women veterans with PTSD, VA investigators and 
colleagues found that prolonged exposure therapy, a type of cognitive 
behavioral therapy, was an effective treatment for PTSD in female 
veterans and active-duty military personnel (Journal of the American 
Medical Association. 2007;297(8):820-830).
    ORD does not systematically collect enrollment data centrally and, 
therefore, the number of participants is not included on the attached 
list. VA assures adequate representation of study participants through 
its scientific merit review process, which all studies undergo. It is 
important to note that nearly all studies funded by ORD that involve 
human subjects include women, except for obvious male relevant issues 
such as prostate or testicular cancer.
    Regarding the list of projects that were not funded, every year, 
nearly 2,000 letters of intent or research proposals are sent to ORD. 
Of these, only about 20 percent are selected for funding, based on 
rigorous peer review for scientific merit and administrative review for 
relevance to the veteran-centric health care mission of VA. In order to 
protect intellectual rights of investigators who may still be pursuing 
funding for their proposals through VA or other sources, ORD does not 
release information about such proposals. It is also important to note 
that from feedback provided to researchers through the review process, 
many of these studies are improved and ultimately funded.
    Regarding the process for selecting research projects, VA 
scientists submit research proposals through their local VA research 
office, which provides oversight and guidance for the local research 
program, using a standard format that describes the scientific 
question, the proposed method to answer the question, and its relevance 
to veterans' health. VA convenes scientific peer review committees, 
comprised of VA and non-VA scientists, to review proposals for 
scientific merit and appropriateness. The review committees assign a 
priority score based on merit.
    The next level of approval occurs within ORD, where ORD staff 
ensures relevance to veteran needs and checks with other ongoing 
projects funded by VA or others to ensure there is no duplication of 
effort. Proposals are then funded in order of merit and 
appropriateness/need based on the two-tier review described above. For 
the project to start, additional approvals are needed, which are done 
through review at the site where research is conducted (e.g., 
Institutional Review Board approval). This ensures local accountability 
for compliance with applicable regulations. In regards to women's 
health, ORD is routinely reviewing and funding new studies.















    Chairman Akaka. Thank you, Senator Murray.
    I will call on our Ranking Member, Senator Burr, for his 
questions.
    Senator Burr. Thank you, Mr. Chairman, and again, thank 
you, Dr. Cross.
    I don't have enough time to go through just the testimony 
on S. 2573, but let me pick apart a few places and help me to 
understand exactly the mindset of the Department of Veterans 
Affairs. Quoting your testimony, ``S. 2573 assumes that early 
treatment intervention by VA health care professionals for a 
covered condition would be effective in either reducing or 
stabilizing a veteran's level of permanent disability from the 
condition, thereby reducing the amount of VA disability 
benefits ultimately awarded for the condition. No data exists 
to support or refute that assumption.''
    Let me make it perfectly clear. My motive here in 
introducing this legislation is not about reducing the amount 
of VA disability benefits. It is about treatment. It is about a 
different outcome. So, I am going to ask you real specifically, 
what data exists to support what VA is currently doing in our 
mental health treatment--given that we see the percentages on 
the outcome side continue to go up--meaning what we are doing 
is not working. Tell me what data you have that I haven't seen 
that says what you are doing is working.
    Dr. Cross. The best data that exists comes from the 
Institute of Medicine and their report that we paid for and 
came out about 6 months or a year ago on what is the standard 
of care for PTSD in the world today. They listed off those 
treatment types of programs that should be included--the best 
possible treatment program. We are doing those. The exposure 
therapy, and cognitive therapy were the things that they 
recommended; and so, we are aligned with what the Institute of 
Medicine recommended.
    Senator Burr. And the assumption that you are making to 
come to the outcome that you have, is that every servicemember 
who has PTSD participates in these programs that you offer. And 
my point is, it is not good enough for us to offer programs if 
people don't participate in them. If people have to drop out of 
the treatment stream because of the financial burdens that 
exist with the family and they don't get the treatment, what is 
the outcome? The outcome is they continue to get worse.
    Every medical journal, every study that has been done says 
an intense up-front treatment for mental health conditions is 
absolutely essential to the outcome. Yet, we believe that just 
because we offer it--we offer a tremendous amount of benefits 
for disabilities. They are scattered all over the country. And 
the fact is that if you enter in Richmond, Virginia, with a 
Traumatic Brain Injury, but don't find out about a state-of-
the-art facility in San Antonio, Texas, and you never get 
there, the likelihood is your outcome is different.
    And we are reliant on being able to say, well, it exists. 
But there's no attempt to try to communicate this throughout. 
And then we wonder why we have hearings where family members 
come in where they have voluntarily taken somebody out of the 
VA system because of their determination of the outcome and put 
them in a private facility to try to get a different outcome. 
Am I blowing this out of proportion?
    Dr. Cross. Sir, I agree, and let me say something. We are 
intrigued by this bill----
    Senator Burr. It is not good enough, Dr. Cross, to be 
intrigued.
    Dr. Cross [continuing]. And we agree----
    Senator Burr. I want you to be passionate about changing 
the outcome----
    Dr. Cross. Can I say----
    Senator Burr [continuing]. Of the future for these kids.
    Dr. Cross. Let me tell you a couple of the things that we 
are doing that relate to this. You say some folks have not come 
in. We agree with that. We are very concerned about that. At 
this very moment, we are contacting 550,000 OEF/OIF veterans 
who have not yet come to see us, calling them on the phone 
saying, ``How are you doing? Having any problems? Can you come 
see us?'' And we put a screening program in place so that even 
if the patient doesn't ask about symptoms related to PTSD, we 
ask about them--made it part of our Electronic Health Record. 
We are taking these concerns very seriously----
    Senator Burr. Let me go back to your testimony just real 
quick. ``Costing this bill is very complex as there are no ways 
for us to determine the total number of veterans who would 
participate in a pilot program, in which year they would enter 
the program, their ultimate disability status, and the amount 
of the medical care that each require. We estimate the increase 
in medical administration costs for every 400,000 new veterans 
entering the VA system to be $280 million per year in addition 
to the $293 million per year in maximum stipend payments.''
    My point is that the entire testimony goes back to, one, we 
can't figure out what this costs. I am not questioning what it 
costs. I am questioning whether what we do works. You are not 
focused on whether what you do today works. You are focused on 
justifying what you spend on it.
    Dr. Cross. Some of the concerns that we have about patient 
care are very significant. Forget the cost. For instance, 
substantial compliance--what does that mean? Does that put the 
treatment provider, the physician, in place of a judge in a way 
that is going to impact their financial status? That is a 
concern to us, because in our C&P programs, we tried to keep 
those separate. Why just mental health? There are other 
conditions that we could use the same thought in regard to. And 
why just provide treatment for mental health and not other 
conditions, even though I say there are other medical 
conditions that very much influence mental health?
    Those are some of the concerns that we would like to work 
out with you and your staff, because we think that there is a 
great deal of interest in this; but there are some concerns 
that we have that we think need to be addressed to make this 
better.
    Senator Burr. Well, it is not my MO to come in and to raise 
issues at the level that I have with this, but it significantly 
disappoints me when we have a delivery system that is so good 
that will not think out of the box, that will not recognize the 
fact that we have a problem.
    Now, Senator Murray and I, we are both passionate about 
mental health treatment. We may have very different approaches 
and where we find commonality, I think we work together. Where 
we don't, we are very passionate about our differences. But 
both of us agree on one thing. This is about the outcome of 
these servicemembers. This is about, do they get better.
    And I would only tell you that when you challenge whether 
this bill works or not based upon the lack of data, let me 
suggest to you that when I look at the data on the outcomes 
that we currently get, we would all opt to go somewhere else 
and not to the Department of Veterans Affairs to get mental 
health treatment because, as Senator Craig said, this is 
spiraling down to where everybody is disabled--and eventually 
100 percent--and I would just suggest to my colleagues, that is 
not the expectation of today's warriors. Their expectation is 
to get well. And if we have a system that is designed only to 
manage getting sicker, then we have made a huge mistake.
    I thank the Chair.
    Chairman Akaka. Thank you very much, Senator Burr.
    Dr. Cross, in your written testimony, you described the 
likely impact of the proposed requirement that every VA 
physician be licensed in the State which they practice. In your 
best estimation, what percentage of VA physicians would be 
forced to be relicensed or relocate and what impact would this 
have on VA's ability to care for veterans?
    Dr. Cross. Thank you, Mr. Chairman. Eighty-three percent of 
VA physicians are board certified at this time. In the Nation, 
the number is approximately 85 percent, so very similar numbers 
for the VA and the Nation. Among VA surgeons, by the way, about 
93.4 percent of VA surgeons are board certified, whereas only 
about 90 percent of those across the Nation outside the VA are 
board certified. So, that is the percentage in terms of board 
certification that would make a difference for us.
    I support board certification. I think it is--I am board 
certified. I think it is very important. I think that we should 
promote it. Requiring it becomes problematic in terms of hiring 
and retention at times, but I think we should move forward to 
make sure that as many as possible, even all of our physicians 
are board certified.
    Chairman Akaka. I am glad to hear that from you, Doctor.
    Your testimony notes that views on S. 2963 are not 
available, yet I understand that there are several accounts 
that the Department does, in fact, support the legislation. 
This legislation would have a significant impact on Vet 
Centers. Does the Department support this legislation, and if 
so, how will Vet Centers and staff not become overwhelmed by 
additional veterans?
    Dr. Cross. Sir, I don't think we have developed our views 
on that yet. That is one of the ones that we are still working 
on.
    Chairman Akaka. Dr. Cross, at the Committee's hearing on 
personnel issues on April 9, we heard about a range of staffing 
issues facing VA facilities. Nursing positions stood out as 
particularly challenging to fill. How can VA better use the 
various alternative work schedules frequently used outside of 
VA to improve recruitment and retention of nurses?
    Dr. Cross. Recruitment and retention of nurses is something 
that is of great interest to the VA and we are quite willing to 
use flexible scheduling or whatever other techniques that we 
can come by to make their practice with us--you know, help them 
to retain those very important staff members.
    I do want to say that we have been thinking outside the 
box. We have been doing innovative things. Our nursing academy 
proposal, for instance, that has already been started--working 
with civilian universities to expand the capacity to train more 
nurses nationwide, and then, of course, in this situation bring 
them into the VA--is already underway. And we have made grants 
with--we made arrangements with--four universities, and I 
understand that we are looking to expand that this year. We are 
looking at ways to be more innovative--provide more innovative 
support for nurses.
    Chairman Akaka. Dr. Cross, you oppose the mobile health 
bill, which is S. 2383, in part because it is duplicative of 
existing programs and ongoing efforts. I believe mobile units 
would have significant value in rural areas and would like to 
see their deployment accelerated. What resources or tools does 
VA require to speed the implementation of mobile health units?
    Dr. Cross. Our Office of Rural Health is putting together a 
package for more outreach, including mobile assets that we can 
send out into the rural environment. Particularly, it might 
include things like preventive health and primary care 
assessments. Our Vet Centers have a proposal that I have 
already accepted to buy a number of vans to reach out to 
locations where counseling might be made available in more 
remote areas.
    The challenge that we had with the bill is this: the bill 
was phrased in such a way and was so specific in terms of how 
often we would go out, who would be on the van--it had so many 
people in the van that I was trying to envision how large it 
would have to be--because it included everything from 
employment counselors, to financial counselors, to PTSD, to 
mental health, to medical care. That was going to be difficult 
for us. So, we are aligned with you in support of the concept. 
Some of the details in the bill do cause us some problems.
    Chairman Akaka. Before I move on, Dr. Cross, nonprofit 
research corporations, NPCs, are providing important support to 
VA research and I know you think it is very important to your 
work. How would the function of NPCs be strengthened if 
multiple facilities were permitted to consolidate research 
corporations to form multi-medical center NPCs?
    Dr. Cross. I will ask Mr. Hall to help me on this, but I do 
want to say that we are doing more large-scale studies that go 
across many boundaries that currently exist, and to try to put 
these large studies together, I think this is one thing that 
might help us in that direction.
    Walt?
    Mr. Hall. The other part of it, Mr. Chairman, is we have a 
number of corporations out there at some of our smaller 
facilities that don't have the critical mass. They don't have 
the funding necessary to pay for all the overhead that is 
necessary to appropriately run the corporations. By allowing 
some of these smaller corporations to combine, to merge into 
large units, they would be better able to fund their overhead 
and fulfill their oversight responsibilities.
    Chairman Akaka. Let me ask a final question. Dr. Cross, I 
am concerned about the potential conflict that would arise for 
health care practitioners if S. 2573 is adopted. What is the 
health care practitioner's primary mission--care for the 
veteran's mental health or for the financial implications of a 
wellness stipend determination? Does leaving the decision in 
the hands of a practitioner create an inherent conflict between 
practitioner and patient?
    Dr. Cross. The primary purpose, Mr. Chairman, of a health 
care provider in the VA is to address the well-being of the 
patient that they are taking care of. In our C&P programs--our 
compensation and pension programs--where we do examinations, we 
do our best to try and separate those examinations for 
compensation from the ongoing treatment that we provide for the 
individual over a period of years. That can get very 
complicated for a physician--having to address treatment needs 
of an individual at the same time as trying to address 
something that has financial implications for that same patient 
at the same time. I think sometimes it can get in the way of 
treatment, and that is why we try to keep it separate.
    Chairman Akaka. I want to thank you for your responses and 
your colleagues, as well, for being here.
    Dr. Cross. Well, thank you, sir. I appreciate it.
    Chairman Akaka. Thank you. I want to excuse the first 
panel.
    I would like to call the second panel up. I welcome our 
witnesses from Veterans Service Organizations to the second 
panel. I appreciate your being here today and look forward to 
your testimony.
    First, I want to welcome Carl Blake, National Legislative 
Director for Paralyzed Veterans of America. Next, I welcome 
Joseph Wilson, Assistant Director for Health Policy for the 
Veterans Affairs and Rehabilitation Commission of the American 
Legion. I also welcome Joy Ilem, Assistant National Legislative 
Director for Disabled American Veterans. And finally, I welcome 
Chris Needham, Senior Legislative Associate of the National 
Legislative Service of Veterans of Foreign Wars.
    I thank all of you for joining us today. Your full 
statements will appear in the record of the Committee.
    Mr. Blake, will you please begin with your testimony.

    STATEMENT OF CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR, 
                 PARALYZED VETERANS OF AMERICA

    Mr. Blake. Thank you, Chairman Akaka. On behalf of 
Paralyzed Veterans of America, I would like to thank you for 
the opportunity to testify today on the proposed health care 
legislation. Due to the number of bills on the agenda, I will 
limit my comments to just a few issues.
    While PVA appreciates the concepts outlined in S. 2573, the 
Veterans Mental Health Treatment First Act, we oppose this 
proposed legislation. We believe that this legislation draws 
attention to a concept that the VA ought to be focused 
primarily on already--the health and wellness of sick and 
disabled veterans. But, this focus should not be at the expense 
of the veteran.
    We cannot argue with the importance of proper and effective 
treatment to address the mental health issues that veterans may 
face. However, we are concerned with the fact that the 
legislation requires the veteran to delay his or her right to 
file a claim while participating in the program. While we can 
certainly see the benefit of a veteran participating in a 
comprehensive treatment program, we see no reason why he or she 
should not still be able to file a claim concurrently. 
Otherwise, the process simply is delayed a year. And while we 
understand the argument that a veteran would receive a stipend 
under this program, we do not believe that this is an 
acceptable method of offsetting the broad range of benefits 
along with compensation associated with an adjudicated claim.
    PVA supports the provisions of S. 2797 that establish 
funding authorizations for construction projects in fiscal year 
2009. We were pleased to see that significant dollars are being 
authorized to finally address the problems with the health care 
facility in Puerto Rico. PVA has been particularly involved 
with this project to ensure that a quality spinal cord injury 
center is maintained at this medical facility.
    We are also particularly pleased to see that funding is 
authorized for the replacement hospital in Denver, Colorado. 
Since the inception of the CARES process a number of years ago, 
we have advocated for this replacement facility and a co-
located SCI center to serve the veterans of the Trans-Mountain 
Region. Our architects have been working with VA staff in 
developing the design and construction plans for this new 
facility, which will obviate the needs of veterans with spinal 
cord injury having to travel to Seattle, Washington, 
Albuquerque, New Mexico, and Milwaukee, Wisconsin, to receive 
specialty care.
    We ask that the Committee pay particular attention to this 
project in light of Secretary Peake's press release of April 
24, 2008, and the VA's comments here today announcing a 
reversal of VA's longstanding position to build a new facility 
on the Fitzsimmons Campus and replace it with leased and shared 
space in a new tower to be constructed by the University of 
Colorado and the University of Colorado Hospital. A similar 
proposal was rejected by then-Secretary Anthony Principi a 
number of years ago, who found that a freestanding, exclusive 
VA facility was the most appropriate approach to meeting the 
health care needs of veterans in this region.
    We ask the Committee to ensure that this project moves 
forward as planned as a unique, freestanding, tertiary care VA 
replacement hospital. Allowing the VA to move forward in the 
manner that Secretary Peake outlined recently could prove 
detrimental to all veterans in the Trans-Mountain Region, 
particularly those with specialty health care needs.
    PVA strongly supports S. 2926, the Veterans Nonprofit 
Research and Education Corporations Enhancement Act. The 
purpose of this legislation is to modernize and clarify the 
existing statutory authority for VA-affiliated nonprofit 
research and education corporations, NPCs. This bill will allow 
the NPCs to fulfill their full potential in supporting VA 
research and education, which ultimately results in improved 
treatments and high-quality care for veterans while ensuring VA 
and Congressional confidence in NPC management.
    PVA has been a strong supporter of the NPCs since their 
inception, recognizing that they benefit veterans by increasing 
the resources available to support the VA research program and 
to educate VA health care professionals. We urge expeditious 
passage of S. 2926 so that veterans may benefit even more from 
the enhancements and operational capabilities and oversight 
that this bill provides.
    Mr. Chairman, I would like to thank you again for the 
opportunity to testify. I would be happy to answer any 
questions that you might have.
    [The prepared statement of Mr. Blake follows:]
   Prepared Statement of Carl Blake, National Legislative Director, 
                     Paralyzed Veterans of America
    Chairman Akaka, Ranking Member Burr, and Members of the Committee, 
on behalf of Paralyzed Veterans of America (PVA) I would like to thank 
you for the opportunity to testify today on the proposed health care 
legislation. The scope of health care issues being considered here 
today is very broad. We appreciate the Committee taking the time to 
address these many issues, and we hope that out of this process 
meaningful legislation will be approved to ensure veterans receive the 
best health care available from the VA.
 s. 2273, the ``enhanced opportunities for formerly homeless veterans 
                  residing in permanent housing act''
    PVA supports S. 2273, the ``Enhanced Opportunities for Formerly 
Homeless Veterans Residing in Permanent Housing Act.'' Homelessness has 
proven to be a major problem among the men and women who have served in 
uniform. While estimates vary, it is believed that as many as 250,000 
veterans are on the street in any given night. This fact seems 
incomprehensible in light of the sacrifices that these men and women 
have made.
    The proposed legislation establishes a pilot program to provide 
grants to up to ten qualifying entities for a period of 5 years. These 
grants will be awarded to public and non-profit organizations to 
coordinate the provision of supportive services that exist in the local 
community. The target within the veteran population for this program 
will be those veterans that have previously participated in the 
Homeless Providers Grant and Per Diem Program. When a veteran achieves 
the goals within the program, he or she is ready to move into a more 
permanent living environment. However, in many situations the veteran 
will still need supportive services to accompany their housing needs as 
they progress toward a goal of self-sufficiency. These entities can 
then coordinate supportive services such as continued case management, 
counseling, job training, transportation, and child care services. By 
addressing each of these issues, the veteran stands a better chance of 
getting off of the street and living a productive life once again.
     s. 2377, the ``veterans health care quality improvement act''
    PVA supports S. 2377, the ``Veterans Health Care Quality 
Improvement Act.'' We certainly appreciate the underlying intent of 
this bill which is to ensure that the health care provided by the VA is 
the very best available. Section 2 of the legislation defines standards 
that must be met for physicians to practice in the VA. It requires the 
disclosure of certain information pertaining to the past performance of 
a physician and requires the Director of each Veterans Integrated 
Service Network (VISN) to investigate any past disciplinary or medical 
incompetence issues of physicians to be hired.
    PVA supports Section 3 of S. 2377 that requires the Under Secretary 
for Health to designate a national quality assurance officer and a 
quality assurance officer for each VISN. This establishes a quality-
assurance program for the health care system and provides a method for 
VA health care workers to report incidents of inconsistency. We believe 
that one of the keys to high quality health care services is an 
affective quality assurance program. This program could be beneficial 
for improving accountability within the health care system.
    We likewise support Section 4 of the legislation that offers 
incentives to attract physicians to work in the VA health care system. 
It also encourages the VA to recruit part time physicians from local 
medical schools. PVA has expressed concern in the past that the VA is 
struggling to attract high quality physicians, particularly to 
specialized services like spinal cord injury care, blind 
rehabilitation, and mental health.
                                s. 2383
    PVA recognizes that there is no easy solution to meeting the needs 
of veterans who live in rural areas. These veterans were not originally 
the target population of men and women that the VA expected to treat. 
However, the VA decision to expand to an outpatient network through 
community-based outpatient clinics reflected the growing demand on the 
VA system from veterans outside of typical urban or suburban settings.
    PVA has no objection to the proposal for a pilot program to use 
mobile systems in not less than three VISNs. However, the one caution 
we would offer is that services provided in this manner tend to be more 
expensive and less cost-effective. We believe that mobile services tend 
to be much more cost-effective in areas where a large segment of the 
target population can be served because it drives down the overall 
cost-per-patient. In other words, the VA could potentially get more 
``bang for its buck'' by having a mobile clinic set up in the downtown 
area of a major city where an existing medical facility may be beyond 
capacity.
    Furthermore, we are concerned about how these mobile centers will 
be staffed. The legislation calls for VA physicians, nurses, and mental 
health specialists, case workers, benefits counselors, and any other 
personnel deemed appropriate to staff the mobile clinic. While we fully 
agree with these staffing guidelines, given the difficulty in hiring 
many of these professionals already, particularly nurses and mental 
health professionals, we remain skeptical about the ability of the VA 
to meet this requirement. We are also concerned about the ability of 
these clinics to meet the needs of women veterans--a segment of the 
veteran population that is rapidly growing, particularly in rural areas 
where National Guard and Reserve units are returning.
    Finally, one last suggestion that we would like to offer is that 
each of these mobile clinics should be accessible for persons with 
disabilities. There are many disabled veterans who might like to take 
advantage of these mobile services, and it would be a real disservice 
to them if they are unable to visit one of these clinics because it is 
inaccessible.
      s. 2573, the ``veterans mental health treatment first act''
    While PVA understands the concepts outlined in S. 2573, the 
``Veterans Mental Health Treatment First Act,'' we oppose this proposed 
legislation. We believe that this legislation tries to draw attention 
to a concept that the VA ought to be focused on already--the health and 
wellness of sick and disabled veterans. But this focus should not be at 
the expense of the veteran. We cannot argue with the importance of 
proper and effective treatment to address the mental health issues that 
veterans may face. However, we believe this legislation would simply 
force near term treatment on veterans in order to save the VA, and by 
extension the Federal Government, money paid out in compensation in the 
long term.
    First, we would point out that the legislation calls for a ``pre-
evaluation'' of the veteran exhibiting symptoms of Post Traumatic 
Stress Disorder (PTSD) to determine if the condition might be related 
to his or her service. This implies a step not unlike the disability 
claims process should already be taking. Furthermore, it calls for the 
Secretary to prescribe regulations dictating what constitutes a 
relationship to military service--a concept already addressed in Title 
38 U.S.C. and the Code of Federal Regulations.
    Second, the legislation requires the veteran to delay his or her 
right to file a claim while participating in the program. While we can 
certainly see the benefit of a veteran participating in a comprehensive 
treatment program, we see no reason why he or she should not still be 
able to file a claim concurrently. Otherwise, the process simply is 
delayed a year. And while we understand the argument that a veteran 
would receive a stipend under this program, we do not believe that this 
is an acceptable method of offsetting the broad range of benefits, 
along with compensation, associated with adjudication of a claim. 
Furthermore, depriving a veteran of his or her entitlement to 
compensation may actually have the unintended effect of providing a 
financial disincentive to participate in rehabilitation and treatment.
     s. 2639, the ``assured funding for veterans health care act''
    PVA supports S. 2639, the ``Assured Funding for Veterans Health 
Care Act,'' introduced by Senator Tim Johnson. Despite the fact that 
Congress has taken significant steps in the last couple of years to 
address the funding needs of the VA, the appropriations process still 
puts the VA at a significant disadvantage each year. For 13 of the past 
14 years, the VA appropriations bill was not passed before the start of 
the new fiscal year on October 1. In fact, on several occasions, the VA 
appropriations bill was not passed before the start of the new calendar 
year, leaving the VA to react accordingly. We certainly appreciate the 
efforts Congress has made recently to provide adequate funding for the 
VA. However, the current process has only met one of the goals we have 
established for funding the VA health care system--sufficiency, 
timeliness, and predictability.
    We believe that it is time for Congress to truly debate alternative 
funding mechanisms to provide for the needs of the VA health care 
system. As such, S. 2639, is one of those alternatives that we believe 
can be effective. Unfortunately, some members in both the Senate and 
House have opposed mandatory funding because it would be too costly; 
however, a Congressional Research Service report provided to Congress 
last year detailing the running expenditures for the Global War on 
Terror since September 11, 2001, revealed that Veterans Affairs-related 
spending constitutes 1 percent of the government's total expenditure 
since that date.
    Without question, there is a high cost for war, and caring for our 
Nation's sick and disabled veterans is part of that continued cost. A 
report by a researcher at Harvard's Kennedy School of Government 
predicted that Federal outlays for veterans of the wars in Afghanistan 
and Iraq would arc between $350 billion and $700 billion over their 
life expectancies following military service--an amount in addition to 
what the Nation already spends for previous generations of veterans. 
Thus, it is clear the government will be spending vast sums in the 
future to care for veterans, to compensate them for their service and 
sacrifice, but these funds will still only constitute a minute fraction 
of total homeland security and war spending.
    Moreover, too much of the opposition to assured funding legislation 
revolves around myths that simply are not true. Outside of cost, one of 
the chief complaints about assured funding is that Congress would lose 
oversight over the VA health care system. This idea is nonsensical at 
best. Most importantly, funding would be removed from the direct 
politics and uncertainties of the annual budget-appropriations process, 
and Congress would still retain oversight of VA programs and health 
care services--as it does with other Federal mandatory programs.
    Some Members of Congress also fear that assured funding would open 
the VA health care system to all veterans. In fact, the Health Care 
Eligibility Reform Act of 1996 theoretically opened the VA health care 
system to all 25 million veterans; however, it was never anticipated 
that all veterans would seek or need VA health care. Current enrollment 
figures do not support the notion that veterans will flood the VA 
health care system. Moreover, the Secretary is required by law to make 
an annual enrollment decision based on available resources--a fact that 
has left the VA health care system closed to eligible Category 8 
veterans for more than 5 years. This bill would not affect the 
Secretary's authority to manage enrollment, but would only ensure the 
Secretary has sufficient funds to treat those veterans enrolled for VA 
health care.
    Finally, as you know, the whole community of national veterans' 
service organizations strongly supports an improved funding mechanism 
for VA health care. However, if the Congress cannot support mandatory 
funding, there are alternatives which could meet our goals of timely, 
sufficient, and predictable funding.
    The Partnership for Veterans Health Care Budget Reform is currently 
working on a proposal for Congress that would change VA's medical care 
appropriation to an advance appropriation which would provide approval 
1 year in advance, thereby guaranteeing its timeliness. Furthermore, by 
adding transparency to VA's health care enrollee projection model, we 
can focus the debate on the most actuarially-sound projection of 
veterans' health care costs to ensure sufficiency. Under this proposal, 
Congress would retain its discretion to approve appropriations; retain 
all of its oversight authority; and most importantly, there would be no 
PAYGO problems.
                                s. 2796
    PVA supports S. 2796, a bill that establishes a pilot program to 
facilitate the use of community-based organizations to ensure that 
veterans receive the care and benefits that they have earned and 
deserve. The program will be carried out in five selected locations by 
providing grants to community-based organizations with the goal of 
providing information and outreach in rural areas and areas that have a 
high proportion of minority veterans. This offers an excellent 
opportunity for the VA to ensure that current information pertaining to 
available benefits for the veterans and their families is available in 
previously underserved geographic areas.
                  s. 2797, construction authorization
    PVA supports the provisions of S. 2797 that establishes funding 
authorizations for construction projects in fiscal year 2009. We are 
pleased to see that significant dollars are being authorized to finally 
address the problems with the health care facility in Puerto Rico. PVA 
has been particularly involved with this project to ensure that a 
quality spinal cord injury (SCI) center is maintained at this medical 
facility.
    We are also particularly pleased to see that funding is authorized 
for the replacement hospital in Denver, Colorado. Since the inception 
of the CARES process a number of years ago we have advocated for this 
replacement facility and a co-located SCI center to serve the veterans 
of the trans-mountain region. Our architects have been working with VA 
staff in developing the design and construction plans for this new 
facility which will obviate the need of veterans with spinal cord 
injury having to travel to Seattle, WA, Albuquerque, NM or Milwaukee, 
WI to receive needed care.
    We ask that the Committee pay particular attention to this project 
in light of Secretary Peake's press release of April 24, 2008, 
announcing a reversal of VA's long-standing position to build a new 
facility on the Fitzsimmons campus and replace it with leased and 
shared space in a new tower to be constructed by the University of 
Colorado and the University of Colorado Hospital. A similar proposal 
was rejected by then-Secretary Anthony Principi a number of years ago 
who found that a freestanding, exclusive VA facility was the most 
appropriate approach to meeting the health care needs of veterans in 
this region. We ask the Committee to ensure that this project moves 
forward, as planned as a unique, free-standing tertiary care VA 
replacement hospital. Allowing the VA to move forward in the manner 
that Secretary Peake outlined recently could prove detrimental to all 
veterans in the trans-mountain region, particularly those with 
specialized health care needs.
      s. 2799, the ``women veterans health care improvement act''
    PVA supports S. 2799, the ``Women Veterans Health Care Improvement 
Act.'' This legislation is meant to expand and improve health care 
services available in the Department of Veterans Affairs (VA) to women 
veterans, particularly those who have served in Operation Enduring 
Freedom and Operation Iraqi Freedom (OEF/OIF). More women are currently 
serving in combat theaters than at any other time in history. As such, 
it is important that the VA be properly prepared to address the needs 
of what is otherwise a unique segment of the veteran population.
    Title I of the bill would authorize a study that would evaluate the 
health care needs of women veterans and the services that are currently 
available to women veterans through the VA. Furthermore, it would also 
authorize a study to identify barriers and challenges that women 
veterans face when seeking health care from the VA. We believe each of 
these studies and assessments can only lead to higher quality care for 
women veterans in the VA. They will allow the VA to dedicate resources 
in areas that it must improve upon.
    Title II of the bill would target special care needs that women 
veterans might have. Specifically, it would ensure that VA health care 
professionals are adequately trained to deal with the complex needs of 
women veterans who have experienced sexual trauma. Furthermore, it 
would require the VA to develop and implement a program of education, 
training, and certification for health care professionals for the 
treatment, including evidence-based treatment, of Post Traumatic Stress 
Disorder (PTSD) and other co-morbid conditions that are proven 
effective for women veterans. While many veterans returning from OEF/
OIF are experiencing symptoms consistent with PTSD, women veterans are 
experiencing unique symptoms also consistent with PTSD. It is important 
that the VA understand these potential differences and be prepared to 
provide care.
    PVA views this proposed legislation as necessary and critical. The 
degree to which women are now involved in combat theaters must be 
matched by the increased commitment of the VA, as well as the 
Department of Defense, to provide for their needs when they leave the 
service. We cannot allow women veterans to fall through the cracks 
simply because programs in the VA are not tailored to the specific 
needs that they might have.
                                s. 2824
    PVA generally supports the provisions of S. 2824, a bill that would 
improve the collective bargaining rights and procedures for review of 
adverse actions for certain health care professionals in the VA. These 
changes would be a positive step in addressing the recruitment and 
retention challenges the VA faces to hire key health care 
professionals, particularly registered nurses (RN), physicians, 
physician assistants, and other selected specialists.
    As we understand current practice, certain specific positions 
(including those mentioned previously) do not have particular rights to 
grieve or arbitrate over basic workplace disputes. This includes 
weekend pay, floating nurse assignments, mandatory nurse overtime, 
mandatory physician weekend and evening duty, access to survey data for 
setting nurse locality pay and physicians' market pay, exclusion from 
groups setting physicians' market pay, and similar concerns. This would 
seem to allow VA managers to undermine Congressional intent from law 
passed in recent years to ensure that nurse and physician pay are 
competitive with the private sector and to ensure nurse work schedules 
are competitive with local markets.
    Interestingly, given the VA's interpretation of current laws, these 
specific health care professionals are not afforded the same rights as 
employees who they work side-by-side with everyday. For instance, 
Licensed Practicing Nurses (LPN) and Nursing Assistants (NA) can 
challenge pay and scheduling policies, while RN's cannot. This simply 
makes no sense to us.
               s. 2889, the ``veterans health care act''
    PVA generally supports the provisions of Section 2 of the proposed 
S. 2889, the ``Veterans Health Care Act.'' This new section is 
consistent with the other authorities granted under Section 1720 of 
Title 38. It is important that if the VA chooses to use this authority, 
then appropriate facilities are chosen to reflect the age and 
complexity of the issues being faced by Operation Enduring Freedom and 
Operation Iraqi Freedom veterans.
    Likewise, we support Section 4 of the proposed bill that would 
prohibit the VA from collecting co-payments from veterans receiving 
hospice care whether in an inpatient or outpatient setting. As we 
recall, the VA actually supported similar legislation during the 109th 
Congress. This legislation only makes sense as it will align with 
current statute that prevents VA from collecting co-payments from 
veterans receiving hospice care in a nursing home setting.
              s. 2899, the ``veterans suicide study act''
    The incidence of suicide among veterans, particularly Operation 
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans, is a 
serious concern that needs to be addressed. Any measure that may help 
reduce the incidence of suicide among veterans is certainly a good 
thing. As such, PVA supports this legislation. This bill would require 
the VA to conduct a study to determine the number of veterans who have 
committed suicide since January 1, 1997.
    It is important to note that VA has made suicide prevention a major 
priority. VA has developed a broad program based on increasing 
awareness, prevention, and training of health care staff to recognize 
suicide risk. A national suicide prevention hotline has been 
established and suicide prevention coordinators have been hired in each 
VA medical center. Research into the risk factors associated with 
suicide in veterans and prevention strategies is underway.
    However, it is equally important to point out that suicide 
prevention is something that can be addressed early on in the mental 
health process. With access to quality psychiatric care and other 
mental health professionals, many of the symptoms experienced early on 
can be addressed in order to reduce the risk of suicide down the road. 
This extends to proper screening and treatment for veterans who deal 
with substance abuse problems as well.
            s. 2921, the ``caring for wounded warriors act''
    PVA fully supports the provisions of S. 2921, the ``Caring for 
Wounded Warriors Act.'' The provisions of this legislation are 
consistent with recommendations included in The Independent Budget for 
fiscal year 2009. The difficulties being faced by caregivers--whether 
family, friend, or professional caregiver--have been documented in 
recent years as more men and women return from Operation Enduring 
Freedom and Operation Iraqi Freedom severely injured. Perhaps, no 
organization understands the importance of caregiver assistance more 
than Paralyzed Veterans of America. A substantial number of our members 
rely on caregivers to function daily.
    A certification and training program for caregivers, as outlined in 
Section 2 of the bill, could be a vital tool for ensuring severely 
injured veterans receive the care they need. It will help them learn to 
cope with the tremendous stress that they, as caregivers, must deal 
with while simultaneously providing care. This is why PVA, in 
conjunction with The Independent Budget, has previously called on 
Congress to formally authorize, and for VA to provide, a full range of 
psychological and social support services as an earned benefit to 
family caregivers of severely injured and ill veterans. Moreover, The 
Independent Budget calls for the VA to ``establish a pilot program 
immediately for providing severely disabled veterans and family members 
residential rehabilitation services, to furnish training in the skills 
necessary to facilitate optimal recovery, particularly for younger, 
severely injured veterans.'' We particularly appreciate the specific 
provision that allows for compensation of caregivers who take part in 
the training program.
    We would like to make a couple of suggestions as it relates to the 
pilot program authorized in Section 2 of the legislation. First, these 
services should not be limited only to caregivers who assist veterans 
who have experienced Traumatic Brain Injury. There are many veterans of 
the current conflict, and previous conflicts, who have experienced 
equally severe injuries and diseases. Second, the certification program 
should not be limited to families as defined by the legislation. There 
are many willing caregivers and paid personal care attendants out there 
who do not necessarily meet the strict criteria of the definition in 
the bill, but who could equally benefit from this legislation.
    PVA likewise supports the authorization of a pilot program for 
respite care as outlined in Section 3 of the proposed bill. As with 
Section 2, we do not believe that the provisions of Section 3 should be 
limited to veterans who have incurred a Traumatic Brain Injury. 
Moreover, we do not believe that the relationship established by this 
legislation should be limited to graduate-level students. As stated in 
The Independent Budget for fiscal year 2009.

        The IBVSOs believe VA should establish a new national program 
        to make periodic respite services available to all severely 
        injured veterans. This program should be designed to meet the 
        needs of younger severely injured or ill veterans, in contrast 
        to the generally older veteran population now served by VA 
        programs. Where appropriate VHA services are not available 
        because of geographic barriers, the VHA should develop 
        contractual relations with appropriate, qualified private or 
        other public facilities to provide respite services tailored to 
        this population's needs.

    Finally, as this Committee moves forward with deliberations on how 
best to provide services to the caregivers and families of severely 
injured veterans it may be worth reviewing VA progress regarding 
Section 214 of Public Law 109-461. Section 214 required VA to implement 
a pilot program to assess and improve caregiver assistance services. 
Public Law 109-461 required the VA Secretary to carry out the pilot 
over a 2-year period within 120 days following enactment of Public Law 
109-461. Caregiver assistance referred to VA services that would assist 
caregivers such as:

     Adult-day care.
     Coordination of services needed by veterans, including 
services for readjustment and rehabilitation.
     Transportation services.
     Caregiver support services, including education, training, 
and certification of family members in caregiver activities.
     Home care services.
     Respite care.
     Hospice services and other modalities of non-institutional 
VA long-term care.
 s. 2926, the ``veterans nonprofit research and education corporations 
                           enhancement act''
    PVA strongly supports S. 2926, the ``Veterans Nonprofit Research 
and Education Corporations Enhancement Act.'' The purpose of this 
legislation is to modernize and clarify the existing statutory 
authority for VA-affiliated nonprofit research and education 
corporations (NPCs). This bill will allow the NPCs to fulfill their 
full potential in supporting VA research and education, which 
ultimately results in improved treatments and high quality care for 
veterans, while ensuring VA and congressional confidence in NPC 
management.
    Since passage of Public Law 100-322 in 1988 (codified at 38 U.S.C. 
Sec. 7361-7368), the NPCs have served as an effective ``flexible 
funding mechanism for the conduct of approved research and education'' 
performed at VA medical centers across the Nation. NPCs provide VA 
medical centers with the advantages of on-site administration of 
research by nonprofit organizations entirely dedicated to serving VA 
researchers and educators, but with the reassurance of VA oversight and 
regulation. During 2007, 85 NPCs received nearly $230 million and 
expended funds on behalf of approximately 5,000 research and education 
programs, all of which are subject to VA approval and are conducted in 
accordance with VA requirements.
    NPCs provide a full range of on-site research support services to 
VA investigators, including assistance preparing and submitting their 
research proposals; hiring lab technicians and study coordinators to 
work on projects; procuring supplies and equipment; monitoring the VA 
approvals; and a host of other services so the principal investigators 
can focus on their research and their veteran patients.
    Beyond administering research projects and education activities, 
when funds permit, these nonprofits also support a variety of VA 
research infrastructure expenses. For example, NPCs have renovated 
labs, purchased major pieces of equipment, staffed animal care 
facilities, funded recruitment of clinician-researchers, provided seed 
and bridge funding for investigators, and paid for training for 
compliance personnel.
    Although the authors of the original statute were remarkably 
successful in crafting a unique authority for VA medical centers, 
differing interpretations of the wording and the intent of Congress, 
gaps in NPC authorities that curtail their ability to fully support VA 
research and education, and evolution of VA health care delivery 
systems have made revision of the statute increasingly necessary in 
recent years. S. 2926 contains revisions that will resolve all of these 
and will allow the NPCs to better serve VA research and education 
programs while maintaining the high degree of oversight applied to 
these nonprofits.
    The legislation reinforces the idea of ``multi-medical center 
research corporations'' which provides for voluntary sharing of one NPC 
among two or more VA medical centers, while still preserving their 
fundamental nature as medical center-based organizations. Moreover, 
accountability will be ensured by requiring that at a minimum, the 
medical center director from each facility must serve on the NPC board. 
This authority will allow smaller NPCs to pool their administrative 
resources and to improve their ability to achieve the level of internal 
controls now required of nonprofit organizations.
    The legislation also clarifies the legal status of the NPCs as 
private sector, tax exempt organizations, subject to VA oversight and 
regulation. It also modernizes NPC funds acceptance and retention 
authorities as well as the ethics requirements applicable to officers, 
directors and employees and the qualifications for board membership. 
Moreover, it clarifies and broadens the VA's authority to guide 
expenditures.
    PVA has been a strong supporter of the NPCs since their inception, 
recognizing that they benefit veterans by increasing the resources 
available to support the VA research program and to educate VA health 
care professionals. We urge expeditious passage of S. 2926 so that 
veterans may benefit even more from the enhancements in operational 
capabilities and oversight that this bill provides.
                                s. 2937
    PVA fully supports the provisions of S. 2937, a bill that provides 
permanent treatment authority for participants in Department of Defense 
chemical and biological testing conducted by Deseret Test Center and an 
expanded study of the health impact of Project Shipboard Hazard and 
Defense (SHAD). The impact of these tests conducted during World War II 
and subsequent years has only become more evident in recent years. 
Given the hardships that these men endured then, it is only appropriate 
that they receive adequate care now.
                                s. 2963
    PVA generally supports the provisions of S. 2963, a bill to enhance 
mental health services for servicemembers and veterans. We believe that 
the scholarship program outlined in Section 1 of the bill is an 
innovative way for the VA to fill important professional positions in 
behavioral specialties. With growing demand on the VA to be able to 
meet the behavioral health needs of the men and women returning from 
Iraq and Afghanistan, this scholarship program can help the VA better 
address that demand.
    PVA has no objection to allowing servicemembers who served in 
Operation Enduring Freedom or Operation Iraqi Freedom to receive 
readjustment counseling and mental health services at Vet Centers as 
called for in Section 2 of the legislation. Vets Centers are the 
frontline access point for these men and women to seek care in the VA. 
It only makes sense to afford these men and women this opportunity. 
Furthermore, this provision continues the move to open certain benefits 
and services to servicemembers who have not become veterans yet.
    Likewise, PVA has no objection to Section 4 of the legislation that 
would allow for suicide of a former member of the Armed Forces that 
occurs during the 2-year period beginning on the date of the separation 
or retirement from the military to be treated as a death in the line of 
duty. This consideration is contingent upon the requirement that the 
servicemember have a medical history of combat-related mental illness, 
Post Traumatic Stress Disorder (PTSD), or Traumatic Brain Injury. Our 
only caution is that for the purposes of this legislation, medical 
history should be defined as having a clinical diagnosis. With the 
considerations of this provision, the surviving spouse or beneficiary 
of the servicemember would then be eligible for certain benefits. This 
legislation is extremely important in light of the ever-increasing 
incidence of suicide, particularly among OEF/OIF veterans.
 s. 2969, the ``veterans' medical personnel recruitment and retention 
                                 act''
    Overall, PVA is extremely supportive of the Committee's efforts to 
enhance VA's ability to recruit and retain valuable health-care 
professionals through the provisions of S. 2969, the ``Veterans' 
Medical Personnel Recruitment and Retention Act.'' As you are aware, 
the Nation is experiencing critical shortages of invaluable health care 
professionals, particularly registered nurses (RN), registered nurse 
anesthetists, physical and occupational therapists, speech 
pathologists, pharmacists and physicians.
    We particularly appreciate the focus on enhancement of VA's ability 
to recruit and retain RN's. However, we would like to ask the Committee 
to consider extending the specialty pay provisions of S. 2969 to 
include nurses providing care in VA's specialized service programs, 
such as spinal cord injury/disease (SCI/D), blind rehabilitation, 
mental health and brain injury.
    Veterans who suffer spinal cord injury and disease require a cadre 
of specialty trained registered nurses to meet their complex initial 
rehabilitation and life-long sustaining medical care needs. PVA's data 
reveals a critical shortage of registered nurses who are providing care 
in VA's SCI/D system of care. The complex medical and acuity needs of 
these veterans makes providing care for them extremely difficult and 
demanding. These care conditions become barriers to quality registered 
nurse recruitment and retention. Many of VA's SCI/D nurses are often 
forced onto light duty status because of injuries they sustain in their 
daily tasks. This situation has become a significant problem because it 
puts additional strain on those SCI/D nurses without medical problems 
to meet patient needs. PVA believes SCI/D specialty pay is absolutely 
necessary if nurse shortages are to be overcome in this VA critical 
care area. We are eager to assist the Committee staff in developing 
legislative language that will create specialty pay for VA nurses 
working in these critical care areas.
    With regards to specific provisions of the legislation, PVA 
supports the provision to eliminate a duplicative probationary period 
for a part-time VA nurse who previously completed the required 
probationary period when in a full-time status. We also support the 
exemption for Certified Registered Nurse Anesthetists from limitation 
on authorized competitive pay. These nurse specialists are in short 
supply and competition is keen for their services. We believe this 
provision could improve recruitment and retention efforts. Likewise, 
PVA supports eligibility of part-time nurses for additional nurse pay 
and the increased limitation on special pay for nurse executives from 
$25,000 to $100,000.
    PVA congratulates the Committee on its aggressive efforts to 
enhance VA's capacity to recruit and retain scarce health care 
professionals. We especially appreciate your consideration of providing 
specialty pay for VA registered nurses serving in VA SCI/D Centers and 
in other specialized care units.
          s. 2984, the ``veterans' benefits enhancement act''
    PVA has no particular position on most of the provisions of Title 
III of S. 2984, the ``Veterans' Benefits Enhancement Act.'' We do have 
concerns however about Section 304 of the proposed legislation. As we 
understand the bill, this section would repeal two reports that are 
required of the VA. The first report is an annual nurse pay report that 
is meant to be submitted to the House and Senate Committees on 
Veterans' Affairs. According to Title 38, this report shall set forth, 
by health-care facility, the percentage of such [pay] increases [to 
nurses] and, in any case in which no increase was made, the basis for 
not providing an increase. We wonder what the motivation is for 
eliminating this reporting requirement. It seems that the information 
garnered from the Nurse Pay Report could be helpful in addressing 
hurdles that exist when hiring nurses.
    We are equally concerned about the repeal of the requirement to 
submit a report to Congress outlined in Section 8107, Title 38 U.S.C. 
Current statute states: ``In order to promote effective planning for 
the efficient provision of care to eligible veterans, the Secretary, 
based on the analysis and recommendations of the Under Secretary for 
Health, shall submit to each committee an annual report regarding long-
range health planning of the Department.'' More importantly it states 
that the report should include: ``A 5-year strategic plan for the 
provision of care under chapter 17 of this title to eligible veterans 
through coordinated networks of medical facilities operating within 
prescribed geographic service-delivery areas, such plan to include 
provision of services for the specialized treatment and rehabilitative 
needs of disabled veterans (including veterans with spinal cord 
dysfunction, blindness, amputations, and mental illness) through 
distinct programs or facilities of the Department dedicated to the 
specialized needs of those veterans.''
    By repealing this report, it seems that this would allow the VA to 
conduct its construction planning without any transparency for key 
stakeholders--specifically the House and Senate Committees on Veterans' 
Affairs. We hope that the Committee will investigate the intent behind 
the repeal of these two reports and consider eliminating these 
provisions from the proposed legislation.
    PVA appreciates the efforts of this Committee to improve the health 
care services available to the men and women who have served and 
sacrificed so much for this country. We look forward to working with 
you to ensure that meaningful changes are made to best benefit 
veterans.

    Thank you again for the opportunity to testify. I would be happy to 
answer any questions that you might have.

    Chairman Akaka. Thank you very much, Mr. Blake.
    Mr. Wilson?

   STATEMENT OF JOSEPH L. WILSON, DEPUTY DIRECTOR, VETERANS 
   AFFAIRS AND REHABILITATION COMMISSION, THE AMERICAN LEGION

    Mr. Wilson. Chairman Akaka, thank you for this opportunity 
to present the American Legion's views on the several pieces of 
legislation being considered by you today. The American Legion 
commends the Committee for holding a hearing to discuss these 
very important and timely issues. Due to the time constraint, I 
will discuss 4 of the 17 pieces of legislation. They include S. 
2383, S. 2797, S. 2573, and S. 2963.
    S. 2383, this bill seeks to implement a pilot program on 
the mobile provision of care and services for veterans in rural 
areas by the Department of Veterans Affairs. As veterans of 
Operation Iraqi Freedom and Operation Enduring Freedom, or OIF 
and OEF, return from the perils of combat, they continue to be 
plagued physically and mentally by the effects of their 
previous environment, to include improvised explosive devices, 
or IEDs, with its major catalyst--automobiles--being a sign of 
impending danger to veterans. Returning to an environment where 
this sign of danger is in abundance, veterans are migrating to 
more rural areas to avoid residing in the vicinity of these 
populated areas that contain automobiles.
    In Section 1(c)(1), the legislation suggests that the pilot 
program be carried out in no less than three Veterans 
Integrated Service Networks, or VISNs. In Section 1(c)(2), 
subtitled ``Locations,'' it states that the pilot program shall 
be carried out in one or more rural areas in each VISN. The 
legislation also requests that the Secretary shall take into 
account the number of veterans residing in or near an area and 
the difficulty of access of such veterans to the nearest VA 
medical facility. The American Legion will also ask that all 
veterans and VISNs be kept in mind during the planning of the 
pilot program's locations to ensure success. The American 
Legion supports this piece of legislation.
    S. 2573, this bill seeks to require a program of mental 
health care and rehabilitation for veterans for service-related 
Post Traumatic Stress Disorder (PTSD), depression, anxiety 
disorder, or related substance abuse disorder, and for other 
purposes. The American Legion is opposed to the provisions of 
this legislation that restrict a veteran's right to file 
disability claims for both service connection and increased 
ratings for PTSD, depression, anxiety disorder, or related 
substance abuse disorder in order to be eligible for 
participation in the treatment and rehabilitation program 
prescribed under this legislation.
    Limiting or restricting a veteran's right to pursue 
disability benefits in order to be eligible for treatment, 
despite a monetary stipend available to those who agree to such 
conditions for treatment purposes, appears to be based on an 
assumption that pursuing a disability claim somehow hinders the 
treatment process. As there is no evidence, scientific or 
otherwise, to support such an assumption, the American Legion 
cannot support such provisions as set forth in this 
legislation. Moreover, such a restriction would set an 
unacceptable precedent that could be applied to other 
conditions or disabilities and compensation claims.
    S. 2797, this bill seeks to authorize major medical 
facility projects and major medical facility leases for the 
Department of Veterans Affairs for fiscal year 2009. The 
American Legion supports the continued push to uphold the 2004 
Capital Asset Realignment for Enhanced Services, or CARES, 
decision and urges Congress to appropriate adequate funds to 
ensure these projects aren't ignored.
    S. 2963, a bill to improve and enhance the mental health 
care benefits available to members of the Armed Forces and 
veterans and to enhance counseling and other benefits available 
to survivors of members of the Armed Forces and veterans. 
Section 2 discusses the eligibility of members of active duty 
Armed Forces who serve in OEF/OIF for counseling and services 
through Vet Centers. The mission of Vet Centers is to provide 
professional readjustment counseling to veterans and their 
families.
    Section 3 discusses restoration of authority of Vet Centers 
to provide referral and other assistance upon request of former 
members of the Armed Forces not authorized counseling. Due to 
current repeated deployments to the combat zone in Iraq and 
Afghanistan, the American Legion believes it is essential for 
VA and the Department of Defense, or DOD, to continue to 
collaborate to improve the continuum of care for those on 
active duty who would eventually become veterans. Early 
intervention by Vet Centers may help to alleviate the more 
debilitating onset of mental health conditions, thereby further 
assisting in the transition process from active duty to veteran 
status, and, ultimately, reintegration into the community.
    Again, thank you, Mr. Chairman, for allowing the American 
Legion this opportunity to present its views on the above-
mentioned issues. We look forward to working with the Committee 
to help increase and improve access to quality care for our 
Nation's veterans.
    [The prepared statement of Mr. Wilson follows:]
   Prepared Statement of Joseph L. Wilson, Deputy Director, Veterans 
       Affairs and Rehabilitation Commission, The American Legion
    Mr. Chairman and Members of the Committee: Thank you for this 
opportunity to present The American Legion's view on the several pieces 
of legislation being considered by the Committee today. The American 
Legion commends the Committee for holding a hearing to discuss these 
very important and timely issues.
s. 2273, enhanced opportunities for formerly homeless veterans residing 
                    in permanent housing act of 2007
    This bill seeks to enhance the functioning and integration of 
formerly homeless veterans who reside in permanent housing by providing 
outreach to low income and elderly veterans and their families who 
reside in rural areas; establish new, or expand existing programs to 
furnish transportation, childcare, and clothing assistance to certain 
individuals with service-related disabilities who are entitled to a 
rehabilitation program.
    While permanent housing provides a stable base for veterans and 
their families the need for resources to improve their way of life is 
just as important. The American Legion supports such pilot programs 
that provide much needed resources to public and private sector 
agencies and organizations to aid homeless veterans and their families. 
These funded pilot programs will extend more opportunities for formerly 
homeless veterans, which in turn allow them to achieve and maintain a 
quality existence, deserving of their service to our country. The 
American Legion supports the Enhanced Opportunities for Formerly 
Homeless Veterans Residing in Permanent Housing Act of 2007.
         s. 2377, veterans health care quality improvement act
    This bill seeks to amend title 38, United States Code, by improving 
the quality of care provided to veterans in Department of Veterans 
Affairs (VA) medical facilities; and to encourage highly qualified 
doctors to serve in hard-to-fill positions in such medical facilities.
    The American Legion believes medical school affiliations have been 
a major factor in VA's ability to recruit and retain high quality 
physicians and to provide veterans access to the most advanced medical 
technology. When implementing this bill The American Legion encourages 
VA to continue to strengthen its affiliation with surrounding medical 
schools in order to recruit and retain highly qualified doctors who are 
already accustomed to the VA environment.
    The American Legion also believes VA should be able to offer 
incentives to new hires and employees who maintain certifications or 
can document on-going training in these areas above and beyond hospital 
credentialing and privileging processes. The American Legion supports 
the Veterans Health Care Quality Improvement Act.
           s. 2383, mobile support for rural veterans program
    This bill seeks to implement a pilot program on the mobile 
provision of care and services for veterans in rural areas by the 
Department of Veterans Affairs. As veterans of Operation Enduring 
Freedom/Operation Iraqi Freedom (OEF/OIF) return from the perils of 
combat, they continue to be plagued physically and mentally by the 
effects of their previous environment, to include Improvised Explosive 
Devices (IED's); with its major catalysts, automobiles, being a sign of 
impending danger, the veteran, returning to an environment where this 
``sign'' of danger is in abundance, veterans are migrating to more 
rural areas to avoid residing in the vicinity of these populated areas 
that contain automobiles.
    In section 1(c)1 the legislation suggests that the pilot program be 
carried out in no less than three Veterans Integrated Service Networks 
(VISN). In section 1(c)2, subtitled, ``Locations,'' it states the pilot 
program shall be carried out in one or more rural areas in each VISN. 
The legislation also requests that the Secretary shall take into 
account the number of veterans residing in or near an area; and the 
difficulty of access of such veterans to the nearest VA medical 
facility.
    The American Legion would also ask that all veterans and VISNs be 
kept in mind during the planning of the pilot program's locations to 
ensure success. The American Legion supports this piece of legislation.
          s. 2573, veterans mental health treatment first act
    This bill seeks to require a program of mental health care and 
rehabilitation for veterans for service-related Post Traumatic Stress 
Disorder (PTSD), depression, anxiety disorder, or a related substance 
use disorder, and for other purposes.
    The American Legion is opposed to the provisions of this 
legislation that restrict the veteran's right to file disability claims 
for both service connection and increased ratings for PTSD, depression, 
anxiety disorder, or a related substance abuse disorder, in order to be 
eligible for participation in the treatment and rehabilitation program 
prescribed under this legislation.
    Limiting or restricting a veteran's right to pursue disability 
benefits in order to be eligible for treatment, despite a monetary 
stipend available to those who agree to such conditions for treatment 
purposes, appears to be based on an assumption that pursuing a 
disability claim somehow hinders the treatment process. As there is no 
evidence, scientific or otherwise, to support such an assumption, The 
American Legion cannot support such provisions as set forth in this 
legislation. Moreover, such a restriction would set an unacceptable 
precedent that could be applied to other conditions/disabilities and 
compensation claims.
           s. 2639, assured funding for veterans health care
    This bill seeks to provide an adequate level of assured funding for 
veterans health care. The American Legion supports this bill.
          s. 2796, community-based organization pilot programs
    This bill seeks to create a pilot program to evaluate the use of 
community-based organizations to provide veterans the care and benefits 
they have earned. The American Legion affirms its support for the 
continued development of community based programs that meet established 
criteria as a means of improving veterans' access to high quality 
health care services in the most appropriate setting.
    s. 2797, bill to authorize major medical facility projects and 
                         major facility leases
    This bill seeks to authorize major medical facility projects and 
major medical facility leases for the Department of Veterans Affairs 
for fiscal year 2009. The American Legion supports the continued push 
to uphold the 2004 Capital Asset Realignment for Enhanced Services 
(CARES) decision and urges Congress to appropriate adequate funds to 
ensure these projects aren't ignored.
      s. 2799, women veterans health care improvement act of 2008
    This bill seeks to expand and improve health care services 
available to women veterans from VA, to include those serving in 
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). Women 
veterans have unique needs to include gender-specific physical care and 
mental health treatment for Military Sexual Trauma (MST).
    S. 2799 will also provide extensive outreach to those unaware of 
the various programs available to assist women veterans with a proper 
transition back into their respective communities. The American Legion 
fully supports this piece of legislation.
 s. 2824, a bill to amend title 38, u.s.c. by improving the collective 
   bargaining rights and procedures for review of adverse actions of 
                        certain employees of va
    The American Legion has no position on this bill.
               s. 2889, veterans health care act of 2008
    The American Legion supports the provisions of this bill which 
seeks to improve veterans' health care benefits.
    Sec. 2 discusses community treatment plans for veterans who suffer 
from a Traumatic Brain Injury, has an accumulation of deficits in 
activities of daily living and instrumental activities of daily living, 
and who, because of these deficits, would otherwise require admission 
to a nursing home even though such care would generally exceed the 
veteran's nursing needs. It allows the Secretary of VA to contract with 
the appropriate entities to provide specialized residential care and 
rehabilitation services to accommodate veterans of OEF/OIF who are 
experiencing the aforementioned.
    The American Legion believes this is an extremely vital factor in 
the continuum of care process because it would provide veterans an 
appropriate form of care that would be most attentive to their needs. 
It would also be the most conducive for reintegration back into the 
community. We concur with such proposals that seek to provide 
convenient access, as well as quality specialized residential care and 
rehabilitation services to our Nation's veterans.
    Sec. 4 discusses copayment exemption for hospice care following 
nursing home care and medical services.
    Sec. 8 discusses an increase in rates of disability compensation 
and dependency and indemnity compensation. The American Legion supports 
this adjustment in compensation benefits, to include dependency and 
indemnity compensation (DIC) recipients. It is extremely essential that 
Congress annually considers the economic needs of disabled veterans and 
their survivors and provides an appropriate cost-of-living adjustment 
to their benefits.
                  s. 2899, veterans suicide study act
    This bill seeks to direct the Secretary of Veterans Affairs to 
conduct a study on suicide among veterans. VA reported that 
approximately 18 suicides among the veteran population of 25 million 
occur daily. In light of the increasing number of veterans taking their 
own lives, the demand for outreach is paramount. Outreach to family 
members is also important, since family and friends are usually the 
first to notice changes in the veteran's mental state.
    The American Legion continues to urge Congress to increase outreach 
efforts by assigning suicide prevention counselors to all VA medical 
facilities.
            s. 2921, caring for wounded warriors act of 2008
    This bill seeks to implement pilot programs on training and 
certification for family caregiver personal care attendants for 
veterans and members of the Armed Forces with Traumatic Brain Injury, 
and to require a pilot program on provision of respite care to such 
veteran and members.
    The American Legion believes the proposals of this bill are 
necessary due to the gradual increase of severely injured veterans of 
OEF/OIF. Any opportunity to assist family caregivers to provide 
qualified personal care for their injured family member must be 
considered. Family caregivers are thrust into their new role as 
personal care attendants at an extremely stressful time. Providing 
training and certification to family caregivers will not only improve 
the abilities of the caregiver, but will benefit the rehabilitation of 
the injured servicemember. The American Legion fully supports this 
piece of legislation.
    s. 2926, veterans nonprofit research and education corporations 
                        enhancement act of 2008
    This bill seeks to amend title 38, U.S.C., to modify and update 
provisions of law relating to nonprofit research and education 
corporations, and for other purposes.
    The American Legion has no position on this bill.
s. 2937, bill to provide permanent treatment authority for participants 
 in department of defense chemical and biological testing conducted by 
   deseret test center and an expanded study of the health impact of 
              project shipboard hazard and defense (shad)
    The American Legion supports this piece of legislation. In 
conducting this study we hereby recommend that all participants in this 
study consider all new information that surfaces and disclose any new 
developments related to SHAD in a timely manner. We also urge all 
involved to ensure that all of the 5,842 participants involved in the 
tests receive prompt notification of their entitlement to benefits and 
health care for any ailment that may have resulted from their 
exposures.
 s. 2963, bill to improve and enhance the mental health care benefits 
 available to members of the armed forces and veterans, and to enhance 
counseling and other benefits available to survivors of members of the 
                       armed forces and veterans
    Sec. 2 discusses the eligibility of members of active duty Armed 
Forces who serve in OEF/OIF for counseling and services through Vet 
Centers. The mission of Vet Centers is to provide professional 
readjustment counseling to veterans and their families.
    Sec. 3 discusses restoration of authority of Vet Centers to provide 
referral and other assistance upon request to former members of the 
Armed Forces not authorized counseling.
    Due to current repeated deployments to the combat zone in Iraq and 
Afghanistan, The American Legion believes it is essential for VA and 
the Department of Defense (DOD) to continue to collaborate to improve 
the continuum of care for those on active duty who will eventually 
become veterans. Early intervention by Vet Centers may help to 
alleviate the more debilitating onset of mental health conditions, 
thereby further assisting in the transition process from active duty to 
veteran status and ultimately reintegration into the community.
 s. 2969, veterans' medical personnel recruitment and retention act of 
                                  2008
    This bill seeks to amend title 38, U.S.C., to enhance the capacity 
of the Department of Veterans Affairs to recruit and retain nurses and 
other critical health-care professionals, and for other purposes.
    The American Legion supports the improvement of VA education-
assistance programs for Advanced Practical Nurses (APNs), Registered 
Nurses (RNs), Licensed Practical Nurses (LPNs), and Nursing Assistants 
by providing incentives such as equitable and competitive wages.
     s. 2984, veterans' benefits enhancement act of 2008, title iii
    To ensure an accurate response from consensus of The American 
Legion is presented, we would prefer to respond at a later date.

    Again, thank you Mr. Chairman for allowing The American Legion this 
opportunity to present its views on the aforementioned issues. We look 
forward to working with the Committee to help increase and improve 
access to quality care for our Nation's veterans.

    Chairman Akaka. Thank you very much, Mr. Wilson.
    Ms. Ilem?

   STATEMENT OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE 
              DIRECTOR, DISABLED AMERICAN VETERANS

    Ms. Ilem. Mr. Chairman and Members of the Committee, thank 
you for the opportunity to present the views of the Disabled 
American Veterans on health care measures before the Committee 
today which cover a range of issues important to DAV veterans 
and their families.
    Of the measures being considered, you requested that we 
direct our oral statement to only three or four bills for which 
we feel most strongly. The first bill we would like to discuss 
is S. 2639, the Assured Funding for Veterans Health Care Act. 
As you are aware, funding reform is a critical issue for DAV 
and the other VSOs making up the Partnership for Veterans 
Health Care Budget Reform. Mr. Chairman, DAV supports S. 2639 
as a reasonable and responsible means to solve the funding 
problems experienced by VA.
    However, we recognize there is strong opposition by some to 
mandatory funding. Therefore, we have been developing an 
alternative approach to achieve the goals of this bill, notably 
sufficient, timely, and predictable funding while addressing 
the concerns over pay-go, Congressional oversight, and fiscal 
responsibility. Our new proposal would shift VA medical care 
appropriations to a 1-year advanced appropriation and require 
that VA's health expenditure forecasting model be audited and 
reported to Congress by GAO.
    VA's internal methodology for estimating the cost of 
providing care to enrolled veterans has become increasingly 
accurate over the past several years. Historically, VA's budget 
problems did not occur because of a flawed model, but rather 
from a flawed budget process. From the time estimates of need 
are developed to the time the administration's budget is 
submitted, there are a number of factors that cause changes to 
the estimate, usually resulting in a less than sufficient 
budget request sent to Congress.
    This new alternative proposal would make VA's data-driven 
actuarial model and its estimates transparent while allowing 
Congress and the administration to retain all their 
discretionary powers and rights. It would shift the focus to 
the best estimate of what VA needs to care for veterans. 
Finally, since the advance appropriation would be 
discretionary, not mandatory, there would be no pay-go 
implications. Mr. Chairman, we urge the Committee to move 
forward this year with either S. 2639 or the alternative 
advanced funding proposal.
    We also express our strong support for S. 2799, the Women 
Veterans Health Care Improvement Act, a comprehensive measure 
aimed at evaluating the unique needs of women veterans, 
including those who served in Operations Iraqi and Enduring 
Freedom, and improving VA's health care and mental health 
services for all women veterans.
    The current number of women serving in active military 
service and its Guard and Reserve components has never been 
larger and this has resulted in proportionately increasing 
rates of enrollment into the VA mental health system. This 
legislation is consistent with recommendations from research 
experts in women's health, the VA Women's Advisory Committee, 
and the VA fiscal year 2009 Independent Budget. Therefore, we 
fully support this measure.
    S. 2921, the Caring for Wounded Warriors Act of 2008, would 
authorize new pilot programs for respite care as well as 
training, certifying, and compensating family caregivers of 
severely wounded veterans and servicemembers. We believe this 
proposal, if implemented carefully, would provide new 
approaches to the care of severely-injured veterans as well as 
welcome relief to their family caregivers. Likewise, these 
proposals are consistent with recommendations made in the 
fiscal year 2009 Independent Budget. Thus, DAV fully supports 
this bill and urges the Committee to work toward its enactment.
    Finally, we would like to briefly mention S. 2573, the 
Veterans Mental Health Treatment First Act. In summary, this 
measure would provide a new program approach to mental health 
care and rehabilitation for veterans with certain post-
deployment mental health conditions. DAV strongly supports the 
provisions of the bill that promote early intervention in 
mental health treatment, prevention of chronic disability, and 
promotion of recovery.
    However, DAV strongly opposes the provision that links 
wellness stipend payments to a veteran's commitment to postpone 
filing a disability claim. While science has enhanced our 
ability to recognize and treat mental health consequences of 
service in combat, the treatments are not universally 
effective. Therefore, we see no justification for the view that 
participation in evidence-based therapy will eradicate the 
illness or significantly reduce the rating evaluation in the 
majority of patients. We suggest that the health care 
provisions and wellness stipend be decoupled from the proposal 
to deny veterans the ability to apply for disability 
compensation during the treatment phase.
    Mr. Chairman, that concludes my statement and I am happy to 
answer any questions you may have. Thank you.
    [The prepared statement of Ms. Ilem follows:]
   Prepared Statement of Joy J. Ilem, Assistant National Legislative 
                  Director, Disabled American Veterans
    Mr. Chairman, Ranking Member Burr and other Members of the 
Committee: Thank you for inviting the Disabled American Veterans (DAV) 
to testify at this important legislative hearing of the Committee on 
Veterans' Affairs. DAV is an organization of 1.3 million service-
disabled veterans, and devotes its energies to rebuilding the lives of 
disabled veterans and their families.
    You have requested testimony today on seventeen bills primarily 
focused on health care services for veterans under the jurisdiction of 
the Veterans Health Administration (VHA) of the Department of Veterans 
Affairs (VA). This statement submitted for the record relates our 
positions on all of the proposals before you today. The comments are 
expressed in numerical sequence of the bills, and we offer them for 
your consideration.
s. 2273--enhanced opportunities for formerly homeless veterans residing 
                    in permanent housing act of 2007
    This bill would authorize the Secretary of Veterans Affairs to 
conduct pilot programs to provide grants to coordinate the provision of 
supportive services available in the local community to very low 
income, formerly homeless veterans residing in permanent housing. It 
would authorize VA to outreach to inform low-income rural elderly 
veterans and their spouses of benefits for which they may be eligible. 
The bill also would establish new or expanded VA programs or activities 
to furnish transportation, child care and clothing assistance to 
certain veterans with service-related disabilities who are eligible for 
a VA rehabilitation program.
    The Independent Budget for Fiscal Year 2009 includes a series of 
recommendations that are consistent with this bill. Therefore, the DAV 
supports its purposes and urges its enactment.
         s. 2377--veterans health care quality improvement act
    This bill would direct the Secretary of Veterans Affairs to 
prescribe standards for appointment and practice as a physician within 
the VHA of the VA. The bill would require appointees to VA physician 
positions, and physicians already employed by VA at the time of 
enactment, to disclose certain private information, including each 
lawsuit, civil action, or other claim against the individual for 
medical malpractice or negligence, and their results. Each appointee 
would be required to disclose any judgments that had been made for 
medical malpractice or negligence and any payments made. The bill would 
require all new physician appointments to be approved by the 
responsible director of the Veterans Integrated Services Network (VISN) 
in which the individual would be assigned to serve and require all VA 
specialty physicians to be board certified in the specialties in which 
the individuals would practice. Also the bill would require State 
licensure by VA physicians in the State of practice.
    The measure would establish new requirements and accountabilities 
in quality assurance at the local, VISN and VA Central Office levels, 
and directs the Secretary to review VA policies for maintaining health 
care quality and patient safety at VA medical facilities. The bill also 
would establish loan repayment programs for physicians in scarce 
specialties, a tuition reimbursement for physicians and medical 
students in exchange for commitments to serve in VA, and enrollment of 
part-time VA physicians in the Federal Employees Health Benefits 
Program. The bill would admonish the Secretary to undertake additional 
incentives to encourage individuals to serve as VA physicians.
    DAV has no adopted resolution from our membership on these specific 
issues. Under current policy, VA is required to investigate the 
background of all appointees, including verifying citizenship or 
immigration status, licensure status, and any significant blemishes in 
appointees' backgrounds, including criminality or other malfeasance. 
The facility in question that likely stimulated the sponsor to 
introduce this legislation was not in compliance with those existing 
requirements, thus raising questions about VA's ability to oversee its 
facilities in the area of physician employment. Corrective action was 
taken by the VA Central Office when some unfortunate incidents related 
to these lapses came to light at that particular facility, and VA has 
advised that it has strengthened its internal policies.
    We appreciate and strongly support the intent of the bill to 
stimulate recruitment and to promote VA physician careers with various 
new incentives, and, while it seems clear that additional oversight is 
necessary, we trust that the new reporting, State licensure and 
certification requirements in the bill would not serve as obstacles to 
physicians in considering VA careers in the future.
   s. 2383--a bill to require va to establish a pilot program on the 
    mobile provision of care and service for veterans in rural areas
    If enacted, this bill would direct the Secretary of Veterans 
Affairs to carry out a pilot program to assess the feasibility and 
advisability of providing care and a variety of services (including 
counseling) to veterans residing in rural areas through a mobile system 
that transports VA medical and benefits personnel, as well as equipment 
and other materials, to the areas designated for the program. It would 
require a mobile system to visit each designated area at least once 
each 45 days and remain present during each visit for at least 48 
hours.
    The bill sets forth coordination requirements concerning 
identification of veterans who are not enrolled in, or otherwise being 
cared for by, the VA health care system, county and local veterans' 
service offices, and use of community-based VA outpatient clinics.
    Resolution 188, adopted at the 2007 DAV national convention, calls 
for additional efforts by the Department to improve and increase access 
to VA health care services in rural, remote and frontier areas. Also, 
in the fiscal year 2009 Independent Budget, we recommended a number of 
actions coordinated through the VA's Office of Rural Health to increase 
availability of health care services in rural areas, and specifically 
including the deployment of innovative means to reach rural veterans 
with effective VA health care services. The aims of this bill are 
generally consistent with our views in both DAV Resolution 188 and the 
Independent Budget; therefore, we support the enactment of this bill.
          s. 2573--veterans mental health treatment first act
    This bill would establish a new approach to dealing with veterans 
who are diagnosed with Post Traumatic Stress Disorder (PTSD), 
depression, anxiety disorder or co-morbid substance abuse disorder 
that, in the judgment of a VA physician, is related to military 
service. Financial support, known as a ``wellness stipend,'' would be 
provided to veterans who were willing to commit to a VA treatment plan 
with substantial adherence to that plan for a specified period of care. 
In order to be eligible for the wellness stipend, the veteran would be 
required to agree not to file a VA disability compensation claim for 
the covered conditions for 1 year or the duration of the treatment 
program, whichever time period would be shorter. Duration of treatment 
would be individualized and determined by the attending VA clinician. 
Under the program, there would be two proposed levels of wellness 
stipends. Receipt of the full wellness stipend would depend on the 
veteran having no service-related rating for PTSD, depression, anxiety 
disorder, or related substance abuse, and having no claim pending for 
one of the conditions mentioned.
    Veterans with no service-connected rating or claim pending for the 
conditions mentioned who agreed not to file a new or an increased 
disability claim for one of the conditions and in addition agreed to 
``substantial compliance'' with a prescribed treatment plan for those 
conditions for the duration of the prescribed program (or 12 months, 
whichever is sooner), would receive $2,000 immediately payable upon 
diagnosis; $1,500 payable every 90 days into treatment upon clinician 
certification of substantial compliance with the treatment regiment; 
and $3,000 payable at the conclusion of the time-limited treatment 
program. Under this proposal, the gross stipend for these veterans 
would be $11,000. This bill also would propose that any veteran, with a 
new or increased disability claim pending for PTSD, depression, anxiety 
disorder or related substance abuse, would receive only a partial 
wellness payment at identical intervals but totaling only up to 33 
percent of the rates discussed above. Any participating veteran who 
failed to comply with the conditions of the program would be removed 
from the program, resulting in cessation of the stipends. The program 
would limit a veteran's participation to a single enrollment unless VA 
determined that extended participation would provide the veteran 
additional assistance in recovery.
    Mr. Chairman, DAV has a growing concern about the effects of 
wartime exposures especially those being identified in the newest 
generation of disabled veterans of the wars in Iraq and Afghanistan. 
Military deployments in Iraq and Afghanistan are among the most 
demanding since the War in Vietnam nearly four decades ago. In addition 
to causing the heavy physical injuries and casualties, the rates of 
``invisible'' wounds of war (primarily PTSD, depression, substance 
abuse, suicidal ideation, and family distress) for those who have 
served in Operations Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) 
are dramatically high and still rising. All too often these conditions 
go unreported and even unrecognized. There are several reasons for the 
emergence of PTSD in these veterans of Iraq and Afghanistan. Many 
studies have shown that more frequent and more intense involvement in 
combat operations increases the risk of developing associated mental 
health conditions. Military commanders report that the combat 
environment in Iraq is intense and constantly dangerous, and some 
serving members are being returned for second, third or even fourth 
deployments. Furthermore, our military is fighting an insurgency absent 
clearly identifiable fronts or marked enemy soldiers; these conditions 
demand vigilance because there are no safe military occupational 
specialties or safe harbors. For an increasing number of veterans of 
these types of conflicts, these stressors result in devastating mental 
health consequences and historically high rates of PTSD, and other 
post-deployment mental health issues.
    Since the beginning of the Global War on Terrorism, more than 1.64 
million American military servicemembers have served in OIF/OEF. Of 
those who have been discharged from active duty, approximately 38 
percent have used VA health care services, and one-in-four have filed 
disability compensation claims. Overall, mental health conditions are 
one of the most common categories of conditions for which veterans 
apply for disability compensation. The most common among those for 
which veterans receive disability benefits is PTSD. Between fiscal year 
1999-2004, PTSD compensation payments increased by 150 percent. This 
significant increase sparked debate and a number of studies were 
undertaken to further explore the issue. In the VA Office of Inspector 
General (OIG) report on a convenience sample of 92 PTSD disability 
claims, 39 percent of veterans reduced their use of mental health 
treatment after receiving a 100 percent service-connected disability 
rating. This report surfaced concerns that receiving disability 
compensation may provide an incentive for veterans to over-report 
symptoms and, worse yet, to remain ill.
    A recent review of the scientific literature addressing this issue 
dispels this erroneous belief and demonstrates that there is no 
conclusive evidence of differences in health care utilization among 
compensation seeking and non-compensation seeking veterans with PTSD, 
nor is there evidence that compensation seeking veterans demonstrate 
less symptom improvement after PTSD treatment than veterans who are not 
seeking compensation.\1\ These careful, peer-reviewed scientific 
studies contradict the OIG findings. While it is possible that a small 
fraction of veterans exaggerate symptoms or fail to participate in 
treatment in order to receive more disability compensation, the 
evidence does not support this behavior as a major factor hindering 
treatment or recovery from PTSD.
---------------------------------------------------------------------------
    \1\ Laffaye C, Rosen C, Schnurr PP, Friedman MJ: Does Compensation 
Status Influence Treatment Participation and Course of Recovery from 
Post-Traumatic Stress Disorder? Military Medicine 2007; 172(10):1039-
1045.
---------------------------------------------------------------------------
    DAV applauds the bill's focus on early intervention for PTSD and 
other service-related mental health problems, its emphasis on recovery, 
and making available financial support so that veterans gain the 
resources to fully engage in the hard work required for effective 
treatment and obtain a better quality-of-life. Three recent Federal 
commission reports and two independent studies have emphasized the need 
for new and improved approaches to compensation and treatment of 
veterans with service-related mental health disabilities. First, 
between 2005 and 2007, the Veterans' Disability Benefits Commission 
(VDBC) studied the benefits and service programs available to veterans, 
servicemembers and family members. The VDBC concluded that ``PTSD is 
treatable, that it frequently recurs and remits, and that veterans with 
PTSD would be better served by a new approach to their care.
    After benefits and care coordination problems were identified at 
Walter Reed Army Medical Center in 2007, the President's Commission on 
Care for America's Returning Wounded Warriors (also commonly known as 
the Dole-Shalala Commission) was appointed and published its report. 
The commission called for major change in the coordination of care and 
benefits for severely wounded service personnel and veterans. In 
addition, Dole-Shalala identified the need for better support of 
seriously injured veterans during their rehabilitation and recovery and 
called for study of long-term transition payments.\2\
---------------------------------------------------------------------------
    \2\ President's Commission on Care for America's Returning Wounded 
Warriors: Serve, Support, Simplify: Report of the President's 
Commission on Care for America's Returning Wounded Warriors. Washington 
DC, July 2007.
---------------------------------------------------------------------------
    The third commission of relevance to today's testimony is the 
President's New Freedom Commission on Mental Health. In 2003, the 
commission published its report. The commission made recommendations to 
transform mental health care in the United States and ``* * * 
envisioned a future when everyone with a mental illness will recover, a 
future when mental illnesses are detected early, and a future when 
everyone with mental illness at any stage of life has access to 
effective treatment and supports--essentials for living, working, 
learning and participating fully in the community.'' The commission 
indicated that this transformation rests on two principles:

     Services and treatments must be consumer and family 
centered.
     Care must be focused on increasing consumers' ability to 
successfully cope with life's challenges, on facilitating recovery, and 
building resilience--not just on managing symptoms.

    By recovery, the commission meant a process that focuses on return 
of function and quality-of-life for those who suffer from mental health 
problems--in which people are able to fully engage life and live, work, 
learn and recreate in their communities. Recovery focuses on 
restoration of ability and is a fundamental departure from traditional 
models that focus primarily on reduction of symptoms. The mental health 
recovery model incorporates the best that medical science has to offer 
but enhances it by promoting a person-centered, team-based model of 
care that brings a full range of health and human services to bear to 
accomplish the maximal psycho-social-spiritual rehabilitation possible. 
The recovery model is a significant paradigm shift that should be fully 
embraced by VHA's mental health system. The commission also found that 
effective treatments were currently available for treatment of mental 
illness and recommended that efforts be stepped up to ensure that all 
providers are given tools and training to consistently deliver 
evidence-based treatments.
    Over the years, science has broadened our knowledge about mental 
health and illnesses including the effects of combat stress and trauma. 
These studies have shown us new paths to effective treatment and 
recovery for military servicemembers and combat veterans. The Institute 
of Medicine (IOM) recently compiled and analyzed all of the research on 
the evidence for treatments proven effective for PTSD.\3\ The IOM 
reported there is sufficient evidence to conclude that prolonged 
exposure and cognitive behavior therapies are effective in treatment of 
PTSD. While many military servicemembers and veterans have access to 
these treatments, gaps still remain in system-wide availability, not 
only in both VA and the Department of Defense (DOD), but also in the 
private mental health sector.
---------------------------------------------------------------------------
    \3\ Treatment of Posttraumatic Stress Disorder: An Assessment of 
the Evidence, The National Academy Press, Washington DC, 2007.
---------------------------------------------------------------------------
    There is an overwhelming body of knowledge that documents the 
growing needs of OIF/OEF veterans for effective mental health services. 
In April 2008, Invisible Wounds of War: Psychological and Cognitive 
Injuries, Their Consequences, and Services to Assist Recovery was 
published by RAND. In addition to a comprehensive literature review, 
this study undertook a population-based telephone survey of 1,965 
servicemembers and veterans who had deployed to Iraq or Afghanistan. 
This survey found substantial rates of mental health problems in the 30 
days before the interviews, with 14 percent screening positive for 
PTSD, 14 percent for major depression and 19 percent for reporting a 
probable Traumatic Brain Injury (TBI) during deployment. Assuming that 
the prevalence of these conditions is representative, this study 
suggests that approximately 300,000 individuals who served in OIF/OEF 
suffer from PTSD or major depression, and 320,000 individuals may be at 
risk for TBI. RAND concluded at least one third of all OIF/OEF veterans 
have one of these conditions and 5 percent report symptoms of all 
three. RAND also found that OIF/OEF veterans seek treatment for PTSD 
and major depression at about the same rate as the general civilian 
population, and like the civilian population, many are not receiving 
any mental health care. Over the past year, only 53 percent of those 
who met criteria for current PTSD or major depression had sought health 
care from a physician or behavioral health provider.\4\
---------------------------------------------------------------------------
    \4\ Tanielian T, Jaycox LH: Invisible Wounds of War: Psychological 
and Cognitive Injuries, Their Consequences, and Services to Assist 
Recovery, RAND Corporation, April 2008, Washington DC.
---------------------------------------------------------------------------
    Recent data also suggest that the problems grow rather than 
diminish in the months after servicemembers return home. The alarming 
figures on marital and family stress, mental health challenges and 
substance abuse concerns were further amplified in a longitudinal 
assessment of mental health problems of 88,235 U.S. Army personnel who 
had served in Iraq. In this published study, soldiers reported a 
fourfold increase in interpersonal conflict on the delayed Post 
Deployment Health Re-Assessment (PDHRA) questionnaire, compared to 
their earlier Post-Deployment Health Assessment (PDHA) screenings. In 
addition, this study showed a large and growing burden of mental health 
and substance abuse concerns. Soldiers reported more mental health 
problems and were referred at higher rates for mental health care on 
the PDHRA when they were screened approximately 6 months after 
deploying home, than they had previously reported when completing 
questionnaires immediately after returning from Iraq. Clinicians who 
screened these soldiers determined that 20 percent of active duty and 
42 percent of Army reservists required mental health care. Of great 
concern are the high rates of alcohol use reported by soldiers but the 
virtual absence of referral to treatment programs as a result of these 
screening programs.\5\ These data have yet to reflect the full impact 
of extended 15-month deployments, the third, fourth or even fifth 
deployments for some individuals, or the impact of redeployed 
servicemembers who may already actively suffer from untreated PTSD or 
``mild'' TBI. Likewise in a prospective military cohort study on the 
health outcomes of over 50,000 individuals who deployed to Iraq or 
Afghanistan, data indicated a threefold increase in new onset of self-
reported PTSD symptoms among deployed members who reported combat 
exposures.\6\
---------------------------------------------------------------------------
    \5\ Miliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment 
of mental health problems among Active and Reserve Component soldiers 
returning from the Iraq War. JAMA, 2008; Vol. 298(18):2141-2148.
    \6\ Smith TC, Ryan MA, Wingard DL, Slymen DJ. Sallis JF, Kritz-
Silverstein D, for the Millennium Cohort Study Team. New onset and 
persistent symptoms of Post Traumatic Stress Disorder self reported 
after deployment and combat exposures: prospective population based US 
military cohort study. BMJ 2008; 336;366-371.
---------------------------------------------------------------------------
    All of these commissions, independent reports, and scientific 
studies provide ample evidence for pursuing early intervention for PTSD 
and other service-related mental health problems, for promoting 
recovery, and for providing adequate financial support so that veterans 
have the resources to engage fully in treatment and return to a better 
life after serving. Participation in treatment and counseling is often 
an intensive and time consuming process. Financial stipends such as 
those proposed by this bill would assure that veterans have at least a 
modicum of support to concentrate on participating as full partners in 
their therapy.
    However, DAV strongly opposes any provision that attempts to link 
wellness stipend payments to a veteran's commitment not to file a 
disability claim. While science has enhanced our ability to recognize 
and treat the mental health consequences of service in combat including 
PTSD, the treatments are not universally effective. Using the best 
research and evidence-based treatment, complete remission can be 
achieved in 30-50 percent of cases of PTSD and partial improvement can 
be expected in most patients.\7\ PTSD and major depression tend to 
remit and recur. There is no justification for the view that 
participation in evidence-based therapy will eradicate the illness or 
eliminate the need for a subsequent claim for disability.
---------------------------------------------------------------------------
    \7\ Friedman MJ: Posttraumatic Stress Disorder Among Military 
Returnees from Afghanistan and Iraq. American Journal of Psychiatry, 
April 2006; 163:4, 586-593.
---------------------------------------------------------------------------
    In addition to the above concerns, we recognize the challenges that 
VA would have in establishing the administrative systems and management 
of this new program. In order to ensure the success of these efforts, 
DAV recommends that VA incorporate the following components into their 
program design:

     The VHA's capacity to provide access to mental health 
services has improved; however, gaps still exist. In order to provide 
high quality, timely mental health care, VA will need to recruit and 
retain additional highly skilled, dedicated mental health providers.
     Every veteran enrolled in the program should be assigned 
to a care manager to coordinate care and jointly track personal 
treatment and recovery plans.
     VA mental health providers should receive ongoing 
continuing medical education, intensive training and clinical 
supervision to ensure that they have the skills and capability to 
deliver the latest evidence-based treatments.
     VA should offer certifications to professionals for PTSD 
treatment, competency in veterans' occupational health, and cultural 
competency in veterans and military life.

    Most of the military members who serve in combat will return home 
without injuries and readjust in a manner that promotes good health. 
However, it is the responsibility of our Nation to treat veterans who 
return with war wounds, both visible and invisible, and to fully 
support their mental health recoveries. Moreover, we believe that while 
transition payments will facilitate their recovery, they are not an 
adequate or acceptable substitute for fair and equitable disability 
compensation for service-related conditions.
    In summary, S. 2573 would require a program of mental health care 
and rehabilitation for veterans for service-related Post Traumatic 
Stress Disorder or other stated post-deployment health conditions. DAV 
strongly supports the provisions of this bill that promote early 
intervention in mental health treatment, prevention of chronic 
disability, and promotion of recovery. However, we cannot support the 
bill in its current form because it restricts the rights of disabled 
veterans to apply for service-connected disability compensation for 
those disabilities under VA care. We suggest that the health care 
provisions and transition payments be decoupled from the proposal to 
deny veterans the ability to apply for disability compensation during 
the treatment phase.
         s. 2639--assured funding for veterans health care act
    Mr. Chairman, as you well know, this bill would reform VA health 
care funding by moving it from its current status as a discretionary 
appropriation to that of mandatory status. The formula proposed by this 
bill is well recognized and has been pending before Congress for the 
past 5 years. As we testified before your Committee on July 25, 2007, 
VA has been unable to manage or plan the delivery of care as 
effectively as it could have, as a result of perennially inadequate 
budget submissions from Presidents of both political parties; annual 
Continuing Resolutions in lieu of approved appropriations; late 
arriving final appropriations; offsets and across-the-board reductions; 
plus the injection of supplemental and even ``emergency supplemental'' 
appropriations to fill gaps. In 13 of the past 14 years, VA has begun 
its year with Continuing Resolutions, creating a number of challenging 
conditions that are preventable and avoidable with basic reforms in 
funding for VA health care.
    DAV is especially concerned about maintaining a stable and viable 
health care system to meet the unique medical needs of our Nation's 
veterans now and in the future. The wars in Iraq and Afghanistan are 
producing a new generation of wounded, sick and disabled veterans, and 
some severe types at a poly-trauma level never seen before. A young 
veteran wounded in Iraq or Afghanistan today with brain injury, limb 
loss, spinal cord injury, burns or blindness will need the VA health 
care system for the remainder of their lives.
    The goal of DAV and other members of the Partnership for VA Health 
Care Budget Reform (Partnership) is to see a long-term solution for 
funding VA health care to guarantee these veterans will have a 
dependable system for the future, not simply next year. Reformation of 
the funding system is essential so Federal funds can be secured on a 
timely basis, allowing VA to manage the delivery of care and to plan 
effectively to meet known and predictable needs. In our judgment a 
change is warranted and long overdue. To establish a stable and viable 
health care system, any reform must include sufficiency, timeliness, 
and predictability of VA health care funding.
    We ask the Committee to consider all the actions Congress has had 
to take over only the past 3 years to find and appropriate ``extra'' 
funding to fill gaps left from the normal appropriations system. Please 
also consider the Administration's efforts to explain to Congress why 
VA experienced a shortfall of billions of dollars each year--admissions 
that were often very reluctantly made. In one case, the President was 
reduced to formally requesting two VA health care budget amendments 
from Congress within only a few days of each other.
    In past Congresses we have worked with both Veterans' Affairs 
Committees to craft legislation that we believe would solve this 
problem if enacted. The current version of that bill is S. 2639, the 
Assured Funding for Veterans Health Care Act, introduced by Senator Tim 
Johnson. A number of objections have been made related to this bill and 
its predecessors: primarily that it would cost too much, that VA would 
have no incentive to be fiscally responsible and that Congress would 
lose its oversight authority. We have previously provided commentary 
that rejects all these criticisms.
    The recent Congressional Research Service report to Congress 
detailing the running expenditures for the Global War on Terror since 
September 11, 2001, revealed that veterans affairs-related spending 
constitutes only 1 percent of the government's total expenditure. 
Without question, there is a high cost for war, but we strongly believe 
that caring for our Nation's sick and disabled veterans is part of that 
continued cost.
    Mr. Chairman, DAV will continue to support S. 2639 as a reasonable 
and responsible means to solve funding problems experienced by VA. 
However, we and the other members of the Partnership understand there 
is strong opposition by some to mandatory funding and so we have been 
developing an alternative approach to achieve the goals of mandatory 
funding--sufficient, timely and predictable funding--while addressing 
the concerns over PAYGO, Congressional oversight, and fiscal 
responsibility. Over the last several weeks, we have briefed both 
majority and minority staffs of this and other relevant Congressional 
committees and Leadership on our alternative proposal. Essentially, 
this new proposal would shift VA medical care appropriations to a 1-
year advance appropriation, and require that VA's health expenditure 
forecasting model be audited and reported to Congress by the Government 
Accountability Office (GAO) on an annual basis.
    Mr. Chairman, VA's internal methodology for estimating the cost of 
providing health care to enrolled veterans has actually become 
increasingly accurate due to the implementation of a new actuarially 
based model developed and refined in the past several years. 
Historically, VA's budget problems have not arisen due to a flawed 
model; but rather from a flawed budget process. From the time such 
estimates of need are developed, to the time when the Administration's 
budget is submitted, there are political and other non-cost factors 
that result in changes to the estimate, usually resulting in a less 
than sufficient budget request sent to Congress. Former Secretary 
Principi admitted as much during his budget testimony in 2004; and in 
2005, then-Secretary Nicholson contradicted his own budget testimony 
within weeks of its delivery by making not one, but two supplemental 
requests for additional health care funding totaling $1.2 billion. The 
reality is that no matter how accurately VA's internal model forecasts 
future costs, that estimate must run a political gauntlet through VA, 
the Office of Management and Budget (OMB), the White House, 
authorizing, budget and appropriations committees, both chambers of 
Congress and both political parties, before it can be approved.
    That is why we propose the GAO audit and report to Congress on an 
annual basis about the accuracy and integrity of VA's health care cost 
forecasting model, as well as the data and assumptions upon which it is 
built. GAO's report would essentially report the most accurate estimate 
of providing currently-authorized health care services to next year's 
anticipated veteran enrollment, adjusted for next year's higher (or 
lower) cost of providing such medical services. By adding this 
transparency to the budget formulation process, Congress and the 
Administration are much more likely to arrive at a final budget that is 
sufficient to meet the anticipated health care needs of all enrolled 
veterans.
    Having addressed sufficiency, we next propose that VA's medical 
care funding be done through a 1-year advance appropriation to ensure 
that it arrives on time in a manner that is easily predictable from 
year to year. Congress can and has provided advance appropriations for 
a number of important programs for both financial and political 
reasons. In some cases, such as in the Department of Housing and Urban 
Development (HUD) Section 8 housing vouchers, and in Head Start, the 
advance appropriation is a partial-year advance. In other cases, such 
as LIHEAP, the Low Income Home Energy Assistance Program, the 
appropriation is done a year in advance to assure that this assistance 
can be delivered before the onset of winter and to allow for the 
purchase of heating oil during the best market conditions of the year 
prior. Other advance appropriations, such as for the Corporation for 
Public Broadcasting, were authorized to allow the program to plan and 
operate without needing to worry that partisan, political debates might 
negatively impact the program at the last moment. Advance 
appropriations are different from biennial budgets: advance 
appropriations pass a 1-year budget one or more years in advance, 
whereas a biennial budget approves a 2-year budget each 2 years.
    In the case of veterans' health care funding, a 1-year advance 
appropriation would greatly enhance the programs by removing both 
financial and political impediments to providing quality medical care 
to veterans. A 1-year advance appropriation would allow Congress to 
approve funding for veterans medical care without VA having to compete 
against other programs. Additionally, since the advance appropriation 
would be discretionary, not mandatory, there would be no PAYGO 
implications. The only difference is that the appropriations act that 
allows funds to flow to VA would have been enacted the year beforehand, 
thus allowing VA to use those funds in an efficient manner.
    Mr. Chairman, if we currently had an advance appropriations process 
for veterans medical care, VA would not have to worry about a budget 
showdown later this fall, or negative consequences of what appears to 
be an almost-certain Continuing Resolution again this year. Instead, 
the fiscal year 2009 appropriation for VA medical care would already 
have been in place and VA could right now be planning where and how to 
expand services in the most efficient and cost-effective manner to meet 
the needs of thousands of returning Iraq and Afghanistan veterans 
expected to come to VA this fall. Some have argued that this approach 
would put veterans' health care ahead of other Federal discretionary 
spending programs. This is true--and we believe there is just cause for 
doing so. When our Nation fights wars, there is no hesitation by 
Congress or the Administration to provide all the funding necessary, 
including emergency supplemental and ``off-budget'' funding. Health 
care for those injured in these wars is one additional cost that 
deserves the highest priority.
    This new alternative proposal would make VA's data-driven, 
actuarial model and its estimates transparent to Congress, while 
allowing Congress and the Administration to retain all their 
discretionary powers and rights. It would shift the terms of the debate 
from political to financial, focusing on the best estimate of the cost 
to care for veterans. By completing the appropriation a year in 
advance, Congress can help assure that veterans health care funding is 
sufficient and finalized ahead of time and in a predictable manner from 
year to year.
    Mr. Chairman, we urge this Committee to provide serious 
consideration to this new alternative VA health care funding proposal, 
and urge you to move forward this year with either our new proposal, or 
with Senator Johnson's mandatory funding bill.
   s. 2796--to require a pilot program on the use of community-based 
  organizations to ensure that veterans receive the care and benefits 
                   they need, and for other purposes.
    This bill would establish a pilot program to facilitate veterans' 
use of community-based organizations to ensure certain veterans receive 
the care and benefits they deserve in transitioning from military to 
civilian life. The program would be carried out in five selected rural 
locations, and in areas with a high proportion of minority groups and 
individuals who have experienced significant disparities in their 
receipt of health care. The program would be conducted through VA 
grants to community-based organizations with the goal of providing 
information, outreach, mental health counseling, benefits and 
transition assistance and other relevant services in rural areas and in 
areas with a high proportion of minority veterans.
    While we have no adopted resolution from our membership supporting 
this precise concept, DAV believes this is a well-intentioned proposal. 
We have some concern about VA as a granting agency for such broad 
purposes, but we believe if it is targeted and carefully managed by VA, 
this function could be an important and creative new tool in rural and 
remote areas where establishing a direct VA service presence would be 
impractical. If the bill is enacted, we also recommend VA carefully 
craft the services expected from a grantee in the area of aiding these 
veterans with their VA disability benefits claims. These are highly 
technical matters and require the assistance of expert service officers 
from the States, the veterans service organization (VSO) community and 
the Veterans Benefits Administration through its veterans benefits 
counselor function. Finally, for any health care involvement associated 
with these grants, we urge VA to coordinate this new grant program 
through its Office of Rural Health. With these caveats, DAV supports 
the enactment of this bill.
s. 2797--to authorize major medical facility projects and major medical 
facility leases for the department of veterans affairs for fiscal year 
                     2009, and for other purposes.
    This bill would authorize four major construction projects at the 
Palo Alto, San Juan and Tampa medical centers, and a new outpatient 
facility in Lee County, Florida. Also, the bill would extend expiring 
authorities for major projects in Denver and New Orleans. Twelve 
capital leases would be authorized as well, along with authorization of 
appropriations of nearly $2 billion to carry out both the major 
construction projects and leases.
    DAV supports this bill and urges its enactment.
      s. 2799--women veterans health care improvement act of 2008
    Title I, sections 101-103 of the bill would authorize and mandate 
longitudinal studies by VA in coordination with the Department of 
Defense (DOD) to evaluate the needs of women who are currently serving, 
and women veterans who have completed service, in OIF/OEF. Also, VA 
would be required to study and report existing barriers that impede or 
prevent women from accessing health care and other services from VA. 
Third, this title would require VA to make an assessment of its 
existing health care programs for women veterans and report those 
findings to Congress. Section 104 of the bill would authorize IOM to 
study and report on the health consequences of women serving in OIF/
OEF.
    Title II, section 201 would amend title 38, United States Code, to 
authorize a period of 30 days of VA-provided or authorized contract 
care for the newborn infant child of a woman veteran. Section 202 would 
make improvements in VA's ability to assess and treat women veterans 
who have experienced military sexual trauma (MST) by requiring a new 
training and certification program to ensure VA health care providers 
develop competencies in caring for these conditions consequent to MST. 
Section 202 would also require the VA to establish staffing standards 
to ensure adequacy of supply of trained and certified providers to 
effectively meet VA's demands for care of MST. Section 203 would 
require a similar training and certification program for VA personnel 
caring for women veterans with PTSD and would mandate the use of 
evidence-based treatment practices and methods in caring for women 
veterans who suffer from PTSD that may be related to MST and/or combat 
exposure. The Secretary would be required to ensure appropriate 
training of primary care providers in screening and recognizing 
symptoms of sexual trauma and procedures for prompt referral and would 
require qualified MST therapists for counseling. Under this authority 
the Secretary would also be required to provide Congress an annual 
report on the number of primary care and mental health professionals 
who received the required training, the number of full-time employees 
providing treatment for MST and PTSD in each VA facility, and the 
number of women veterans who had received counseling, care and services 
associated with MST and PTSD.
    Section 204 would authorize a 2-year pilot program in at least 
three VISNs of reimbursement for child care services expenses for 
qualified veterans receiving mental health, intensive mental health or 
other intensive health care services, whose absence of child care might 
prevent veterans from obtaining these services. ``Qualified veteran'' 
would be defined as a veteran with the primary caretaker responsibility 
of a child or children. The authority would be limited to reimbursement 
of expenses.
    Section 205 would establish a non-medical model pilot program of 
counseling in retreat settings for recently discharged women veterans 
who could benefit from VA establishing offsite counseling to aid them 
in their repatriation with family and community after serving in war 
zones and other hazardous military duty deployments. Section 206 would 
require the VA to establish full-time women veterans program managers 
at VA medical centers. Section 207 would require recently separated 
women veterans to be appointed to certain VA advisory committees.
    Mr. Chairman, women veterans are a dramatically growing segment of 
the veteran population. The current number of women serving in active 
military service and its Guard and Reserve components has never been 
larger and this phenomenon predicts that the percentage of future women 
veterans who will enroll in VA health care and use other VA benefits 
will continue to grow proportionately. Also, women are serving today in 
military occupational specialties that take them into combat theaters 
and expose them to some of the harshest environments imaginable, 
including service in the military police, medic and corpsman, truck 
driver, fixed and rotary wing aircraft pilots and crew, and other 
hazardous duty assignments. VA must prepare to receive a significant 
new population of women veterans in future years, who will present 
needs that VA has likely not seen before in this population.
    This comprehensive legislative proposal is fully consistent with a 
series of recommendations that have been made in recent years by VA 
researchers, experts in women's health, VA's Advisory Committee on 
Women Veterans, the Independent Budget, and DAV. DAV was proud to work 
with Senator Murray and the original cosponsors of the bill in crafting 
this proposal. A similar bill was introduced in the House (H.R. 4107) 
on a bipartisan basis by Representatives Herseth Sandlin and Brown-
Waite. DAV strongly supports this measure and urges the Committee to 
approve it and move it toward enactment.
    s. 2824--to amend title 38, united states code, to improve the 
   collective bargaining rights and procedures for review of adverse 
   actions of certain employees of the department of veterans affairs
    We do not have an approved resolution from our membership on this 
specific labor-management issue, but we do have concerns about the 
reported deteriorated state of labor relations in the VA. DAV typically 
concentrates on matters dealing with quality, access, and convenience 
of VA health care and other services and benefits for veterans, and 
relies on VA to manage its system properly to meet those ends. However, 
we believe labor organizations that represent employees in recognized 
bargaining units within the VA health care and benefits system have an 
innate right to information and participation that results in making VA 
a workplace of choice, and particularly to fully represent VA employees 
on issues impacting working conditions and ultimately patient care.
    Congress passed section 7422 of title 38, United States Code, in 
1991, in order to grant specific bargaining rights to labor in VA 
professional units, and to promote effective interactions and 
negotiation between VA management and its labor force representatives 
concerned about the status and working conditions of VA physicians, 
nurses and other direct caregivers appointed under title 38, United 
States Code. In providing this authority Congress granted to VA 
employees and their recognized representatives a right that already 
existed for all other Federal employees appointed under title 5, United 
States Code. Nevertheless, Federal labor organizations have reported 
that VA has severely restricted the recognized Federal bargaining unit 
representatives from participating in, or even being informed about, 
human resources decisions and policies that directly impact conditions 
of employment of the VA professional staff within these bargaining 
units. We are advised by labor organizations that when management 
actions are challenged VA has used subsections (b), (c) and (d) of 
section 7422 as a statutory shield to obstruct any labor involvement to 
correct or ameliorate the negative impact of VA's management decisions, 
even when management is allegedly not complying with clear statutory 
mandates (e.g., locality pay surveys and alternative work schedules for 
nurses, physician market pay compensation panels, etc.).
    Facing VA's refusal to bargain, the only recourse available to 
labor organizations is to seek redress in the Federal court system. 
However, recent case law has severely weakened the rights of title 38 
appointees to obtain judicial review of arbitration decisions. Title 38 
employees also have fewer due process rights than their Title 5 
counterparts in administrative appeals hearings.
    It appears that the often hostile environment consequent to these 
disagreements diminishes VA as a preferred workplace for many of its 
health care professionals. Likewise, veterans who depend on VA and care 
from physicians, nurses and others who provide direct professional 
medical care can be negatively affected by that environment.
    We believe this bill, which would rescind VA's ability to refuse to 
bargain on matters within the purview of section 7422 by striking 
subsections (b), (c) and (d) and that would clarify other critical 
appeal rights of title 38 appointees, is an appropriate remedy and 
would return VA and labor to a more balanced bargaining relationship in 
issues of importance to VA's professional workforce. Therefore, DAV 
commends the sponsors for introducing this bill, and the Committee for 
considering it, and we would have no objection to its enactment.
             s. 2889--the veterans health care act of 2008
    Mr. Chairman, you requested DAV's views only on sections 2 through 
6 of this bill. Section 2 would provide VA specific contracting 
authority to obtain specialized residential care and rehabilitation 
services for OIF/OEF veterans who are suffering from TBI, and who are 
exhibiting such cognitive deficits that they would otherwise require 
admission to nursing home facilities. Section 3 would provide full-time 
VA board-certified physicians and dentists the opportunity for 
continuing medical education, with VA reimbursement of expenses up to 
$1,000 per year for such continuing education. Section 4 would exempt 
veterans in VA hospice care from the requirement of making copayments 
to VA for those services. Section 5 rescinds consent procedures related 
to VA tests for human immunodeficiency virus. Section 6 would authorize 
VA to disclose the name and address of a member of the armed services 
or of a veteran to a third party insurer in order to bill for 
collections of reasonable charges for care or services provided for an 
individual's nonservice-connected condition(s).
    Except for the proposal in section 2, DAV has no resolutions from 
our members on any of the matters contained in this bill, but we see no 
reason to object to their passage. We do note, in section 2, that its 
language would limit eligibility for specialized residential 
rehabilitation contract care to one subset of veterans with residuals 
of TBI--those who served in OIF/OEF. Other veterans, of past and future 
conflicts, with TBI might also benefit from these services. Resolutions 
079 and 175, adopted at DAV's 2007 National Convention, call for 
strengthening and enhancing VA long-term care programs for service-
disabled veterans, and for addressing comprehensively the needs of 
disabled veterans of all wars who suffered TBI. We ask the Committee to 
consider broadening the eligibility for this new contract residential 
rehabilitation care option in section 2 of the bill to any veteran with 
a service-incurred TBI.
                s. 2899--the veterans suicide study act
    This bill would require the Secretary, in conjunction with the 
Department of Defense, the Centers for Disease Control and Prevention, 
and all State public health and veterans affairs agencies and 
equivalent offices, to conduct a study to determine the number of 
veterans who have died by suicide between January 1, 1997, and the date 
of the enactment of this bill.
    DAV has no adopted resolution from our membership dealing 
specifically with suicides in the veteran population. However, we agree 
with the Chairman that full and accurate data on the issue is crucial 
to VA's ability to reduce veterans' suicides. We note that the 
Committee has formally requested data from VA, including:

     The number of veterans who committed suicide or attempted 
to commit suicide;
     The number of veterans who have committed suicide or 
attempted to commit suicide while receiving care from VA;
     Information on VA's efforts to improve outreach and 
assistance for veterans between the ages of 30 and 64 years of age; 
and,
     All of VA's health care quality assurance reviews related 
to suicides and suicide attempts over the past 3 years.

    While as a general observation we would have no objection to a bill 
requiring a study on suicide, we believe the study envisioned in this 
bill would be highly challenging to carry out, and might not satisfy 
Congress with dependable, accurate results. Therefore, we would 
appreciate reviewing VA's available data on suicides and attempted 
suicides, and we encourage continued oversight by the Committee of VA's 
efforts to reduce suicide in the veteran population.
          s. 2921--the caring for wounded warriors act of 2008
    This bill would authorize new pilot programs for training, 
certifying and compensating family caregivers of severely wounded 
veterans and servicemembers, and would establish a second program to 
deploy graduate students in the health sciences as providers of respite 
care for severely disabled veterans and servicemembers in exchange for 
course credit.
    Section 2 of the bill would establish up to three VA pilot programs 
for assessing the feasibility of providing training and certification 
for, and subsequent compensation to, family caregivers of severely 
disabled veterans and severely injured servicemembers who remain on 
active duty status but are presumably under VA care. In developing the 
pilot programs the VA Secretary would be required to do so in 
conjunction with the Secretary of Defense. In selecting the locations 
of the pilot programs, the Secretary would be required to give special 
emphasis to the VA's poly-trauma center locations. The bill would 
require curricula to be developed to incorporate applicable standards, 
protocols and best practices to govern this pilot program. Under the 
terms of the bill, the Secretary would determine the eligibility of a 
family member for participation, and the type of care a family member 
would provide would be based on the needs of the veteran as determined 
by the veteran's attending physician. The bill would authorize 
compensation to be paid to a family caregiver for care and services 
rendered to the veteran or servicemember (in the case of a severely 
disabled servicemember, the bill would require reimbursement to VA by 
TRICARE for benefits provided under this authority). The bill would 
authorize VA to provide certain supportive services to a family 
caregiver, including an assessment of needs and referral to services 
that can assist them in continuing in that crucial role. This bill 
would not preclude VA reimbursement for health care services provided 
by a non-family member, nor would it bar access to other services and 
benefits otherwise available to disabled veterans with brain injury.
    Section 3 of the bill would authorize a VA pilot program to assess 
the feasibility of providing respite care to severely disabled veterans 
and severely injured servicemembers remaining on active duty (who are 
under VA care), with a special emphasis on Traumatic Brain Injury, 
through students enrolled in graduate programs of education in certain 
health sciences. These students, in social work, psychology, physical 
therapy and similar fields, would be recruited by VA to provide relief 
to family caregivers, and would furnish socialization and cognitive 
skills development care to both family members and their patients in 
respite. The bill would require this pilot program to be carried out at 
no more than 10 locations, near VA facilities with relationships, 
academic affiliations, or established partnerships with institutions of 
higher education with graduate programs in appropriate mental health, 
rehabilitation or related fields. This section would require 
recruiting, providing specified training in applicable standards, 
protocols and best practices, and matching of interested students with 
disabled veterans and servicemember families. Participating students 
would submit required reports to a VA attending physician, meet other 
VA requirements as specified by the Secretary, and would receive 
coursework credit for such duties as determined by the Secretary in 
coordination with a participating or affiliated school.
    These two ideas are worthy and if implemented carefully, could 
provide major new approaches to the care of severely injured veterans, 
and provide welcome relief to their family caregivers. DAV was pleased 
that Senator Clinton's staff consulted with DAV in developing this 
proposal to aid caregiver families. Also, these proposals are fully 
consistent with recommendations of the fiscal year 2009 Independent 
Budget. Thus, DAV strongly supports this bill and urges the Committee 
to work toward its enactment.
  s. 2926--the veterans nonprofit research and education corporations 
                        enhancement act of 2008
    This bill would modernize and enhance oversight and reporting 
requirements of nonprofit research and education corporations that 
support VA biomedical research by managing extramural grant funds made 
available to VA principal investigators. It would also provide new 
guidance and policy requirements for the operation of these 
corporations within the VA research program, and would be responsive to 
recent recommendations for improved accountability within some of these 
corporations made by the VA Inspector General.
    The basic statutory authority for these corporations was enacted in 
1988, so this bill would be the first significant amendment to that 
statute. If enacted this bill would authorize the corporations to 
fulfill their full potential in supporting VA biomedical research and 
education, the results of which would improve treatments and promote 
high quality care for veterans, while underwriting VA and Congressional 
confidence in these corporations' management of public and private 
funds.
    While DAV has no adopted resolution on this particular matter, DAV 
is a strong supporter of a robust VA biomedical research and 
development program, and we believe enactment of this bill would be in 
that program's best interest. Therefore, DAV would have no objection to 
enactment of this bill.
 s. 2937--to provide permanent treatment authority for participants in 
  department of defense chemical and biological testing conducted by 
   deseret test center and an expanded study of the health impact of 
     project shipboard hazard and defense, and for other purposes.
    This bill would authorize permanent health care eligibility for 
veterans who were exposed to potentially toxic substances during their 
military service, as participants in ``Project SHAD,'' a chemical 
warfare military testing exercise. The bill would also require the VA 
Secretary to contract with IOM to conduct an expanded study of the 
health impact of veterans' participation in these exercises. The bill 
would permit the IOM to take into account the results of its previously 
authorized study on Project SHAD.
    DAV has no objection to the enactment of this bill.
    s. 2963--to improve and enhance the mental health care benefits 
   available to members of the armed forces and veterans, to enhance 
    counseling and other benefits available to survivors of members
    Section 1 of the bill would authorize a new scholarship program for 
education and training of behavioral health care specialists for Vet 
Centers of VA's Readjustment Counseling Service. The bill would specify 
the terms of eligibility for candidates for scholarships under this 
authority, and would authorize the Secretary to determine scholarship 
amounts. Recipients of such scholarships would be required as a 
condition of participation to serve as behavioral health care 
specialists in VA's Vet Center program. The bill specifies conditions 
warranting repayment in cases in which recipients fail to fulfill their 
obligated service, with specific terms of repayment to be determined by 
the Secretary. The bill would authorize $2 million annually to carry 
out its purposes.
    Section 2 of the bill would authorize eligibility for OIF/OEF 
veterans, including serving members of the National Guard or Reserve, 
regardless of their duty status, to receive counseling and services 
through VA's Vet Centers. The bill would require the Secretaries of 
Veterans Affairs and Defense to promulgate regulations to carry out the 
purposes of this section.
    Section 3 would provide VA's Vet Centers authority to refer for 
non-VA mental health care and counseling services any individual whose 
military discharge serves as a bar for the individual to receive VA 
benefits. The section would also admonish the Secretary, if pertinent, 
to advise such ineligible individuals of the individual's right to 
apply for governmental review of the character of that individual's 
military discharge.
    Section 4 of the bill would statutorily reclassify suicides of 
certain veterans (cases of occurrence of suicide within 2 years of 
discharge or release from active duty) as deaths in the line of duty 
for purposes of eligibility of survivors for benefits associated with 
burial and other benefits under title 38, United States Code; the 
Survivor Benefit Plan under title 10, United States Code; and for death 
and other benefits under the Social Security Act. If enacted this 
section would require refunds of reductions in retired pay made in case 
of suicide under the Survivor Benefit Plan to surviving spouses and 
children of military-retired veterans who commit suicide within the 
specifications of the section. The section would limit applicability of 
these benefits to veterans and military retirees with medical histories 
of combat-related mental health conditions, PTSD, and TBI while 
serving.
    Section 5 would authorize the Secretary of Defense to provide 
grants to non-profit organizations to provide peer emotional support 
services to survivors of members of the Armed Forces and veterans. 
Rules for eligibility, application, amounts, and duration of the grant 
program would be determined by the Secretary of Defense.
    While DAV has no resolutions from our membership supporting the 
specific matters entertained by this bill, we believe each of these 
proposals would be helpful to survivors of military servicemembers and 
veterans whose lives are lost to suicide. Therefore, DAV supports the 
purposes of this bill and would have no objection to its enactment.
       s. 2969--the veterans' medical personnel recruitment and 
                         retention act of 2008
    Section 2 of the bill would provide authority to the Secretary of 
Veterans Affairs to establish additional ``hybrid Title 38-Title 5'' 
occupations (32 such occupations have been established by previous acts 
of Congress in section 7401, title 38, United States Code, including 
psychologist, physician assistant, licensed vocational or practical 
nurse, social worker, and numerous technical health fields). Under this 
section the Secretary would be required to report any such 
reclassification of VA occupations to the OMB, to your Committee and 
its House counterpart. This section would also add ``nurse assistant'' 
as a specific new occupational class in this hybrid category. Section 2 
would clarify probationary periods and appointment policies for full-
time and part-time registered nurses. The section also would authorize 
VA on a case-by-case basis to reemploy Federal annuitants with 
temporary appointments in selective health care positions under 
sections 7401 and 7403, title 38, United States Code, without 
offsetting their retirement annuities paid to them under title 5, 
United States Code. This section would provide VA additional authority 
to raise compensation of personnel employed in the immediate Office of 
the Under Secretary for Health; provide VA pharmacist executives 
eligibility for special incentive pay; and provide clarification on 
compensation policy for VA physicians, including cost of living 
adjustments and market pay provisions in chapter 74, title 38, United 
States Code. Finally, it would provide additional policy on nurse pay 
caps, special pay for nurse executives; locality pay systems for VA 
nurses; part-time nurse pay rules; weekend pay rules, as well as 
clarified direction on the use and disclosures on wage surveys in nurse 
locality pay determinations.
    Section 3 of the bill would add a new section 7459, title 38, 
United States Code, to specify VA policy on VA's use of overtime by VA 
nurses, in effect outlawing VA's practice of requiring ``mandatory 
overtime,'' and extending specific protections to VA registered nurses, 
licensed practical or vocational nurses, nursing assistants (and other 
nursing positions designated by the Secretary for purposes of these 
protections), under the Civil Rights Act of 1964, from discrimination 
or any adverse action based on their refusal to work required overtime. 
Under the section the VA Secretary would be provided an emergency 
exigency power in certain circumstances to require a nurse to work 
overtime, but the section defines the term ``emergency'' within narrow 
grounds. Section 3 also clarifies language on weekend duty and other 
alternative work schedules for VA nurses, and would provide a number of 
associated technical and conforming amendments.
    Section 4 of the bill would reinstate the former Health 
Professionals Educational Assistance Scholarship Program, an authority 
that expired in 1998, and would extend its coverage to employees 
appointed under paragraphs (1) and (3) of section 7401, title 38, 
United States Code. It would add ``retention'' as an additional purpose 
of VA's Education Debt Reduction Program, and would increase the 
amounts of assistance to eligible VA employees. The section would 
establish a loan repayment program targeted to VA clinical research 
personnel who come from disadvantaged backgrounds.
    Mr. Chairman, DAV has no resolution adopted by our membership 
addressing these matters, but we are strong supporters of VA as a 
preferred employer. We see the provisions in this measure as supportive 
of that goal and therefore would not object to their enactment. 
Nevertheless, we note that our colleagues in the VA labor community are 
concerned about ceding additional authority to the Secretary to expand 
the ``hybrid'' appointment authority without further intervention from 
Congress, and we believe these unions may have a valid basis for those 
concerns, based on VA's apparent struggle to establish qualification 
and classification standards for some of the occupational classes 
already included in that hybrid authority. Therefore, we defer to their 
expertise in this case and ask the Committee's further consideration of 
those matters in Section 2 of the bill.
         s. 2984--the veterans benefits enhancement act of 2008
    Mr. Chairman, you have requested our views only on Title III of 
this bill.
    Section 301 would make permanent VA's existing authority to provide 
``noninstitutional extended care services,'' a health care service 
originally authorized in Public Law 106-117, the 1999 Veterans 
Millennium Health Care and Benefits Act.
    Section 302 would extend for 5 years, until 2013, VA's existing 
authority to provide nursing home care to veterans rated 70 percent or 
more service-connected disabled, and to veterans in need of nursing 
home care for service-connected conditions. This section would extend 
through 2013 VA's authority to establish nonprofit research and 
education corporations and VA's existing contractual recovery audit 
programs for its fee-basis, contract hospitalization and other contract 
medical services activities.
    Section 303 of the Title III would provide the Secretary permanent 
authority to provide health care to veterans possibly exposed to 
chemical and biological warfare agents conducted by the Deseret Test 
Center. Similar language is included in S. 2937, also before the 
Committee today.
    Section 304 of the bill would repeal an existing annual report to 
Congress on pay adjustments made to the basic pay of VA nurses and 
certain other health care personnel appointed under section 7401, title 
38, United States Code. The section would also repeal VA's existing 
annual report on long-range planning, including operational and 
construction plans for VA health care facilities.
    Section 305 of Title III would change the reporting date of an 
annual executive branch report to the Committees on Veterans' Affairs 
of the Senate and House detailing research undertaken by any agency of 
government dealing with Persian Gulf War illnesses. The section would 
also specify a termination of such annual reports in 2013.
    Section 306 of the bill would specify that VA payments under the 
Civilian Health and Medical Program of the Department of Veterans 
Affairs (CHAMPVA) would constitute payments in full that extinguish any 
CHAMPVA beneficiary's financial liability to providers under that 
program.
    Section 307 of the bill would provide that health care providers of 
care to children of Vietnam veterans with spina bifida participating in 
VA's health care program would be authorized to bill liable third 
parties for excess costs not paid by VA for health care services to 
these eligible children.
    Section 308 of this Title would authorize a VA practitioner to 
release certain medical information concerning a veteran's condition, 
to a veteran's surrogate when a veteran lacks decisionmaking capacity; 
when a veteran has not formally designated a representative nor 
authorized a release of such information; and, when the VA practitioner 
deems the conveyance of such information to be supportive of an 
informed decision the surrogate needs to make related directly to the 
care or condition of the veteran. This authority would apply only in 
cases involving substance-use disorder and addictions, infection with 
the human immunodeficiency virus, and in sickle cell anemia cases.
    Section 309 of the bill would require that applicants for, and 
recipients of, VA health care furnish the Secretary the veteran's 
private health plan contract information (specifications dealing with 
coverage, the plan's identifying number and the group code, if 
applicable) as well as Social Security Number. Under the Section, this 
information would become a condition of eligibility for VA health care, 
and a veteran's declination to provide such information would be 
grounds for determination of ineligibility for VA health care.
    Although DAV has no resolutions specific to the matters entertained 
in S. 2984, we are generally supportive of the provisions in this bill 
with exception of those matters in Section 304. We believe, both in 
instances of its knowledge of, and oversight in, VA practices with 
regard to paying nursing personnel and in conducting its strategic 
planning, that these reporting requirements should be retained in the 
law. We are particularly concerned at VA's proposal to discontinue its 
construction-related reporting while asking the Committee to rely 
primarily on VA's budget proposal as a source for relevant information 
on construction planning. The current reporting requirement in Section 
8107 of title 38, United States Code, covers extensively more than 
simply the requested facility construction and leasing authorizations 
retained in the annual budget for a given year. We believe both 
Congress and the community of veterans service organizations, in 
properly representing veterans' interests, need to continue receiving 
these comprehensive reports on VA's strategic plans, including its 
construction planning.

    Mr. Chairman, this concludes my testimony and I will be pleased to 
consider any questions by you or other Members of the Committee.

    Chairman Akaka. Thank you very much, Ms. Ilem.
    Mr. Needham?

STATEMENT OF CHRISTOPHER NEEDHAM, SENIOR LEGISLATIVE ASSOCIATE, 
 NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE 
                         UNITED STATES

    Mr. Needham. Mr. Chairman and Members of the Committee, on 
behalf of the 2.3 million men and women of the Veterans of 
Foreign Wars of the U.S. and our Auxiliaries, I would like to 
thank you for the opportunity to present our views at today's 
important legislative hearing.
    There is a wide range of health care bills before us, so I 
will limit my remarks to a few of them. Our full comments on 
all may be found in our written statement.
    First is S. 2799. We are pleased to support the Women 
Veterans Health Care Act. This bill would expand upon and 
improve the health care services provided to women veterans. 
Female veterans in OEF/OIF are experiencing types of conflicts 
that previous generations did not. They are involved in a 
conflict with no true front line and in a high-stress situation 
with almost no relent. The difficulties they face are a 
challenge for VA, which still is adapting to how it treats 
women veterans as it is a system that is predominately used to 
caring for male veterans. It is essential that VA's strategies 
for dealing with OEF/OIF issues are not one-size-fits-all. VA 
has made great strides, but the Department can certainly do 
more.
    To that end, there are a few sections of the bill that I 
would like to highlight. Section 101 would create a long-term 
study of the health of female OEF/OIF veterans, which can only 
help to better serve their needs in the future.
    Section 102 would study potential barriers to care, which 
would allow VA to develop strategies to expand access.
    Section 203 would create training programs on how to deal 
with women veterans suffering from PTSD. It is likely that 
today's conflicts have different impacts upon men and women, 
and a mental health strategy that adapts to the needs of female 
veterans will likely see more success.
    We have had a longstanding resolution in support of Section 
206, which would mandate full-time Women's Program Managers at 
VA medical centers. We have found that many of these program 
managers are assigned on a part-time basis, doing that job in 
addition to their regular duties. With the growth in the number 
of female veterans, full-time employees would better be able to 
help the facility fulfill its duty to female veterans. We urge 
the Committee to pass this important bill.
    The second bill today is S. 2921, the Caring for Wounded 
Warriors Act. This bill would create pilot programs to help 
family caregivers. The first program would let VA develop 
training and certification programs so that family caregivers 
can be compensated as personal care attendants. We strongly 
support this provision. For veterans suffering from the effects 
of severe Traumatic Brain Injuries, intensive care is critical. 
We have seen over the last few years that many families put 
their lives on hold at great financial penalty to care for 
their wounded heroes. This compassionate bill would allow these 
family members to be compensated for their time and effort in 
caring for those grievously wounded men and women.
    The second program aims to expand respite care services to 
give these family caregivers a well-deserved break when they 
need it with proper oversight and management. We strongly 
support this, as well.
    The third bill I will speak to is S. 2963. This 
comprehensive bill would make many improvements to the mental 
health care provided to veterans in the Armed Forces. We ask 
the Committee to approve this legislation, too.
    Section 2 of this bill would allow active duty members to 
seek counseling service through Vet Centers. This is a terrific 
idea that could do a lot to break down one of the largest 
barriers of care--the stigma associated with seeking help. 
Giving these men and women a care option outside of regular DOD 
channels would allow them to seek care when they need it with 
no fear of reprisal. They would be free to do what is right for 
themselves, not what they believe they need to do to further 
their career or to avoid a negative impression from others.
    Our only concern with this, though, is that Vet Centers are 
becoming victims of their own success. Increasing numbers of 
veterans have flocked to them, pushing their workload closer to 
the breaking point. If we are going to expand their services, 
we simply must have an expansion of staffing. To that end, 
Section 1 of the bill, which would create scholarship and 
incentive programs to recruit and train new staff, is a good 
step.
    Before I conclude, just a quick note on S. 2639. The VFW 
continues to support this bill as it would lead to our ultimate 
goal of an adequate and on-time budget. But we understand the 
reticence of many to support a mandatory funding stream. With 
the Partnership for Veterans Health Care Budget Reform, we 
continue to look for new solutions that will achieve the same 
goal--a health care budget that is sufficient, timely, and 
predictable.
    Mr. Chairman, this concludes my statement and I would be 
happy to answer any questions you may have.
    [The prepared statement of Mr. Needham follows:]
     Prepared Statement of Christopher Needham, Senior Legislative 
 Associate, National Legislative Service, Veterans of Foreign Wars of 
                           The United States
    Mr. Chairman and Members of the Committee: On behalf of the 2.3 
million men and women of the Veterans of Foreign Wars of the U.S. and 
our Auxiliaries, I thank you for the opportunity to present our views 
at today's important legislative hearing. There is a broad range of 
health care legislation before us, ranging from funding the system to 
expanding care and services to our newest veterans. Our members 
appreciate the role you allow us to play in their consideration.
                                s. 2273
    The VFW supports the ``Enhanced Opportunities for Formerly Homeless 
Veterans Residing in Permanent Housing Act.''
    This legislation would authorize the VA secretary to create a pilot 
program to provide grants to a number of entities providing housing for 
homeless veterans. Included in it would be grants for support services 
to low-income formerly homeless veterans residing in permanent housing, 
and grants for programs that assist veterans with transportation and 
child-care issues when working with VA's vocational rehabilitation 
programs. Both are worthy goals that could positively help these 
veterans get back on their feet.
    We also strongly support section four of the bill, which would 
award grants for programs to conduct outreach to elderly and rural 
veterans and their spouses with respect to VA's pension programs. There 
certainly must be a great number of men and women who are not aware of 
their entitlement to this helpful benefit. Getting them access to the 
benefits they deserve and providing full outreach to them is clearly 
the right thing to do.
       s. 2377, the veterans health care quality improvement act
    The VFW offers our support to this important bill, which aims to 
improve the quality of health care practitioners within VA.
    It would tighten hiring practices for VA physicians by requiring 
them to disclose previous malpractice judgments, disciplinary actions 
and ongoing investigations. The importance of this issue came to light 
with the unfortunate incidents at the Marion VA facility. A doctor 
practiced medicine there despite agreeing to stop practicing in a 
different State and having two malpractice settlements and a 
disciplinary action elsewhere. If the doctor had had to disclose those 
facts, VA likely would not have hired him.
    The bill would also create a quality assurance officer to oversee a 
health care quality assurance program. The program is designed to be an 
independent reporting system with multiple layers to ensure that any 
concerns about the quality of care are addressed and vetted 
independently.
    A third part of the bill would create several new programs to help 
encourage high-quality doctors to work for VA. It would create loan 
repayment programs, tuition reimbursement for physician students, and 
allow part-time physicians to enroll in the Federal employee health 
benefits plan. These incentives would help VA hire experienced doctors 
as well as recruit and retain younger physicians.
    If approved, this bill would likely mean higher quality physicians 
in VA, and for that reason, we urge its passage.
                                s. 2383
    The VFW is happy to back this bill, which would create a pilot 
program to provide mobile health care services to veterans in rural 
areas. It would bring VA health care providers and caseworkers directly 
to veterans in locations where access to a clinic or an office is 
highly limited. The mobile services would provide basic health 
treatments, provide prescriptions, screen for mental health issues as 
well as providing support and information with respect to the 
compensation system and other veterans benefits.
    The number 1 issue brought up by rural veterans is the difficulty 
they have in accessing care. This is an innovative attempt to find a 
solution to some of the problems faced by veterans, by bringing them to 
VA instead of forcing them to travel many hours for even basic health 
care. This bill is a good step in addressing some of those problems, 
and we hope that if passed, the results from the pilot program would 
allow for the expansion of this program throughout the country.
                                s. 2573
    While we appreciate the effort of the bill to try a new approach at 
tackling these difficult issues, the VFW does not support the 
``Veterans Mental Health Treatment First Act.''
    The aim of the bill is to incentivize treatment for veterans 
suffering from PTSD and other mental health issues. While that on its 
face is a good thing, much of the rationale behind it, we believe, is 
wrong. There are two main premises lurking behind the bill: (1) 
Veterans exaggerate their mental health problems to game the system and 
get higher levels of compensation; (2) Veterans discontinue their 
treatment because there is a financial disincentive to not get better, 
or to even get worse. Both are wrong.
    On the first, we continue to believe that veterans do not 
exaggerate their symptoms. While it's true that the number of mental 
health diagnoses have increased dramatically over the last decade, that 
is not evidence in and of itself of fraud, nor is it an indication that 
something is wrong with the system. To us, it's a sign that veterans 
are becoming more aware of the terrific range of services and benefits 
VA provides them, and that these men and women are finally able to come 
forward with what must certainly be a difficult decision. Seeking help 
is not easy, and for many years, we have seen a negative stigma 
associated with mental health issues--look no further than the 
stereotypical image of the wacko Vietnam veteran. Coming forward to 
seek help is not easy, and rather than looking askance at those who do, 
we should trust that they are doing what they need to do to become 
healthy and whole.
    The Institute of Medicine's 2007 study, ``PTSD Compensation and 
Military Service'' bears this out further. In the section discussing 
the trends in PTSD compensation, the study notes several reasons for 
the increase. While noting that PTSD diagnoses have gone up while 
anxiety disorders have decreased, they observe that it is possible that 
``some of the growth in PTSD was actually a change in diagnostic 
labeling with, for example, fewer veterans being classified with other 
anxiety disorders than in the past because these veterans were now 
being diagnosed with PTSD.'' If true, then the problem--if there is 
truly a problem--lays not with the veteran as this bill assumes, but 
with VA's ability to diagnose mental health disorders.
    In the same section, the study notes some other reasons for the 
increase. The information they found ``is consistent with the 
suggestion that the growth in PTSD awards is due to a greater 
willingness on the part of veterans to apply for PTSD compensation. It 
may also, though, reflect in part an increasing tendency for VA to 
recognize a diagnosis of PTSD and, more generally, to recognize 
disability resulting from any mental disorder.'' Again, the problem--if 
you can call veterans seeking out the treatment they need a problem--is 
with VA's diagnosis, not with veterans looking for treatment options.
    On the second premise of the bill, the IOM's study found that this 
is a mistaken belief as well. In the chapter on ``Other PTSD 
Compensation Issues,'' they note that most other scientific evidence 
does not support the 2005 VAOIG report, which claimed to have found 
evidence that veterans receiving compensation received less mental 
health treatment. ``Longitudinal studies suggest that disability claim 
approval results in increased use of mental-health services. Cross-
sectional research shows that veterans with service-connected 
disability for PTSD do not differ from non-service-connected veterans 
in their levels of participation in treatment, and there is some 
evidence that service-connected veterans are more likely to participate 
in treatment.''
    Overall, with the bill, we have serious problems with asking 
veterans to forgo their disability compensation. Even with the payments 
for treatment that this bill would provide, we cannot support 
legislation that will require a veteran to give up--even temporarily--
one of their entitlements. This is especially true in the case of a 
veteran who would ultimately be diagnosed with a high level of PTSD or 
mental health issue, even after treatment. The wellness stipend would 
not come close to that level of compensation, financially harming the 
veteran. And since there is no way for a veteran to know what his or 
her disability rating is ultimately going to be, a number of veterans 
and their families could be financially harmed by the choice to 
participate in the program. The choice is free for them to make, but 
veterans lack enough information prior to making it to determine 
whether it is a good decision or not.
    Also, because the evidence indicates that the vast majority of 
veterans are already seeking care, are we sure that this would be the 
proper incentive to get new patients into treatment? If most already 
are seeking some sort of health care treatment through VA, it stands to 
reason that a number of those incentive payments would be provided to 
people already in the system, wasting money that could otherwise be 
used to bolster VA's mental-health programs.
    We certainly support expanding access to health care options for 
veterans with mental health problems, and we would certainly like to 
see all veterans using the terrific resources of the VA health care 
system, but as the bill is written, the VFW cannot support it.
                                s. 2639
    The VFW has had a long-standing resolution in support of amending 
the current discretionary funding process. We support the ``Assured 
Funding for Veterans Health Care Act'' as it would meet our goal of 
having a funding mechanism to provide VA with a sufficient, timely and 
predictable budget.
    While great strides have been made in the yearly increases provided 
to VA, we are concerned that that same political will may not be there 
in the future once the Nation's attention shifts from the overseas 
conflicts. Further, we are disappointed with the timeliness of the 
health care budget. For 13 of the last 14 years, VA has not had its 
health care budget when the fiscal year began, forcing VA to make do 
with insufficient funding under continuing resolutions. We have also 
seen in previous years the need to go back to the drawing board halfway 
through the fiscal year to provide more money for VA through an 
emergency supplemental appropriation because insufficient money was 
provided the first time.
    Taken together, these all point to a system that is broken and a 
system badly in need of reform.
    VA's hospital managers cannot be expected to efficiently manage and 
plan for the health care needs of this Nation's veterans when they are 
unsure of their funding level from year to year and when the budget 
they do receive is months late. This yearly uncertainty impairs VA's 
ability to recruit and retain staff--a significant challenge recently 
with specialty care providers--contract for services and perform proper 
planning and other administrative functions.
    We need an assured funding mechanism that provides VA with a 
sufficient, predictable and timely funding stream so that VA can 
efficiently and effectively provide first-rate health care to this 
Nation's veterans.
                                s. 2796
    The VFW supports this legislation, which would create pilot 
programs for community-based organizations to help veterans better 
understand the benefits and services available to them. The grants 
provided under this program would allow organizations to set up 
telephone hotlines, assist veterans in applying for benefits, help 
families adjust to deal with the transition, provide outreach 
information on benefits and to help coordinate health care and benefits 
services to veterans.
    While VA and the military services have done a better job about 
informing veterans--especially separating servicemembers--about their 
benefits and entitlements, we still can do a better job. As this bill 
acknowledges, there are gaps in awareness that should be filled so that 
all veterans equally have access to the full range of benefits. By 
working with community-based groups, the bill could better coordinate 
those groups underserved by VA and who may be less aware of their 
veterans benefits, and we strongly urge its passage.
                                s. 2797
    The VFW supports this bill, which would authorize the construction 
and leasing of a number of major medical facilities throughout the 
country. Included in the list of projects are the top construction 
priorities as determined by VA's capital asset prioritization process. 
It also extends and increases the authorization for several projects 
previously authorized but that have not yet been completed.
    The VFW hopes that Congress will fully fund VA construction so that 
we can move beyond the CARES process and address the growing backlog of 
construction needs throughout the country.
                                s. 2799
    The VFW is pleased to offer our strong support for this 
legislation, which would expand and improve upon the health care 
services provided to women veterans. Female veterans from OEF/OIF are 
experiencing many types of conflict that previous generations did not. 
They are involved in a conflict with no true frontline and in a high-
stress situation with almost no relent.
    The difficulties they face, and the level of reported mental health 
issues that all OEF/OIF veterans have is itself a challenge for VA. It 
is essential that VA's strategies not be a one-size-fits-all approach, 
but one that adapts and provides our men and women with tailored 
programs to give them every chance to return to civilian life fully 
healthy. This is especially so for our women veterans, many of whom are 
facing unprecedented levels of stress and conflict, and who, when they 
return, enter a VA that is predominantly used to caring for male 
veterans.
    VA has made great strides in the care provided to women veterans, 
but they can definitely do more. The Women Veterans Health Care 
Improvement Act would push VA even further along, and would address 
some of the most critical issues our female veterans face.
    Title I of the bill would authorize a number of studies and 
assessments as to VA's capacity for care, but also for what the future 
needs of women veterans will be. Section 101 would create an essential 
long-term epidemiological study on the full range of health issues 
female OEF/OIF veterans face. This is critical because it is uncharted 
territory. With increasing numbers of women veterans in a hostile 
combat zone, there are higher rates of exposures and incidents that 
must be studied so that we know what health care issues will come up in 
the short- and long-term. There is much we do not know, and lots of 
essential information that is necessary to study to ensure that VA is 
meeting their full needs.
    Section 102 would require VA to study any potential barriers to 
care faced by women veterans to determine any improvements that VA must 
make so that women veterans can access the care to which they are 
entitled. This is especially true of those women veterans who choose 
not to use VA care. Is it because of a stigma associated with VA, a 
previous bad experience or other reasons? To better prepare for the 
future, VA must know the answers to these questions and we strongly 
support this study. Along those same lines, section 103 would require 
VA to develop an internal assessment of the services it provides to 
women veterans, as well as plans to improve where it finds gaps. We, 
too, welcome this assessment. Section 104 would study the health 
consequences of military service among female OEF/OIF veterans.
    We fully support the sections contained in Title II of the 
legislation, which deal with the improvement and expansion of health 
care programs for women veterans. We especially appreciate the addition 
of two recently separated female veterans to the VA Advisory Committees 
on women veterans and minority veterans.
    The VFW supports section 204, which would create a pilot program to 
provide child care for veterans receiving health care through VA. This 
is a terrific idea, which has the potential to eliminate a barrier for 
care, especially for single parents.
    We also strongly support section 206, which requires VA to have a 
full-time women veterans program manager at each medical center. We 
have had a long-standing resolution in support of this issue as a 
number of current program managers are assigned as part-time employees, 
or given the task in addition to their other duties. This severely 
limits their effectiveness and their ability to help the medical 
facility fulfill its duty to women veterans.
                                s. 2824
    The VFW takes no position on this legislation.
                         s. 2889, sections 2-6
    The VFW approves of the changes in sections two through six of this 
bill, which was introduced by request of VA.
    Section 2 would allow VA to contract for specialized residential 
and rehabilitation care for certain OEF/OIF veterans. We have supported 
contracting for care in specialized circumstances where VA is otherwise 
unable to adequately provide care. Ideally, we would like VA to gain 
the in-house expertise to handle these issues, especially since a 
number of these veterans are likely to be accessing VA for their health 
care for many years, but contracting for care is valuable in the short-
term. Ultimately, though, we need VA to have the care of these brave 
men and women in mind over the long term.
    Section 3 would reimburse certain physicians and dentists for their 
continuing education expenses, which can only help to serve as a 
recruitment benefit for those seeking to practice at VA.
    Section 4 would prevent veterans receiving hospice care from having 
to pay copayments. This is a humane thing to do when a veteran is 
nearing the end of his or her life, and it shows compassion to their 
families at a most difficult time.
    Section 5 would repeal section 124 of Pub. L. 100-322, which set 
out the specific circumstances and requirements under which VA could 
conduct testing for HIV. If repealing this section will result in VA 
being able to provide testing to more at-risk veterans with less 
inconvenience, then we support it.
    We do not oppose Section 6, which would allow VA to permanently use 
information from the IRS and Social Security Administration for income-
verification purposes.
                                s. 2899
    The VFW certainly supports the idea of the ``Veterans Suicide 
Act.'' This bill would require VA to study the number of suicides among 
veterans using information from the Department of Defense, veterans 
organizations, the Centers for Disease Control and Prevention, and 
various State offices.
    The risk and problems of suicide among service men and women have 
come to the forefront over the last few months, especially with the 
increased attention paid to the various mental health issues many OEF/
OIF veterans face. These reports have painted a confusing picture with 
uncertainty over the quality and accuracy of data, but the bottom line 
is that even one suicide is one too many.
    Understanding the rate, the number of attempts and various other 
figures is essential for VA to properly implement a successful strategy 
of suicide prevention. VA certainly has improved their efforts and 
treatment is readily available for those who seek it, but more can 
certainly be done, and fully understanding the size and scope of the 
problem is one step toward a solution.
    We would note that VA recently testified before the House Veterans' 
Affairs Committee on their efforts at data collection, which primarily 
relies on matching names and information it has with the efforts of the 
Center for Disease Control's National Death Index. We believe that they 
are on the right track with collecting the bulk of this information, 
but we would urge you to continue oversight to ensure that they remain 
on the right track and that they yield meaningful results.
    To that end, we applaud the recent efforts of Chairman Akaka in 
requesting more information about suicides from VA, and we hope that 
this action will help us get closer to the truth.
                                s. 2921
    The VFW urges passage of the ``Caring for Wounded Warriors Act.'' 
This legislation would create two pilot programs to improve care for 
veterans suffering from Traumatic Brain Injuries. Both pilot programs 
would provide support for family caregivers, who are increasingly 
taking on a pivotal role in the health care and day-to-day life of 
those veterans affected by these disabilities.
    The first program would require VA to develop a training and 
certification program for family caregivers to serve as personal care 
attendants. This would qualify them to receive compensation from VA for 
the services they are rendering to their loved ones. This compassionate 
program would absolutely make a positive difference in the lives of 
those affected. It would allow more family members to play an active 
role, ensuring that the veteran receives excellent care from someone 
who truly cares about their condition.
    The second program would test the feasibility of using properly 
trained graduate students to provide respite care for families serving 
as caregivers. This is an innovative approach at managing a difficult 
problem, and with proper oversight of this program, we would support 
it.
    We think the provisions of this bill would be of real benefit to 
those veterans suffering from the effects of TBI. We strongly support 
its passage, and would hope that the pilot program would yield results 
that would merit it being expanded nationwide where appropriate.
                                s. 2926
    The VFW endorses the ``Veterans Nonprofit Research and Education 
Corporations Enhancement Act.'' This legislation would make several 
changes, which would strengthen and improve the nonprofit research 
corporations affiliated with VA. These NPCs help VA to conduct research 
and education and assist in the raising of funds for VA's essential 
projects from sources VA otherwise might not have access to, including 
private and public funding sources.
    Included in the legislation is a section that would reaffirm that 
these NPCs are 501(c)(3) organizations that are not owned or controlled 
by the Federal Government. This is important to ensure that they are 
able to receive funding from all intended sources and to clarify their 
purpose in accordance with various State laws or private foundation 
regulations.
    It would also allow for the creation of multi-medical center NPCs 
to streamline and make the administration of these important 
organizations more efficient. Ultimately, this should make more funds 
available for critical research purposes. Additionally, it would 
improve the accountability and oversight of these corporations, 
requiring more information in their annual reports and periodic audits 
of their activities. As these corporations continue to expand, we urge 
continued oversight of their actions to ensure that they continue to 
serve the best interest of America's veterans.
    The legislation would address some of the concerns laid out in the 
recent VAOIG report, ``Audit of Veterans Health Administration's 
Oversight Nonprofit Research and Education Corporations.''
                                s. 2937
    The VFW supports this legislation, which would permanently extend 
treatment for veterans who participated in chemical and biological 
tests conducted by the Department of Defense through the Deseret Test 
Center.
    Project 112/Project SHAD were programs started in 1962 to test the 
capability of protecting and defending potential chemical and 
biological warfare threats. The tests, conducted through the Deseret 
Test Center in Utah, involved nearly 6,000 servicemembers as part of 
134 planned tests. These tests sometimes used highly toxic agents, such 
as sarin and VX, as well as infectious bacteria.
    With the uncertainty of their medical conditions as well as the 
DOD's delays in declassifying essential information, VA has provided 
cost-free health care to these veterans for conditions that may be 
related to their exposure. This has clearly been the right thing to do. 
This bill would give these veterans permanent access to health care for 
the treatment of any potentially related conditions.
    Although a May 2007 Institute of Medicine study found no clear 
evidence of specific long-term health effects related to the 
participation of these tests, the authors also made it clear that 
``their findings should not be misconstrued as clear evidence that 
there are no possible long-term health effects.'' With this in mind, 
giving these servicemembers the benefit of the doubt is sound policy.
                                s. 2963
    This comprehensive legislation would make many needed improvements 
to the mental health care services provided to veterans, but also to 
members of the Armed Forces and survivors. This bill recognizes that 
many of today's war wounds are invisible wounds--wounds that often take 
months to appear--making the transition our service men and women face 
all the more difficult. The looming crisis necessitates action, and 
this bill is a strong first step in that direction.
    Sections 1 through 3 of the bill concern Vet Centers. The VFW is a 
strong supporter of Vet Centers and their approach to providing care--
especially mental health care--to veterans. VA has done a pretty good 
job expanding their reach, but they are victims of their own success. 
We are starting to see Vet Centers struggle with difficult workloads as 
increasing numbers of veterans turning to them for the essential 
services they provide. A report done by the staff of the House Veterans 
Affairs Subcommittee on Health showed that these centers are nearing a 
breaking point. They need more staff to manage the workload. Section 1 
would help this in that it provides a scholarship program for 
individuals seeking education and training in health care specialties 
needed by the Vet Centers. Finding qualified mental health 
professionals is a challenge for VA, and the more incentive they can 
provide potential employees, the more likely that these men and women 
will turn to VA as their employer of choice.
    Section 2 would allow OEF/OIF veterans to receive counseling 
services through Vet Centers, even before they separate. With the 
number of these brave men and women diagnosed or likely to be diagnosed 
with a mental health condition, expanding access to health care 
services for them is the right thing to do. This change is important 
for two reasons. First, military mental health services come with a 
stigma. That stigma has been shown repeatedly to be the biggest 
impediment to these men and women getting care when they need it. 
Allowing them to seek care outside regular military channels can only 
serve as an incentive for them to get care early, when it is often 
found to be most effective. With no fear of reprisal or reporting, they 
are free to do what they need for themselves, instead of having to 
worry about their careers or the impressions of others. The second 
reason is that the military does not have a sufficient number of mental 
health care providers. While this legislation does not absolve the 
military of their need to properly care for these men and women while 
in service, it helps fill in the gaps in care that too often swallow up 
those in need.
    We do have some slight concerns about this provision in combination 
with the issue of the current demand for services, though. With the 
anticipated expansion in workload this change would make, we would like 
to see more resources dedicated to staffing Vet Centers to ensure that 
those currently utilizing them are not delayed or denied care.
    Section 3 would require VA to help seek outside counseling services 
for veterans who are otherwise not authorized to receive care through 
VA. This is clearly the right thing to do.
    Section 4 would treat suicides of veterans who have a combat-
related mental health issue, PTSD or TBI on their record as being in 
the line of duty if it occurred within 2 years of their separation. 
This would entitle their family members and beneficiaries to the range 
of benefits this Nation provides to help them deal with the tragedy. It 
acknowledges that these invisible wounds of war are often as traumatic 
and life altering as the physical wounds, even if their impact can 
occur years after the veteran faces the last shot.
    Section 5 would allow DOD to provide grants to non-profit 
organizations that provide support for survivors of deceased members of 
the Armed Forces and veterans. These services would expand and go 
beyond the limited services provided by the military's casualty 
assistance officers and can only help ease the burden on these families 
at a most difficult time in their lives.
                                s. 2969
    The VFW asks the Committee to approve the ``Veterans Medical 
Personnel Recruitment and Retention Act.'' We believe that this 
legislation would dramatically improve VA's ability to recruit and 
retain high-quality medical professionals and that this would increase 
the quality of care provided to this Nation's veterans.
    VA has had difficulty attracting and retaining medical 
professionals. Many facilities are understaffed, which is in essence a 
rationing of health care. The April 2008 hearing this Committee held on 
these issues showed a broad range of reasons for why VA has 
difficulties recruiting and retaining health care employees, and we 
believe that this legislation addresses the largest of those concerns.
    It would increase pay for critical jobs, bringing them in line with 
what the private sector can pay. It would create special incentive pays 
for certain specialties and hard-to-fill positions. It would create 
market pay and provide adjustments for localities to bring salaries in 
line with what local markets bear for similar employees elsewhere.
    Beyond compensation, it would make nursing more attractive, by 
limiting mandatory overtime and providing for flexible work schedules, 
which are highly attractive to potential recruits in a highly 
competitive labor market.
    It would also improve educational assistance programs, loan 
repayments and provide education debt reduction for certain employees.
    Taken together, these meaningful changes would likely improve VA's 
ability to recruit and retain employees, making VA the employee of 
choice for greater numbers of health care professionals. We strongly 
support these provisions, and we would urge its swift passage.
                           s. 2984, title iii
    Title III of this legislation, which was introduced at VA's 
request, deals with various health care matters.
    Section 301 adds non-institutional extended care services to the 
list of medical services VA provides. Section 302 extends various 
authorities, including nursing home care through 2013 and research 
corporations through 2013. Section 303 gives permanent authority for 
medical care services to veterans who participated in certain chemical 
and biological testing. We strongly support this section. Section 304 
would amend annual reporting requirements and section 305 would change 
reporting requirements for the annual Gulf War research report; we do 
not object to either.
    Section 306 would consider would determine that payment by the 
Secretary for care provided under CHAMPVA would be considered payment 
in full, eliminating any liability for the beneficiary to pay. We 
support this. Section 307 would allow health care providers who give 
services to children of Vietnam veterans born with Spina Bifida to seek 
the full costs of care from third parties. In that this would likely 
mean more care providers would provide the often intensive care these 
children need, we would be inclined to endorse it.
    Section 308 would allow VA to share records of patients who lack 
decisionmaking capacities with their representatives. Section 309 would 
require a veteran to provide third-party insurance information and 
their social security number for verification purposes when receiving 
VA health care. We are not opposed to this, and proper and full 
collections from third parties can only help free up health care 
resources that could be better spent elsewhere in the system.

    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions that you or the Members of the Committee may have. 
Thank you.

    Chairman Akaka. Thank you very much, Mr. Needham.
    Now I will call first on Senator Murray for her questions.
    Senator Murray. Thank you, Mr. Chairman, and thank you all 
for your testimony and long-time service for veterans.
    Ms. Ilem, let me start with you. The VA, you just heard 
them express strong opposition to the staffing standards for 
MST care in the women veterans health bill before. I just 
wanted to ask you, as a woman veteran yourself, you have 
undoubtedly heard from female veterans who have received 
treatment for MST at VA facilities. Have the women that you 
have talked to or heard from that have been treated for MST 
been satisfied with their current treatment or care? Do they 
feel they have been rushed? What has been their experience?
    Ms. Ilem. I haven't heard negative things from women 
veterans themselves regarding it. They usually have very high 
praise for the counselors, their mental health providers for 
MST. What we have heard, though, is on the side of the 
providers. These are often very complex cases, very time 
consuming cases, and there is a high burn-out rate among 
providers who provide this very unique type of care. And so, 
our concern is to make sure, number 1, that we do have 
providers that are adequately trained; have expertise in 
military sexual trauma, since it is unique; and have a good 
cultural understanding/background of military service and that 
component of women within the military service.
    So, we think it would be important to definitely have 
qualified providers and to make sure that they don't have burn-
out rates. It is very interesting to see VA's numbers in terms 
of how many people they really have--if not certified, but 
officially--that claim expertise in these areas, because that 
would be, to us, very critical for those patients.
    Senator Murray. Do you think there is care across the 
country that is the same, or do you see different things in 
different places?
    Ms. Ilem. I think that the care can vary from facility to 
facility, and I guess the biggest thing that we often hear is 
that a provider leaves that has expertise, whether it is in 
their medical health or mental health for women veterans, but 
when they leave, it is a very big gap, and they often have a 
hard time recruiting for those positions or maintaining those 
positions, but it is usually a big hole, obviously, when they 
leave, and so I think that is a key issue.
    Senator Murray. So, I assume you support the staffing 
standards that we have put in the bill?
    Ms. Ilem. Yes.
    Senator Murray. One of the other things that we discussed 
quickly with the VA was the issue of barriers for women 
accessing VA facilities, child care in particular, and I often 
find there is a lack of understanding from some people why 
child care is a barrier to women getting care, especially 
mental health care. Ms. Ilem, do you have any views on that?
    Ms. Ilem. I think that the studies that have been done--and 
we have been hearing this for years now--about a barrier to 
care that often women are the primary caretaker of children, 
not always, but predominately; and oftentimes if they have 
intensive mental health treatment or intensive medical 
appointments to attend to, it is difficult for them to secure 
child care in those cases. And I think VA--in looking over VA's 
statement just briefly, it does give concern as you mentioned--
that they admit that this is known to be a barrier to care for 
women veterans oftentimes and, therefore, if we are really 
trying to do outreach for women and look at those barriers, 
what is the point if we are not going to do something about it? 
I can appreciate that they are saying it is going to come out 
of their medical care budget. However, this is an access to 
medical care issue, we believe.
    Senator Murray. I agree. Any other comments from any of you 
on this? Mr. Wilson?
    Mr. Wilson. Yes, Senator Murray. I have visited the State 
of Washington--Walla Walla, Spokane VA Medical Center, as well 
as Puget Sound--and something unique and particular that I 
noticed that wasn't consistent across the board was a private 
entrance for those suffering from--or seeking help for--MST. I 
think I visited in 2006 and returned in 2007. In 2006, there 
was no private entrance, and that was in Puget Sound, and we 
returned in 2007 and there was a private entrance.
    The difference in those two visits were basically comments 
by women. They were pretty apprehensive about visiting there. 
So, any issue that arises, including child care, that stigma 
was in their minds. So, any little issue would turn them away. 
While we couldn't tell how many were there, or we couldn't 
assess how many were there, there were women who were exiting 
from the building and we interviewed them regarding how they 
felt about that and we got a positive response, and that is as 
opposed to other VA medical centers they visited where they did 
not have a private entrance.
    Senator Murray. I thank you for pointing that out. We 
worked very closely with our VA facilities in the State of 
Washington to provide that separate entrance, because 
particularly for women suffering from mental health, or MST in 
particular, it is very challenging to walk into a waiting room 
with all men, and that has eased their access tremendously. We 
have gotten great positive feedback from that, because the last 
thing we want, Mr. Chairman, is for these women with MST, with 
PTSD, with other mental health issues, to choose not to get 
care, and that is why this bill is so important. Everything 
within it is to make sure those women get the care they need.
    So, I really appreciate, Mr. Chairman, your having the 
hearing on this. I know you have scheduled a markup for later, 
and I look forward to working with you to get it passed. So, 
thank you to all of our witnesses today.
    Chairman Akaka. Thank you. Thank you very much, Senator 
Murray.
    This question is to all of our witnesses. In your 
testimony, you all expressed your support for allowing active 
duty servicemembers to access Vet Centers for readjustment 
counseling. However, only one of you addressed the issue of the 
impact that allowing an entire new population into the Vet 
Center system may have on its resources. Do you believe that 
sufficient capacity currently exists within the veterans system 
to allow all active duty servicemembers through its doors? Mr. 
Blake?
    Mr. Blake. Well, Mr. Chairman, I would say that as it is 
currently constructive, that it probably doesn't have 
sufficient capacity, but I think that this is a leap worth 
taking and if it means improving the capacity of the Vet 
Centers, then it should be done. I think given some of the 
discussion about the stigma relating to mental health and 
seeking treatment, it is certainly something that has come out 
for active duty soldiers. I know there have been a number of 
things announced by DOD in recent weeks regarding trying to 
destigmatize seeking mental health treatment, but the fact is 
that stigma still exists; and if opening the Vet Centers to 
these individuals opens another door for them to seek that 
treatment, then we need to take whatever steps are necessary.
    Chairman Akaka. Thank you. Mr. Wilson?
    Mr. Wilson. I think we could mirror the concept of Vet 
Centers, as Mr. Blake stated, regarding the stigma at the VA 
medical facility; and it may not be there, but the thought is 
Vet Centers provide a very comfortable atmosphere. We visited 
well over 50 last year and they are consistent across the 
board. They have been around since 1979. Something seems to be 
working, and I have heard VA medical center employees outside 
of the Vet Center. I think they are a little envious and want 
to work closely with Vet Centers--well, they actually are 
working closely with Vet Centers. So, I think that is--and that 
is good.
    In answer to your question, I think that we should allow 
our Armed Forces members to access Vet Centers. They have 
proven effective in the past and are currently effective.
    Chairman Akaka. Ms. Ilem?
    Ms. Ilem. Just briefly, I would concur with my colleagues' 
statements regarding this issue. I think that they would have 
to address the capacity issue of the centers--that it is 
extremely important, given especially our Guard and Reserves, 
as they go into veteran status, back on active duty, and 
repeated deployments; and that the OEF/OIF veteran population 
has repeatedly indicated that they have concerns about going 
within the military structure due to the impact on their career 
or stigma within. So, if it offers an opportunity to get early 
treatment for some of these conditions and delay or prevent 
long-term problems, we think it would be in their best 
interest.
    Chairman Akaka. Thank you. Mr. Needham?
    Mr. Needham. As we said in our testimony, we have slight 
concerns about the future. It is our understanding that Vet 
Centers are basically managing right now. The concern is with 
the added burden of them as well as the returning 
servicemembers in the future, but we brought that up not as our 
objection to the bill. Like the other organizations have said, 
we strongly support this provision. It is something that we 
think would have a tremendous impact on the quality-of-life of 
active duty as well as when they separate and could lead to 
perhaps fewer diagnoses of PTSD or other mental health 
illnesses in the future, or at least the illnesses being less 
severe.
    The key thing is, like we said, we just need to devote more 
resources to staffing for Vet Centers. We strongly support 
passage of that provision, but like we said, we just need more 
staff.
    Chairman Akaka. Thank you. Mr. Blake, you discussed PVA's 
support of S. 2921, Senator Clinton's bill to support family 
caregivers. It is also my understanding that this program is 
based upon a similar program in San Diego for spinal cord 
injury patients. Can you tell us more about the San Diego 
program and how it has helped SCI patients and their 
caregivers?
    Mr. Blake. I would say first, Senator, that I am not the 
subject matter expert and I can probably pull together more 
information to submit to you. But, as I understand what the 
program does, it is not unlike what the legislation proposes 
here on a broader scale. The San Diego VA undertook an 
initiative along with the spinal cord injury center (that is 
co-located there) to provide a training program that would 
result in certification for personal care attendants for 
veterans who have experienced spinal cord injury, who are among 
the most severely disabled, obviously, veteran population.
    What this does is it provides family members who often are 
the personal care attendants or caregivers of these individuals 
the professional training and the certification they need, and 
the skills and abilities to kind of become an extension of the 
specialized treatment of these veterans outside of the VA 
medical center itself. It also opens up some financial 
assistance to these caregivers as a result of the certification 
they receive from the VA.
    We have advocated for expanding this program in the past. 
We are certainly glad to see that Senator Clinton's legislation 
would undertake that proposal.
    Chairman Akaka. Thank you. This question is to all of you. 
Please share with us what your members and your staff in the 
field relay to you about the impact that delayed funding has 
had on patient care and facilities across the VA system. Mr. 
Wilson?
    Mr. Wilson. Delayed construction and space----
    Chairman Akaka. Yes, and facilities and patient care--
delayed funding for them.
    Mr. Wilson. Yes. The commonality from my guys who actually 
travel throughout VA medical centers, as far as delayed 
funding, to ensure that I represent the full consensus of the 
American Legion, I would like to reserve my response to a later 
date.
    Chairman Akaka. The question was, what impact does that----
    Mr. Wilson. Yes. I would like to reserve the response for a 
later date, just to ensure that I represent the full consensus 
of the American Legion.
    Chairman Akaka. Thank you. Anyone else?
    Ms. Ilem. I am happy to take a stab at it.
    Chairman Akaka. Ms. Ilem?
    Ms. Ilem. I think not only from our membership, but 
thinking back to the testimony actually before this Committee 
in July 2007 regarding funding reform or funding issues, were 
the comments made for the record or in written statements from 
the former Directors of the VA about what the impact really was 
on patient care. And the one thing that I remember is that they 
all had in common that health care for veterans was their 
absolute highest priority within trying to deal with the budget 
that they had. But, those impacted on a series of things 
including: maintenance, delay in maintenance issues, capital 
asset issues, being able to hire staff, and a variety of other 
issues, which then, in turn, to us equates to there can 
definitely be an impact on health care of veterans related to 
those things that we have seen over the years. So, I think 
those issues are important to remember as an impact of the 
delayed funding that occurs.
    Chairman Akaka. Mr. Needham?
    Mr. Needham. I think one of the challenges, as Joy just 
said, is certainly the recruitment and retention of staff--that 
if there is year-to-year uncertainty about what the final 
budget number is, it makes hiring and retaining effective staff 
difficult. I mean, we have certainly seen in the last few years 
VA having problems with secondary care, particularly with 
mental health counselors, as they are trying to increase the 
number there; and certainly an on-time budget affiliated with 
that would allow VA to better plan and process, to know what 
the ultimate number of employees they are going to need, and to 
recruit and attract those employees ahead of time.
    Chairman Akaka. Thank you. Thank you for that.
    Let me ask Senator Murray, do you have any further 
questions?
    Senator Murray. I don't have any additional questions at 
this time.
    Chairman Akaka. Well, let me ask a final question to this 
panel. In your testimony, all of you expressed your support of 
my personnel bill and I thank you for that. I would like to 
ask, however, what your thoughts are on VA's assertion that the 
provision in S. 2377--requiring that VA doctors be licensed in 
the State that they are practicing in--could be detrimental to 
the recruitment of VA physicians. VA's concerns stem largely 
from the fact that because VA is a nationwide system, many 
physicians often cross State lines to practice medicine within 
the system. Do you have a comment on this?
    Mr. Blake. Senator, I would say it is certainly a valid 
concern. Maybe I am a little unclear as to what the legislation 
calls for. Maybe I don't understand. If a doctor is licensed in 
another State but not in this particular State, can they still 
practice, or must they then get licensed in the particular 
State? I think we have to be careful that it doesn't limit the 
VA's ability to hire individuals who would otherwise be needed 
professional staff. So, I think it is a valid concern and I can 
understand at the same time, in light of the discussion about 
Marion, Illinois, where this becomes a concern, as well. But, I 
think some more thought needs to be put into this and a little 
bit--dig in a little deeper to see what the real impact could 
be of this particular provision.
    Chairman Akaka. Thank you. Any other comments? Mr. Wilson?
    Mr. Wilson. Yes, Senator. In light of what occurred in 
Marion--and it seemed to have begun in Massachusetts, but it 
ended in Massachusetts and--it was, I will say, negotiated and 
manipulated over to Marion and there was no effective 
communication. Tragedies took place. I think that is a loophole 
that should be closed and we are not so sure that that loophole 
is closed. We are not sure if it is occurring elsewhere. 
Because you have one piece of legislation in one State and 
another in another as far as requirements, there is going to be 
a gap or loophole unless we get to communicating. And the one 
who suffers, or the ones who suffer, will be the veterans.
    Chairman Akaka. Thank you. Any other comment? Ms. Ilem?
    Ms. Ilem. I would just briefly indicate I think the VA did 
raise some valid concerns today and I know they mentioned in 
their statement that no other Federal agency, I believe, had 
those requirements and it could impede them in terms of their 
flexibility and the VISN layout where they cross State lines 
and things like that. So, certainly we are hoping that the 
Committee will take an additional look at that and consider it 
based on VA's expertise.
    Chairman Akaka. Thank you. Mr. Needham?
    Mr. Needham. Yes. If the reason for imposing the 
requirement is for a proper vetting procedure, then perhaps, as 
is being suggested, there are other ways to go about vetting to 
determine that a doctor is qualified in a particular State 
without necessarily having a license in that State.
    Chairman Akaka. Well----
    Mr. Blake. Senator, could I add one thing?
    Chairman Akaka. Yes, Mr. Blake?
    Mr. Blake. I think the Marion situation points out a 
problem with communication across the VA system and not 
necessarily a breakdown of the licensing or certification of 
the doctors themselves. A concern we would have would be for 
specialized care doctors, like those who provide care for 
spinal cord injured veterans. It is a very limited pool of 
professionals out there that can provide this type of care and 
it is a very competitive market. So, if a doctor is prevented 
from being hired simply because they are not at this time 
licensed in a particular area and yet they have well-
established credentials and have otherwise demonstrated the 
ability, we would have some concerns with not hiring an 
individual, particularly in a specialized care field where they 
might be needed.
    Chairman Akaka. I thank this panel very much for your 
testimonies and this will be helpful to us. Thank you very 
much.
    I would like to welcome the third panel. First, I welcome 
Dr. Stan Luke, Vice President for Programs of Helping Hands in 
Hawaii. I welcome J. David Cox, a Registered Nurse and the 
National Secretary-Treasurer of the American Federation of 
Government Employees. Next, I welcome Cecilia McVey, a 
Registered Nurse and former President of the Nurses 
Organization of Veterans Affairs. I also welcome Donna Lee 
McCartney, Chair of the National Association of Veterans 
Research and Education Foundations. I welcome our fifth 
witness, Dr. Sally Satel, Resident Scholar at the American 
Enterprise Institute. And finally, I welcome Dr. Thomas Berger, 
Chair of the National PTSD and Substance Abuse Committee for 
Vietnam Veterans of America.
    I thank all of you for being here today. Please know that 
your full testimony will appear in the record of the Committee.
    I would like to call on Dr. Luke to please begin your 
testimony, and thank you very much for coming from Hawaii to 
testify. Thank you.

  STATEMENT OF STAN LUKE, Ph.D., VICE PRESIDENT FOR PROGRAMS, 
                      HELPING HANDS HAWAII

    Mr. Luke. Chair Akaka, Senator Murray, distinguished 
Members of the Committee, thank you for the opportunity to 
offer testimony on this critical matter. I am Dr. Stanley Luke, 
a clinical psychologist and the Vice President of Programs for 
Helping Hands Hawaii, a provider of mental health services for 
Hawaii adults.
    Since the start of the Iraq War, we have seen an increase 
in demand for treatment of PTSD and Traumatic Brain Injury. 
There are two major problems that we have identified. First, 
barriers to treatment. The volume of eligible veterans has 
increased so much that the system is unable to accommodate the 
demand. The consequence on a clinical level is that those with 
PTSD and Traumatic Brain Injury are left untreated and their 
illnesses and injuries get worse, resulting in increased family 
conflict, financial burdens, and many veterans dropping out of 
necessary treatment out of frustration.
    Second, delays and hurdles in disability applications. Many 
veterans experience financial hardship because their 
applications are delayed in a system that is overwhelmed. For 
many disabled veterans, this confluence of financial pressure, 
frustration with the system, and their attendant disability 
results in bad outcomes.
    Consider the following hypothetical case, which is typical. 
Sergeant John Doe comes home from a tour of duty in Iraq and 
Afghanistan. He was wounded and removed from his unit, stayed 
in a military hospital in Germany, and returns to his hometown. 
Upon return, he is having nightmares, irritable mood, family 
conflicts, hypervigilance, and a startle response--classic Post 
Traumatic Stress Disorder. Anything, a pile of trash on the 
side of the road, an abandoned car, can trigger a memory of an 
IED or another upsetting occurrence. This is the kind of 
psychiatric disorder that requires immediate attention after 
separation from the military. The current delays exacerbate the 
condition and may result in violent behaviors.
    From a Hawaii perspective, the lack of a stand-alone 
veterans hospital means that active duty military and the 
veterans are treated at the same facility. This makes it nearly 
impossible for Tripler Hospital and the VA clinic to handle 
both groups effectively and efficiently. There is literally not 
enough room.
    From a Native Hawaiian perspective, it would be unusual and 
uncharacteristic for a soldier to assert that he or she is 
experiencing mental health problems and needs help. The 
cultural disconnect between the skilled VA staff and the so-
called, quote, ``local'' people decreases the likelihood that 
Hawaii's veterans will willingly seek the services that they 
need.
    Our Hawaii-based efforts have focused on bridging the 
divide and utilizing our cultural competency to assist veterans 
in accessing the care they deserve. The proposal for a pilot 
program to assess the feasibility and the advisability of using 
community-based organizations to ensure that veterans receive 
the care and benefits that they need is a wise beginning.
    Helping Hands Hawaii has endeavored to start this process 
with the establishment of a small office dedicated to 
identifying eligible veterans and assisting them with 
navigating the complexities of the VA system, as well as 
providing group therapy and other necessary case management 
services. A staff psychologist and a case manager have been 
visiting National Guard units both before and after deployment 
to educate soldiers about their treatment options and rights. 
In addition, we have been collaborating with Native Hawaiian 
health centers and a health-related organization called Papa 
Ola Lokahi to reach out to eligible veterans.
    As someone with a specialization in treating PTSD, I want 
to personally thank the Members of this Committee for their 
vigilance and their commitment to providing the care that our 
returning soldiers need. With pilot projects such as this, 
combined with your oversight and sufficient funding, we will 
honor our veterans, improving their quality-of-life and perhaps 
even saving lives.
    Thank you for the opportunity to provide testimony.
    [The prepared statement of Mr. Luke follows:]
  Prepared Statement of Dr. Stanley Luke, Vice President of Programs, 
                          Helping Hands Hawaii
    Chair Akaka, Senator Burr, distinguished Members of the Committee, 
thank you for the opportunity to offer testimony on this critical 
matter. I'm Dr. Stanley Luke, a clinical psychologist, and the Vice 
President of Programs for Helping Hands Hawaii, a provider of mental 
health services for Hawaii adults.
    Since the start of the Iraq War, we've seen an increase in demand 
for treatment of PTSD, and Traumatic Brain Injury. There are two major 
problems that we've identified:
                      first, barriers to treatment
    The volume of eligible veterans has increased so much that the 
system is unable to accommodate the demand. The consequence on a 
clinical level is that those with PTSD and Traumatic Brain Injury are 
left untreated, and their illnesses and injuries get worse, resulting 
in increased family conflict, financial burdens, and many veterans 
dropping out of necessary treatment out of frustration.
         second, delays and hurdles in disability applications
    Many veterans experience financial hardship because their 
applications are delayed in a system that is overwhelmed. For many 
disabled veterans, this confluence of financial pressure, frustration 
with the system and their attendant disability results in bad outcomes.
      consider the following hypothetical case, which is typical:
    Sergeant John Doe comes home from a Tour of Duty in Iraq and 
Afghanistan. He was wounded and removed from his unit, stayed in a 
military hospital in Germany, and returns to his home town. Upon 
return, he's having nightmares, irritable moods, family conflicts, and 
hypervigilance, and a startle response--classic Post Traumatic Stress 
Disorder. Anything, a pile of trash on the side of the road, an 
abandoned car, can trigger a memory of an IED or another upsetting 
occurrence.
    This is the kind of psychiatric disorder that requires immediate 
attention after separation from the military. The current delays 
exacerbate the condition, and may result in violent behaviors.
    From a Hawaii perspective, the lack of a stand-alone veterans 
hospital means that active duty military and the veterans are treated 
at the same facility. This makes it nearly impossible for Tripler 
Hospital and the VA Clinic to handle both groups effectively and 
efficiently. There is literally not enough room.
    From a native Hawaiian perspective, it would be unusual and 
uncharacteristic for a soldier to assert that he or she is experiencing 
mental health problems and needs help. The cultural disconnect between 
the skilled VA staff and so called ``local'' people decreases the 
likelihood that Hawaii's veterans will willingly seek the services that 
they need. Our Hawaii-based efforts have focused on bridging the divide 
and utilizing our cultural competency to assist veterans in accessing 
the care they deserve.
    The proposal for a pilot program to assess the feasibility and 
advisability of using community based organizations to ensure that 
veterans receive the care and benefits that they need is a wise 
beginning.
    Helping Hands Hawaii has endeavored to start this process, with the 
establishment of a small office dedicated to identifying eligible 
veterans and assisting them with navigating the complexities of the VA 
system, as well as providing group therapy and other necessary case 
management services. A staff psychologist and a case manager have been 
visiting National Guard Units, both before and after deployment to 
educate soldiers about their treatment options and rights. In addition, 
we've been collaborating with native Hawaiian health centers and a 
health related organization called Papa Ola Lokahi to reach out to 
eligible veterans.
    As someone with a specialization in treating PTSD, I want to 
personally thank the Members of this Committee for their vigilance and 
their commitment to providing the care that our returning soldiers 
need. With pilot projects such as this, combined with your oversight, 
and sufficient funding, we will honor our veterans, improve their 
quality of life, and perhaps even save lives.

    Thanks for the opportunity to provide testimony.

    Chairman Akaka. Thank you very much, Dr. Luke.
    Mr. Cox?

STATEMENT OF J. DAVID COX, R.N., NATIONAL SECRETARY-TREASURER, 
      AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO

    Mr. Cox. Chairman Akaka, Ranking Member Burr, and 
distinguished Members of the Committee, thank you for the 
opportunity to testify today on behalf of the American 
Federation of Government Employees and the nearly 160,000 VA 
employees we represent. My oral statement focuses on pending 
health care personnel legislation.
    Chairman Akaka, we greatly appreciate your introduction of 
S. 2969. It offers a comprehensive solution for VA nurse 
recruitment and retention problems. Your bill recognizes the 
importance of VA's part-time nurses and provides them with the 
right to become permanent employees. Last year, the VA rejected 
AFGE's grievance on mandatory nurse overtime. This bill will 
ensure that the VA has a sound and safe policy to protect 
nurses and patients from prolonged, unnecessary overtime 
consistent with overtime limits already in place in 15 States.
    Provisions to increase management training on the nurse 
locality pay process will address chronic implementation 
problems. Increased employee access to pay survey data will 
make facility directors more accountable for their locality pay 
policies. For this reason, AFGE strongly opposes the proposal 
in Section 304 of S. 2984 that eliminates the current reporting 
requirements on nurse pay adjustments.
    AFGE strongly objects to Section 2(a) of S. 2969, expanding 
the Secretary's Title 38 authority and converting thousands of 
nursing assistants to a hybrid Title 38 process that is plagued 
by severe backlogs, as simply bad policy. Delayed appointments 
of psychologists and social workers are impeding the VA's 
ability to meet the unprecedented demand of OEF/OIF veterans 
for mental health treatment. Employees placed in hybrid Title 
38 positions also lose their veterans' preference protections. 
AFGE urges this Committee to reject this proposal to expand 
Title 38 authority and rather conduct a pilot project using a 
streamlined Title 5 hiring process to compare the two systems.
    AFGE also thanks Senator Murray for introducing S. 2799, to 
ensure the VA meets the unique health care needs of women 
veterans.
    Turning to S. 2824, that restores Title 38 collective 
bargaining rights, we are very grateful to Senator Rockefeller 
for responding to the VHA personnel crisis by introducing this 
bill, and cosponsors Webb and Brown. S. 2824 is an essential 
enforcement tool for past and future recruitment and retention 
legislation aimed at front-line nurses, physicians, and other 
Title 38 providers.
    In 1991, Congress enacted Section 7422 of Title 38 to 
provide these providers with the rights to challenge improper 
personnel policies through grievances, arbitrations, and the 
courts. Providers lost these rights because the VA began using 
an arbitrary interpretation of the three exceptions in Section 
7422 of Title 38, professional conduct and competency, peer 
review, and compensation. Management's 7422 policy directly 
contradicts Congressional intent, as is evident in the plain 
language of the law and legislative history. Management's 7422 
policy is inconsistent with its own position in a 1996 labor-
management agreement to allow grievances over working 
conditions that affect patient care indirectly, such as 
scheduling matters and access to pay survey data.
    The Under Secretary for Health's published decisions reveal 
a direct assault on the rights established through legislation 
on nurse locality pay in 2000, physician pay in 2004, and 
limits on nurse overtime the same year. The VA testified that 
S. 2824 will allow labor to disrupt patient care, but 
management's rights to determine the agency's mission under 
Title 5 already protect against that. The VA cannot point to a 
single case where a grievance involved a challenge to medical 
procedures. VHA employees who have full grievance rights, such 
as LPNs, psychologists, social workers, and pharmacists, never 
use these rights to disrupt patient care.
    The VA testified that employees already have a fair process 
through the Under Secretary for Health review, but fair to 
whom? One hundred percent of these decisions have been in favor 
of management for the past 3 years. Shouldn't VA health care 
dollars be spent on caring for veterans, not looking for ways 
to block legitimate concerns of hard-working, dedicated nurses 
and physicians?
    Thank you, Mr. Chairman. I will be glad to take any 
questions.
    [The prepared statement of Mr. Cox follows:]
Prepared Statement of J. David Cox, R.N., National Secretary-Treasurer, 
          American Federation of Government Employees, AFL-CIO
    The American Federation of Government Employees, AFL-CIO (AFGE) 
thanks you for the opportunity to testify today on behalf of the nearly 
160,000 AFGE members working at the Department of Veterans Affairs 
(VA), more than two-thirds of whom are on the front lines caring for 
veterans at VA hospitals, clinics and long-term care facilities. AFGE's 
testimony will focus primarily on pending personnel legislation.
    In my nearly 25 years as a registered nurse and union official at 
the Salisbury, North Carolina VA Medical Center, I have seen the impact 
of many Veterans Health Administration (VHA) personnel policies on 
provider recruitment and retention providers. In the 1980's, I saw 
firsthand how good labor-management relations helped transform the VA 
into a world-class health care system, enabling the VA to become a 
model in patient safety, health care information technology, and best 
practices due to regular collaboration between front line providers and 
management.
    Sadly, what I have seen over the past 7 years is a sea change in 
VA's personnel practices that now hurt, rather than help recruitment 
and retention, and exclude front line providers from medical affairs. 
We are extremely grateful to Chairman Akaka and other Members of the 
Committee for their efforts to make VHA's personnel practices more 
competitive, transparent and equitable.
 s. 2969. veterans' medical personnel recruitment and retention act of 
                                  2008
    We greatly appreciate Chairman Akaka's comprehensive effort to 
address VA nurse recruitment and retention in this legislation. AFGE 
supports S. 2969 except for the provision in Section 2(a) to expand the 
Secretary's Title 38 authority.
    Section 2(b) provides a long overdue adjustment to the rules that 
apply to part-time registered nurses (RN), allowing them to earn the 
rights of permanent employment and to retain permanent status if 
previously full-time. The flexibility of a part-time schedule is a 
valuable recruitment and retention tool in today's nursing shortage.

    Section (3):
    Mandatory Overtime: Fifteen States already limit the amount of 
overtime that a nurse can be forced to work. State legislatures enacted 
these protections because of a growing body of research finding that 
prolonged overtime puts both the nurse and patient at risk. It is time 
for the VA to implement its own evidence-based overtime policy using a 
common definition of emergency to mandate longer hours. Section 3 will 
establish a sensible and safe overtime policy that ensures that all 
nursing positions are equally protected:

    Pay:
    Section 3 will ensure that VA pay policies are more consistent and 
competitive. Lifting the current pay caps for Certified Registered 
Nurse Anesthetists and Licensed Practical Nurses will enable facilities 
to offer these employees needed pay incentives. Clearer rules on 
premium and overtime pay for all nursing positions will increase the 
uniformity of VA pay policies and decrease nurse frustration.
    Management training on the nurse locality pay process will increase 
compliance with the 2000 nurse locality pay law that Congress enacted 
to address recruitment and retention; greater employee access to pay 
survey data will add accountability to the locality pay process to 
ensure that surveys are done timely and properly and that needed pay 
adjustments are made. AFGE is strongly opposed to any proposal that 
lessens accountability for nurse pay policies, including the proposal 
in Section 304 of S. 2984 to eliminate current reporting requirements, 
as will be discussed.
    An effective nurse locality pay process also serves the interests 
of veterans who cannot get hospital beds due to staffing shortages, and 
the interests of taxpayers footing large bills for agency nurses and 
diversion of patients to non-VA hospitals.
    Section 4 provides a much needed boost to the Educational Debt 
Reduction Program (EDRP). This program has a long and impressive track 
record in attracting new nurses to the VA and supporting current 
employees who want to pursue RN careers in the VA.

    Section 2(a):
    AFGE strongly objects to Section 2(a). Conversion of nursing 
assistants to hybrid Title 38 and expanded Secretary discretion to 
convert other positions will devastate a severely backlogged hybrid 
appointment process. Employees already face extreme delays in 
appointment and promotion. Ironically, we hear reports that on average, 
it is quicker to hire or promote under Title 5, even though Congress' 
top objective in establishing hybrid positions was to provide a faster 
alternative to Title 5.
    Delays in hybrid appointments have already hurt the VA's ability to 
expand its mental health capacity to treat OEF/OIF veterans. For 
example, all new hybrid employees were supposed to be boarded by 
September 30, 2006 but many VA psychologists are still waiting to be 
boarded; AFGE waited over 4 years for social worker qualification 
standards.
    Hybrid Title 38 employees are not covered by the same veterans' 
preference rules as their Title 5 counterparts. Therefore, expanded 
hybrid authority will adversely impact veterans' employment 
opportunities at the VA--the Federal agency that should be a model 
employer for others.
    In the alternative, AFGE recommends that the VA suspend future 
hybrid appointments pending the completion of a pilot project using a 
streamlined Title 5 hiring process and comparative study of the two 
systems. AFGE would like to work with the Committee to develop this 
pilot project. It can also provide valuable lessons for other Federal 
agencies.
   s. 2824. title 38 collective bargaining rights and procedures for 
                       review of adverse actions
    AFGE supports S. 2824. We greatly appreciate the leadership of 
Senator Rockefeller in introducing this urgently needed legislative 
remedy to the current personnel crisis at VHA. We also extend our 
gratitude to original cosponsors, Committee members Webb and Brown, and 
Senator Mikulski, for cosponsoring S. 2824.
    S. 2824 is an essential companion to any past or future legislation 
that addresses VHA recruitment and retention of the following providers 
(``provider''): RNs, physicians, physician assistants, chiropractors, 
podiatrists, optometrists, dentists and expanded-duty dental 
auxiliaries (also known as ``pure Title 38'' or ``non-hybrid Title 38'' 
employees.)
    S. 2824 will reverse the damaging and unintended consequences of 
the 1991 law that added Section 7422 (``7422'') to Title 38. Section 
7422 widely impacts employee rights in grievances, arbitrations, labor-
management negotiations, unfair labor practices (ULP) and litigation 
before the Federal Labor Relations Authority (FLRA) and courts.
    S. 2824 will curb the VA's widespread noncompliance with Federal 
laws that make the VA a desirable place to work such as physician and 
RN pay laws, limits on nurse overtime, rights to information and equal 
employment laws. Current 7422 policy has undermined nearly every recent 
Congressional attempt to address VHA recruitment and retention, leaving 
providers with ``rights without remedies'' which, according to the old 
adage ``are no rights at all.''
    How can one section of the law cause so much harm to these valuable 
members of VA's health care workforce? That harms result from 
management's arbitrary interpretation of three narrow exceptions in the 
law to block provider rights: professional conduct and competence 
(defined as direct patient care or clinical competence); peer review; 
and compensation.
    Management's 7422 policy is arbitrary because it directly 
contradicts Congressional intent as to the scope of these three 
exceptions. Specifically:

     Congress viewed Title 38 and Title 5 employees as having 
the same collective bargaining rights when it enacted the Civil Service 
Reform Act (CSRA) in 1978.
     Congress enacted Section 7422 in direct response to a 1988 
Federal appeals court decision involving annual nurse ``comparability 
pay'' increases. The Court held that the VA could not be compelled by 
the CSRA to engage in collective bargaining over conditions of 
employment for Title 38 providers. Colorado Nurses Ass'n v. FLRA, 851 
F.2d 1486 (D.C. Cir. 1988).
     The plain language of the 1991 law narrows the scope of 
the exceptions by specifying that the matter must relate to ``direct 
patient care'' or ``clinical competence.''
     The 1990 House committee report on the underlying bill 
defined the ``direct patient care'' exception as ``medical procedures 
physicians follow in treating patients.'' This report also cited 
guidelines for RNs wishing to trade vacation days as falling outside 
the exception. (H. Rep. No. 101-466 on H.R. 4557, 101st Cong., 2d 
Sess., 29 (1990)).

    Management's 7422 policy is also arbitrary because it contradicts 
its own 1996 agreement with labor to clarify the scope of the law and 
resolve remaining disputes in a less adversarial manner. Sadly, the VA 
unilaterally abandoned this useful, inclusive agreement in 2003. More 
specifically, in that agreement:

     The VA committed to a new process for resolving 7422 
disputes that departed from the ``adversarial, litigious, dilatory * * 
* nature of past labor-management relations.''
     The VA acknowledged that providers provide valuable input 
into medical affairs: ``We recognize that the employees have a deep 
stake in the quality and efficiency of the work performed by the 
agency.''; ``The purpose of labor-management partnership is to get the 
front line employees directly involved in identifying problems and 
crafting solutions to better serve the agency's customers and 
mission.''
     The VA recognized the narrow scope of the direct patient 
care exception, i.e. it does not extend to ``many matters affecting the 
working conditions of Title 38 employees [that] affect patient care 
only indirectly'' (emphasis provided).
     The VA agreed that scheduling matters may be grievable: 
``For example, scheduling shifts substantially in advance so that 
employees can plan family and civic activities may make it more 
expensive to meet patient care standards under certain circumstances. 
That does not relieve management of either the responsibility to assure 
proper patient care or to bargain over employee working conditions.''
     The VA agreed that pay matters other than setting pay 
scales are grievable: ``Under Title 38, pay scales are set by the 
agency, outside of collective bargaining and arbitration. Left within 
the scope of bargaining and arbitrations are such matters as: 
procedures for collecting and analyzing data used in determining 
scales, alleged failures to pay in accordance with the applicable 
scale, rules for earning overtime and for earning and using 
compensatory time, and alternative work schedules.''

    The 7422 appeals process: Section 7422 gives the Undersecretary of 
Health (USH) the sole authority to determine what matters are 
grievable. USH decisions are posted on the VA website. AFGE is not 
informed about unpublished decisions or pending cases.
    A review of posted decisions and member reports received by AFGE 
reveals how VA's 7422 policies directly undermine recruitment and 
retention legislation passed over the past decade and deprive providers 
of a fair appeals process. For example:

     No right to grieve over denial of request to review nurse 
locality pay survey data
    - Background: Congress enacted legislation in 2000 to authorize 
    directors to conduct third party surveys to set competitive nurse 
    pay (P.L. 106-419)
    - USH Ruling: ``Compensation'' exception blocks employees' access 
    to third party survey data. (Decision dated 1/06/05)

     No right to grieve over VA nurse mandatory overtime policy
    - Background: Congress enacted legislation in 2004 requiring 
    facilities to establish policies limiting mandatory overtime except 
    in cases of ``emergency'' (P.L. 108-445)
    - USH Ruling: National grievance over definition of ``emergency'' 
    for requiring overtime is barred by the ``professional conduct or 
    competence'' exception. (Decision dated 10/22/07)

     No right to grieve over composition of panels setting 
physician pay
    - Background: Congress enacted legislation in 2004 to use local 
    panels of physicians to set market pay that would be competitive 
    with local markets (P.L. 108-445). AFGE contended that management 
    unfairly excluded practicing clinicians and employee 
    representatives from the panels.
    - USH Ruling: Grievance barred by ``compensation'' exception. 
    (Decision dated 3/2/07)

     Other grievances blocked by VA's 7422 policy (based on 
member reports of pending disputes or unpublished USH decisions)
    - No right to challenge Intimidation of arbitration witnesses: 
    After two VA nurses testified for the union at arbitration, 
    management sent them letters questioning their conduct and 
    suggesting that they could be subject to discipline. The union 
    filed an unfair labor practice with the FLRA which initiated steps 
    to file charges against management. Management invoked the 
    ``professional conduct or competence'' exception to suspend FLRA 
    action pending an USH ruling.
    - No right to challenge performance rating based on use of approved 
    leave: Management invoked 7422 when a nurse tried to grieve the 
    lowering of her performance rating that was based on her authorized 
    absences using earned sick leave and annual leave, and carried out 
    without any written justification.
    - No right to challenge error in pay computation: Management 
    invoked 7422 when a nurse was incorrectly denied a within-grade pay 
    increase because of lost time arising out of a work-related injury 
    covered by workers compensation.
    - No right to challenge low reimbursement for costs of required 
    training: Management invoked 7422 when a nurse tried to grieve the 
    amount of reimbursement she received for attending required 
    training to maintain her Advanced Practice RN certification.
    - Exclusion from hospital affairs: Management invoked 7422 to block 
    a local union's efforts to have input into the drafting of medical 
    staff bylaws that impact personnel policies.
    - No right to challenge unfair bonus policies: VA physicians are 
    unable to challenge policies that are not in compliance with the 
    2004 physician pay law because managers set arbitrarily low bonuses 
    and impose unfair performance measures based on factors beyond the 
    physician's control.
    Recent court decisions upholding the VA's 7422 policy highlight the 
need for Congressional action to enforce critical workplace rights and 
recruitment and retention legislation:

     In AFGE Local 446 v. Nicholson, 475 F.3d 341 (D.C. Cir. 
2007). The Federal court held that the VA operating room nurses could 
not file a grievance over denial of premium pay weekend and evening 
shifts.
     In AFGE Local 2152 v. Principi, 464 F.3d 1049 (9th Cir. 
2006), a VA physician was removed from his surgical duties at age 76 
and his specialty pay was discontinued. The court held that the 
physician's grievance alleging unlawful age and gender discrimination 
was barred by the ``professional conduct or competence'' exception in 
7422. The court rejected the union's contention that management's 7422 
assertion was a mere pretext for unlawful discrimination. (Similarly, 
in a posted USH decision dated 6/1/07, a nurse alleging that 
management's denial of specialized skills pay was racially motivated 
was not allowed to pursue a grievance.)
    Amending 7422 will not hurt patient care. Opponents to S. 2824 are 
likely to suggest that labor will try to disrupt patient care if 7422 
is amended. In fact, Title 5 makes the three exceptions in 7422 
redundant and unnecessary. Federal sector unions are only authorized to 
negotiate on ``conditions of employment'' as that term is defined in 5 
USC 7103(a)(14). In contrast, 5 USC 7106(a)(1) makes it a management 
right (i.e., not to be modified at the bargaining table) for an agency 
to determine its ``mission.''
    Furthermore, a review of published cases that have come before the 
USH did not reveal even one attempt to interfere with medical 
procedures or other direct patient care matters.
    Finally, if grievance rights can interfere with VHA operations, 
then why do hybrid Title 38 providers hired under Title 5 and working 
side by side with ``pure'' Title 38 providers have rights to grieve 
over these prohibited matters? For example, psychologists have full 
grievance rights while psychiatrists do not; licensed practical nurses 
have full grievance rights while RNs do not.
    The current dispute resolution process for 7422 is broken and 
biased against employees. Opponents of S. 2824 are also likely to argue 
that employees already have a fair process though the USH for resolving 
7422 disputes. Numbers tell a very different story: Of the 25 published 
USH decisions over the past 3 years, the USH ruled in favor of 
management one hundred percent of the time. Opponents are unlikely to 
mention that many, many more cases never get to the USH even though the 
law clearly states that he has sole authority to make these rulings. 
Across the country, human resource departments with no authority 
regularly make 7422 determinations and refuse to go through the proper 
USH channels.
    The current 7422 process wastes taxpayer dollars. Finally, the VA's 
7422 policies result in a great waste of taxpayer dollars that would be 
much better spent on patient care. The Asheville case previously 
discussed was pending for 7 years. HR departments in facilities around 
the country regularly block or delay the Section 7422 review process, 
draining resources and staff time away from the VA's mission of caring 
for veterans.
         s. 2639. assured funding for veterans health care act
    AFGE supports S. 2639 to fund VA health care through mandatory, 
rather than discretionary appropriations. The current lack of 
predictability and adequacy in the VA health care funding process 
causes havoc every year in the budget process nationally, and in the 
ability of facility directors to plan for staffing, equipment and other 
operational expenses. VA health care is hurting from year after year of 
continuing resolutions, budget shortfalls and supplemental funding 
arriving long after the start of each new fiscal year. AFGE urges the 
Committee to support reform of the funding system so that VA health 
care dollars are available on a timely and predictable basis, based on 
a funding formula that reflects current demand and cost of providing 
medical care to our veterans.
    AFGE also supports alternative approaches, such as those being 
developed by the Partnership for VA Health Care Budget Reform 
(Partnership) that would utilize 1-year advance appropriations, an 
approach that has a strong track record for other Federal agencies. 
AFGE also supports annual Congressional oversight of the VA's health 
care forecasting model. Politics has already exacted a huge toll on the 
functioning of VA's world class health care system. Again, we urge this 
Committee to move forward with S. 2639 or the Partnership's alternative 
funding proposal.
      s. 2799. women veterans health care improvement act of 2008
    AFGE supports this important legislation to address the needs of 
the unprecedented number of female veterans entering the VA health care 
system. These veterans have unique medical and mental health needs that 
should be the focus of more research, best practices and health care 
innovations. S. 2799 will ensure that women veterans receive care 
through specialized programs and that more female providers are 
available to care for them. Currently, many women veterans must receive 
at least a portion of their health care outside the VA system. Women 
veterans deserve equal access to VA's exemplary in-house care, and S. 
2799 will make it possible for VA to build the capacity to achieve that 
goal.
                s. 2889. veterans health care act of 200
    AFGE objects to Section 3 of this bill. AFGE has no position on 
other sections of this bill. At a time when the VA is facing widespread 
difficulties recruiting and retaining physicians and relies 
increasingly on costly fee basis care, this proposal to weaken the 
already modest professional education benefit in 38 USC Section 7411 is 
a step in the wrong direction. Physicians already face a growing number 
of challenges to receiving reimbursement for continue medical education 
(CME). The $1000 maximum annual payment has not been increased since 
1991, and today, the typical CME program costs three times that amount 
or higher.
    VA's in-house CME courses are helpful but not sufficient to meet 
the increasingly high credit requirements set by medical boards. In 
addition, boards are setting more stringent standards for qualifying 
courses. We hear from many members that management is often reluctant 
to provide physicians with the time to attend grand rounds and other 
in-house courses.
    In addition, VA physicians want and deserve exposure to a wide 
breadth of medical knowledge through courses offered by their 
colleagues in their practice areas outside the VA. The proposal in S. 
2889 to give directors greater discretion to deny reimbursement for 
outside courses (``may reimburse'' would replace ``shall reimburse'') 
is certain to result in more frustration by VA physicians already 
facing so many obstacles to receiving this modest annual reimbursement. 
The problem is already so widespread that AFGE filed a national 
grievance and settlement discussions with the VA are currently in 
progress.
    Therefore, AFGE urges this Committee to defer any revisions to 
Section 7411 pending settlement of the national grievance, and further 
study of current State medical board requirements and costs of outside 
courses.
          s. 2984. veterans' benefits enhancement act of 2008
    We oppose Section 304. At a time when the VA is facing a critical 
nursing shortage and Congress is scrutinizing nurse pay policies to 
increase their effectiveness in recruitment and retention, it would be 
very unwise to eliminate the once-a-year reporting requirement in 38 
USC 7451(f). VA's locality pay process needs greater, not less, 
accountability. As already discussed, management is unwilling to share 
survey pay data with employees at the local level. Congress must have 
this data at the national level to determine whether locality pay 
adjustments (or lack of adjustments) are justified, and whether 
additional funding or training needed to carry out this important nurse 
pay process effectively. This bill runs directly counter to the goals 
of Section 3 of S. 2969. We urge the Committee to reject Section 304 of 
S. 2984 and instead, expand the transparency and accuracy of the 
locality process as proposed by S. 2969.

    Thank you.

    Chairman Akaka. Thank you very much, Mr. Cox.
    Ms. McVey?

STATEMENT OF CECILIA McVEY, MHA, R.N., FORMER PRESIDENT, NURSES 
                ORGANIZATION OF VETERANS AFFAIRS

    Ms. McVey. Mr. Chairman and members of the Senate Veterans' 
Affairs Committee, the Nurses Organization of Veterans Affairs, 
NOVA, would like to thank you for inviting us to present 
testimony on the Veterans Medical Personnel Recruitment and 
Retention Act of 2008. I am Cecilia McVey, Associate Director 
for Patient Care Nursing at the VA Boston Health Care System 
and I am here today as the Immediate Past President of NOVA. 
NOVA is a professional organization for registered nurses 
employed by the Department of Veterans Affairs.
    NOVA respects and appreciates what our labor organizations, 
such as AFGE and NAGE, do for VA nurses. NOVA clearly deals 
with the VA on R.N. professional matters, not working 
conditions, for which VHA R.N.s have their union 
representatives. Because this Committee has invited NOVA to 
share its views on this bill, however, I am here to offer the 
following observations.
    NOVA has identified retention and recruitment of health 
care staff members as a critically important issue in providing 
high quality health care to America's heroes. NOVA supports the 
Veterans Medical Personnel Recruitment and Retention Act of 
2008 based on the following rationale. Waiver of offset from 
pay for certain reemployed annuitants will allow VA to bring 
back a corporate and clinical knowledge housed in these 
individuals and allows VA to utilize some of its most precious 
resources. There aren't comparable restrictions on nurses who 
retire from the military.
    Senior Executive Schedule position in VHA is critical to 
ameliorate the pay inequities which have grown with each 
subsequent year. Nurse executives and medical center directors, 
for example, do not receive pay comparable with their peers in 
the private sector. This underscores the need for VA to move 
quickly to remedy a problem that is already manifesting itself 
in turnover and in recruitment problems at key upper-level 
positions in VA.
    The mean salary for a nurse executive, for example, is 
$129,000. Many nurse executives did not receive additional pay 
in the form of a bonus because a bonus was not mandatory.
    There is a need to increase the pay limitation for VA 
nurses from Level 5, currently $136,200, to Level 4, currently 
$145,400, of the Executive Schedule to address the pay 
disparity between the Nurse 5 maximum rate and the GS-15 rate 
in some geographic areas. A change to 38 U.S.C. 7451 is needed 
to increase the pay cap under the nurse locality pay system.
    This change would also favorably affect the same issue 
which pertains to our Certified Registered Nurse Anesthetists. 
A search of a commercial website that lists job openings for 
CRNAs revealed that in 66.8 percent of the listings, the 
potential pay rates exceeded the VA cap.
    Information and training on locality pay surveys would also 
assist in applying a law which is not flawed but merely needs 
the appropriate application in order to be successful.
    Reestablishment of the VA Health Professionals Scholarship 
Program for non-VA employees needs to be reinstituted to 
compete for recruitment of students who are currently not VA 
employees. NOVA's recommendation would be to include the 
addition of the following Section 4, improvements to certain 
educational assistance programs, and reinstate the scholarship 
program as described in U.S.C 7611-7618, which expired in 1988, 
with the following additional provisions: Qualifying education 
or training leading to employment in Title 38 or hybrid Title 
38 occupation; provision of funding at $25 million per annum.
    Inclusion of the revised definition of nurses who wish to 
work the 36/40 work week as utilized in the community will 
address this misinterpretation of the statement in the current 
VHA handbook and should read, ``The Secretary may provide, in 
the case of nurses employed at such facility, that such nurse 
who works six regularly scheduled 12-hour periods of service 
within a pay period shall be considered for all purposes to 
have worked a full 80-hour pay period.'' Current use of this 
retention tool has been rendered ineffective and not applicable 
because of this interpretation.
    NOVA also requests your support to eliminate the 19th step 
restriction under the special rate authorization for LPN/LVN, 
as has been done previously for Physical Therapists and 
Pharmacists based on a highly competitive market for this 
occupation. This has been a longstanding issue and we look 
forward to its resolution for this critical and worthy group of 
caregivers that we are consistently having challenges to hire 
due to current regulations.
    NOVA appreciates the Committee on Veterans Affairs' 
attention to these timely actions to further enhance the VA 
workforce. Thank you.
    [The prepared statement of Ms. McVey follows:]
 Prepared Statement of Cecilia McVey, Immediate Past President, Nurses 
                    Organization of Veterans Affairs
   veterans' medical personnel recruitment and retention act of 2008
    Mr. Chairman and Members of the Senate Veterans' Affairs Committee, 
the Nurses Organization of Veterans Affairs (NOVA) would like to thank 
you for inviting us to present testimony on the Veterans' Medical 
Personnel Recruitment and Retention Act of 2008.
    I am Cecilia McVey, BSN, MHA, RN, Associate Director for Patient 
Care/Nursing at the VA Boston Health care System and am here today as 
the Immediate Past President of NOVA. NOVA is the professional 
organization for registered nurses employed by the Department of 
Veterans Affairs.
    NOVA respects and appreciates what our labor organizations such as 
AFGE and NAGE do for VA nurses. NOVA clearly deals with VA on RN 
professional matters, not working conditions for which VHA RNs have 
their union representatives. Because this Committee has invited NOVA to 
share its views on this bill, however, I am here to offer the following 
observations.
    NOVA has identified retention and recruitment of health care staff 
members as a critically important issue in providing high quality 
health care to America's heroes. As Veterans Health Administration 
(VHA) executives face growing vacancies, elevated turnover due to 
retirements and increasingly complex care delivery, the demands on the 
workforce today are greater than ever.
    NOVA supports the Veterans' Medical Personnel Recruitment and 
Retention Act of 2008 based on the following rationale.

     Waiver of offset from pay for certain reemployed 
annuitants will allow VA to bring back a corporate and clinical 
knowledge housed in these individuals and allows VA to utilize some of 
its most precious resources. During this time of a critical nursing 
shortage, it is more important than ever to keep these valuable 
resources to provide the best care to veterans. There aren't comparable 
restrictions on nurses who retire from the military.
     Senior Executive Schedule Position in VHA is critical to 
ameliorate the pay inequities which have grown with each subsequent 
year. Nurse Executives and Medical Center Directors, for example, do 
not receive pay comparable with their peers in the private sector. This 
underscores the need for VA to move quickly to remedy a problem that is 
already manifesting itself in turnover and in recruitment problems for 
key upper level positions in the VA. The mean salary, for example, for 
a Nurse Executive is $129,000. Many Nurse Executives did not receive 
additional pay in the form of a bonus that is included in retirement 
computation under Public Law 108-445, because the bonus was not 
mandatory.
     There is a need to increase the pay limitation contained 
in 38 USC 7451(c)(2) for VA nurses from level five (currently $136,200) 
to level four (currently $145,400) of the Executive Schedule to address 
the pay disparity between the nurse five maximum rate and the GS-15 
maximum rate in some geographic areas.
     A change to 38 USC 7451 is needed to increase the pay cap 
under the nurse locality pay system. With an increase to EL-4, each 
nurse pay schedule, which is currently limited by the EL-5 cap, would 
be recalculated based upon the existing beginning rate for the grade. 
This change would also favorably affect the same issue which pertains 
to the Certified Registered Nurse Anesthetists (CRNA). Presently, the 
pay of 286 of the 531 CRNA's (54 percent) in VA is frozen at the 
Executive Schedule, Level V ($139,600). A search of a commercial 
website that lists job openings for CRNA's revealed that in 66.8 
percent of the listings, the potential pay rates exceeded the VA cap.
     Information and training on Locality Pay Surveys would 
also assist in applying a law which is not flawed but merely needs the 
appropriate application in order to be successful. VA nurses are 
concerned they do not receive appropriate pay raises due to this 
inappropriate application of the law which impacts both recruitment and 
retention during this critical nursing shortage. We support any and all 
activities that lead to increased education and enhancement as well as 
knowledge of application of Locality Pay Law.
     Reestablishment of the Health Professionals Scholarship 
Program (for non-VA employees) needs to be reinstituted to compete for 
recruitment of students, who are not currently VA employees.

    NOVA's recommendation would be to include the addition of the 
following to Section 4--Improvements to Certain Educational Assistance 
Programs and reinstate the scholarship program, as described in USC 
7611-7618 (expired 1988) with the following additional provisions.

     Qualifying education or training leading to employment in 
Title 38 or Hybrid Title 38 Occupation. Priority for funding of the 
occupation education to be determined by the Department of Veterans 
Affairs based on recruitment needs.
     Provision of funding at 25 million dollars per annum. 
These additional monies would allow funding of other high need 
occupations such as pharmacists, since the law that expired did not 
include all Title 38.
     Inclusion of the revised definition of nurses who wish to 
work the 36/40 work week as utilized in the community will address this 
misinterpretation of the statement in the current VHA handbook and 
should read, ``The Secretary may provide, in the case of nurses 
employed at such facility that such nurse who works six regularly 
scheduled 12 hour periods of service within a pay period shall be 
considered for all purposes to have worked a full 80 hour pay period.'' 
Currently use of this retention tool has been rendered ineffective and 
not applicable because of the interpretation.
     NOVA also requests your support to eliminate the 19th step 
restriction under the special rate authorization for LPN/LVN as had 
been done previously for Physical Therapists and Pharmacists based on 
the highly competitive market for this occupation. This has been a 
longstanding issue and we look forward to its resolution of this 
critical and worthy group of caregivers that we are consistently unable 
to hire due to current regulations.

    NOVA appreciates the Senate Committee on Veterans' Affairs' 
attention to these timely actions to further enhance the VA workforce.

    Chairman Akaka. Thank you very much, Ms. McVey. I am also 
aware that your son and his girlfriend are here today at this 
hearing and I just want to add a welcome to them.
    Ms. McVey. Thank you.
    Chairman Akaka. Thanks. Ms. McCartney?

 STATEMENT OF DONNA McCARTNEY, CHAIR, NATIONAL ASSOCIATION OF 
  VETERANS RESEARCH AND EDUCATION FOUNDATIONS, AND EXECUTIVE 
    DIRECTOR, PALO ALTO INSTITUTE FOR RESEARCH AND EDUCATION

    Ms. McCartney. Chairman Akaka and Members of the Committee, 
thank you for the opportunity to testify with regard to S. 
2926, the Veterans Nonprofit Research and Education 
Corporations Enhancement Act of 2008.
    I worked for VA for over 28 years in various administrative 
capacities and it is my privilege to continue my service to 
veterans in my current position as the Executive Director of 
the Palo Alto Institute for Research and Education at the VA 
Palo Alto. I mention this because the fundamental purpose of 
the nonprofits that are the subject of S. 2926 is to serve 
veterans by supporting VA research and education to improve the 
quality of care that veterans receive.
    At this time, 84 affiliated nonprofits provide VA medical 
centers with this highly valued flexible funding mechanism for 
administering $230 million in non-VA Federal research awards 
and private sector funds in support of VA-approved research and 
education activities. These nonprofits provide a full range of 
onsite support services to VA researchers, thus enabling 
investigators to focus on their research and care of veteran 
patients.
    For example, a seed grant to my institution provided 
several years ago from our funds to a gastroenterology 
clinician investigator resulted in his finding that an easily 
overlooked type of abnormality in the colon is the most likely 
type to turn cancerous and is more common in this country than 
previously thought. This finding will change colonoscopy 
practices and may well lead to widespread earlier detection of 
a cancer that is preventable or curable through surgery.
    Chairman Akaka, we are so pleased that you introduced this 
bill. There is a rapidly growing nonprofit affiliated with the 
Honolulu VA that just accepted a $3.3 million Department of 
Defense award to conduct research on veterans with Post 
Traumatic Stress Disorder. That nonprofit and all the other VA 
nonprofits, and, ultimately, veterans will benefit from S. 
2926.
    It is noteworthy that the bill's objectives are consistent 
with the findings in the recently released VA Office of 
Inspector General review of five nonprofits and VHA's oversight 
of these nonprofits. Two major provisions in S. 2926 directly 
address the OIG findings. First, Section 2 allows formation of 
multi-medical center research corporations. This will allow 
interested VA facilities with small research programs to 
affiliate with larger ones to ensure an appropriate level of 
internal controls, including segregation of financial duties. 
Second, the last item in Section 5(a) broadens VA's ability to 
guide nonprofit expenditures.
    S. 2926 provides a number of other welcome enhancements to 
the nonprofit authorizing statute. Section 4(b)(2) of the bill 
allows the boards of directors to acquire members with the 
legal and financial expertise needed to ensure sound governance 
and financial management. Section 5(a) permits efficient 
administration of funds generated by educational activities. 
Additionally, Section 5(a) of the bill permits VA to continue 
to benefit from the more than 500 nonprofit employees on 
Intergovernmental Personnel Act assignments to VA from the 
nonprofits.
    S. 2926 also contains a number of useful clarifications of 
these organizations' status and purposes. For example, Section 
2(c) codifies--without changing--their legal status as State 
chartered independent nonprofits subject to VA oversight and 
regulation.
    Thus far, my testimony has focused on the substantive 
changes that S. 2926 will implement. Before I conclude, I want 
to emphasize that this statute makes no changes in VA's power 
to regulate and oversee the nonprofits. Further, their records 
remain fully available to the Secretary and his designees, to 
the Inspector General, and to the Government Accountability 
Office.
    In conclusion, I urge the Committee to report S. 2926 to 
the Senate for enactment at the earliest possible opportunity. 
We believe enactment will allow these nonprofits to maximize 
their support for VA research and education while ensuring both 
VA and Congressional confidence in their management.
    Chairman Akaka, thank you again for introducing this 
legislation and for the opportunity to testify today. I would 
be pleased to answer any questions you may have.
    [The prepared statement of Ms. McCartney follows:]
 Prepared Statement of Donna McCartney, Chair, National Association of 
Veterans' Research and Education Foundations, and Executive Director of 
           the Palo Alto Institute for Research and Education
 s. 2926 the ``veterans nonprofit research and education corporations 
                       enhancement act of 2008''
    Chairman Akaka and Members of the Committee, Thank you for the 
opportunity to testify on behalf of the National Association of 
Veterans' Research and Education Foundations (NAVREF) in regard to S. 
2926, the ``Veterans Nonprofit Research and Education Corporations 
Enhancement Act of 2008.''
    NAVREF is the membership organization of the 85 VA-affiliated 
nonprofit research and education corporations (NPCs) originally 
authorized by Congress under Public Law 100-322, and currently codified 
at sections 7361 through 7368 of the United States Code. NAVREF's 
mission is to promote high quality management of the NPCs and to pursue 
issues at the Federal level that are of interest to its members. NAVREF 
accomplishes this mission through educational activities for its 
members and interactions and advocacy with agency and congressional 
officials. Additional information about NAVREF is available on its web 
site at www.navref.org.
    I am Donna McCartney, the chair of the NAVREF Board of Directors 
and the executive director of the Palo Alto Institute for Research and 
Education (PAIRE). I worked for VA for over 28 years in various 
administrative capacities, and it is my privilege to continue my 
service to veterans in my current position. I mention this because the 
fundamental purpose of the nonprofits that are the subject of S. 2926 
is to serve veterans by supporting VA research and education to improve 
the quality of care that veterans receive.
                       background about the npcs
    In 1988, Congress allowed the secretary of the Department of 
Veterans Affairs to authorize ``the establishment at any Department 
medical center of a nonprofit corporation to provide a flexible funding 
mechanism for the conduct of approved research and education at the 
medical center.'' [38 U.S.C. Sec. 7361(a)] At this time, 85 NPCs 
provide their affiliated VA Health Care Systems and medical centers 
with a highly valued means of administering non-VA Federal research 
grants and private sector funds in support of VA research and 
education.
    Last year, the NPCs collectively administered $230 million with 
expenditures that supported nearly 5,000 VA-approved research and 
education programs. These nonprofits are dedicated solely to supporting 
VA and veterans. This includes providing VA with the services of nearly 
2,500 without compensation (WOC) research employees who work side-by-
side with VA-salaried employees, all in conformance with the VA 
background, security and training requirements such appointments 
entail.
    For example, at the Palo Alto NPC, the nonprofit for which I am the 
executive director, we have 130 research employees and support 170 
projects. Of these, approximately one-third are Federal awards. During 
fiscal year 2007 we expended $10.4 million in support of VA research 
and education activities and expect our fiscal year 2008 expenditures 
to approach $16 million. We provide a full range of on-site support 
services to VA researchers, including assistance preparing and 
submitting their research proposals; publishing the results; hiring lab 
technicians, study coordinators and other dedicated staff to work on 
the projects; procuring supplies, services and equipment; monitoring 
the required VA approvals; facilitating travel to scientific 
conferences, and providing a host of other services that enable 
investigators to focus on their research and veteran patients.
    Beyond administering research projects and education activities 
these nonprofits support a variety of VA research infrastructure and 
administrative expenses. They have provided seed and bridge funding for 
investigators; staffed animal care facilities; funded recruitment of 
clinician researchers; paid for research administrative and compliance 
personnel; supported staff and training for institutional review boards 
(IRBs); and much more.
    At my own institution, a seed grant PAIRE provided several years 
ago to a gastroenterology clinician-investigator resulted in his 
finding that an easily overlooked type of abnormality in the colon is 
the most likely type to turn cancerous, and is more common in this 
country than previously thought. This finding, reported on the front 
page of the March 5, 2008, New York Times and in the Journal of the 
American Medical Association, will change colonoscopy practices and may 
well lead to widespread earlier detection of a cancer that is 
preventable or curable through surgery. This year alone we have been 
able to make nine similar awards to VA Palo Alto investigators, in the 
hope of equally significant research success down the road.
             s. 2926 enhances and clarifies npc authorities
    Chairman Akaka, I am so pleased that you introduced this bill. 
There is a rapidly growing NPC affiliated with the Honolulu VA that 
just accepted a $3.353 million Department of Defense (DOD) award to 
conduct research on telemental health and cognitive processing therapy 
for rural combat veterans with Post Traumatic Stress Disorder (PTSD). 
That nonprofit and all the other NPCs--and ultimately veterans--will 
benefit from S. 2926.
    The bill heading correctly states that the purpose is to ``modify 
and update'' the 1988 statute, but we also view this as an opportunity 
to modernize and clarify the statute after nearly 20 years of 
experience under its current terms. The NPCs have already proven 
themselves to be valued and effective ``flexible funding mechanisms for 
the conduct of approved research,'' and this bill will further enhance 
their value to VA.
    The objectives of S. 2926 are consistent with the findings in the 
recently released VA Office of Inspector General (OIG) review of five 
NPCs and VHA's oversight of them. I know that VHA is working hard to 
address the shortcomings in oversight that the OIG identified. And we 
on the nonprofit side are working equally hard to ensure that we have 
appropriate controls over funds and equipment (including supporting 
documentation for all transactions), and that all NPC officers, 
directors and employees are certifying their awareness of the 
applicable Federal conflict of interest regulations. While we firmly 
believe that NPC boards and administrative employees strive to be 
conscientious stewards of NPC funds, we thank the OIG for its thorough 
review of those five NPCs and for bringing to light these areas in need 
of improvement.
    It is noteworthy for the Committee that the OIG report cited no 
actual misuse of funds or instances of conflicts of interest, dual 
compensation of Federal employees or fraud. However, we take very 
seriously the OIG finding that these NPCs nonetheless did not have 
adequate controls over some of the funds they manage. We believe that 
two major provisions in S. 2926 directly address this finding.
    First, section 2 of S. 2926 allows formation of ``multi-medical 
center research corporations'' (MMCRCs). That is, two or more VA 
medical centers may share one NPC, subject to board and VA approval, 
while preserving their fundamental nature as medical center-based 
organizations. This will allow interested VA facilities with small 
research programs to join with larger ones. Or several smaller 
facilities may pool their resources to support management of one NPC 
with funds and staffing adequate to ensure an appropriate level of 
internal controls, including segregation of financial duties.
    Second, the last item in section 5(a) of S. 2926 addresses the OIG 
criticism by broadening VA's ability to guide NPC expenditures. The 
only constraint on VA is that such guidance must be consistent with 
other Federal and State requirements as specified in laws, regulations, 
executive orders, circulars and directives--of which there are many--
applicable to other 501(c)(3) organizations. The purpose of this 
limitation is to avoid the possibility of imposing on NPCs conflicting 
requirements and reducing their ability to remain ``flexible funding 
mechanisms.''

    S. 2926 provides a number of other welcome enhancements to the NPC 
authorizing statute.
     Section 4(b)(2) of the bill broadens the qualifications 
for the two mandatory non-VA board members beyond familiarity with 
medical research and education. This will allow NPCs to use these board 
positions to acquire the legal and financial expertise needed to ensure 
sound governance and financial management.
     Section 4(c) of the bill also deletes the overly broad 
stipulation in the current statute that these non-VA board members may 
not have ``any financial relationship'' with any for-profit entity that 
is a source of funding for VA research or education. This absolute 
prohibition conflicts with regulations applicable to Federal employees 
with respect to conflicts of interest, which are invoked for all NPC 
directors and employees in section 7366(c)(1) of title 38, United 
States Code. Unlike the deleted provision, Federal conflict of interest 
regulations provide means of recusal as well as de minimus exceptions. 
Additionally, the prohibition has been interpreted to apply to any 
individual who has ever accepted compensation or reimbursement from a 
for-profit sponsor of VA research for purposes unrelated to VA 
research, thereby eliminating many otherwise desirable and qualified 
individuals from serving on NPC boards.
     Section 5(a) of the bill provides NPCs with authority to 
reimburse the Office of General Counsel (OGC) for legal services 
related to review and approval of Cooperative Research and Development 
Agreements (CRADAs), the form of agreement used to establish terms and 
conditions for industry-funded studies performed at VA medical centers 
and administered by NPCs. The funds generated under this provision will 
help OGC to staff Regional Counsel offices to accommodate the workload 
these agreements entail and to provide training in CRADA requirements 
and related VA policies.
     Section 5(a) also increases the efficiency of NPC 
administration of funds generated by educational activities. This 
clause allows NPCs to charge registration fees for the education and 
training programs they administer, and to retain such funds to offset 
program expenses or for future educational purposes. However, it also 
explicitly sustains the existing prohibition against NPCs accepting 
fees derived from VA appropriations.
     Additionally, section 5(a) of the bill includes authority 
for VA to reimburse NPCs for the salary and benefits of NPC employees 
loaned to VA under Intergovernmental Personnel Act (IPA) assignments 
conducted in accordance with section 3371 of title 5, United States 
Code. This provision responds to recent OIG questions asking whether 
such reimbursements are allowable and permits VA to continue to benefit 
from this efficient and cost-effective mechanism to acquire the 
temporary services of skilled research personnel.

    S. 2926 also contains a number of useful clarifications of NPC 
status and purposes.
     Section 2(c) codifies--without changing--the legal status 
of the NPCs as state-chartered, independent organizations exempt from 
taxation under section 501(c)(3) of the Internal Revenue Service (IRS) 
code and subject to VA oversight and regulation. This clause of the 
bill codifies the congressional intent, previously expressed in the 
House report that accompanied the original NPC authorizing statute (H. 
Rept. 100-373), that nonprofits established under this authority would 
not be corporations controlled or owned by the government. As a result, 
S. 2926 resolves longstanding differences of opinion among 
stakeholders, overseers and funding sources about the legal status of 
NPCs.
     Section 3(a)(1) of the bill establishes that in addition 
to administering research projects and education activities, NPCs may 
support ``functions related to the conduct of research and education.'' 
This resolves differences of opinion about the allowability of NPC 
expenditures that support VA research and education generally, such as 
purchase of core research equipment used by many researchers for many 
projects, and enhances the value of NPCs to VA facilities.
     Section 5(a) ascertains that all NPC-administered research 
projects must undergo ``scientific'' rather than ``peer'' review. This 
change recognizes that peer review is not necessary or appropriate for 
all research projects administered by NPCs. However, the bill leaves in 
place the overarching requirement for VA approval and the medical 
center's Research and Development Committee remains in a position to 
determine on a case-by-case basis whether a project also requires peer 
review as a condition of approval for NPC administration.

    In addition to these enhancements and clarifications, S. 2926 
reorganizes the NPC authorizing statute to put all provisions regarding 
their establishment and status in one section; describes their purposes 
in another; and gathers in one section the clauses enumerating their 
powers. Many other revisions are largely technical and conforming 
amendments.
         s. 2926 preserves measures providing oversight of npcs
    Thus far my testimony has focused on the substantive changes that 
S. 2926 will implement. Before I conclude, I want to emphasize that 
this statute makes no changes in VA's power to regulate and oversee the 
NPCs. Further, NPC records remain fully available to the Secretary and 
his designees; to the Inspector General; and to the Government 
Accountability Office (GAO). Likewise, NPCs are still required to 
undergo an annual audit by an independent auditor in accordance with 
the sources--Federal or private--and amount of its prior year revenues, 
and they must submit to VA the resulting audit report along with 
detailed financial information and descriptions of accomplishments.
    In the wake of the Sarbanes-Oxley Act and new Federal Accounting 
Standards Board (FASB) requirements and auditing standards, even the 
most basic form of nonprofit audit has become an effective means for 
assessing an organization's financial controls. Additionally, as more 
NPCs assume responsibility for Federal grants, a higher percentage of 
NPC funds are subject to Generally Accepted Government Accounting 
Standards (GALAS) and OMB Circular A-133, the most rigorous and 
comprehensive level of auditing standards. Before the last independent 
financial audit of the Palo Alto nonprofit, my accounting staff had to 
respond to 40 pages of questions about our controls over funds and 
program compliance, and the auditors were on-site examining and testing 
our records for several weeks. I can assure you from personal 
experience that these audits are comprehensive and provide a sound 
framework for examining an organization's controls over funds as well 
as compliance with program requirements.
                               conclusion
    In conclusion, on behalf of NAVREF and the NPCs, I urge the 
Committee to report S. 2926 to the Senate for enactment at the earliest 
possible opportunity. The NPCs are already a highly efficient means to 
maximize the benefits to VA of externally-funded research conducted in 
VA facilities, ably serving to facilitate research and education that 
benefit veterans. Additionally, they foster vibrant research 
environments at VA medical centers, enhancing VA's ability to recruit 
and retain clinician-investigators and other talented staff who in turn 
apply their knowledge to state-of-the-art care for veterans.
    Twenty years after the VA-NPC public-private partnership was first 
authorized by Congress, and co-incident with expiration of authority to 
establish new NPCs, this is a timely opportunity to update and clarify 
the NPCs' enabling legislation. This bill will accomplish those 
objectives. Experience working within the statute has brought to light 
its many strengths, but also areas that will benefit from modification, 
enhancement and updating, particularly in light of the increasing 
complexity of both research and nonprofit compliance. We believe 
enactment of S. 2926 will allow NPCs to better achieve their potential 
to support VA research and education while ensuring VA and 
congressional confidence in their management.

    Chairman Akaka, thank you again for introducing this legislation 
and for the opportunity to testify on behalf of NAVREF during this 
hearing. We look forward to working with you, the Members of the 
Committee and your House counterparts toward enactment of S. 2926. I 
would be pleased to answer any questions you may have.

    Chairman Akaka. Thank you very much, Ms. McCartney.
    Now we will hear from Dr. Thomas Berger.

STATEMENT OF THOMAS J. BERGER, Ph.D., CHAIR, NATIONAL PTSD AND 
  SUBSTANCE ABUSE COMMITTEE, ON BEHALF OF VIETNAM VETERANS OF 
                            AMERICA

    Mr. Berger. Good morning, Mr. Chairman, other distinguished 
Senators who are here, and guests. On behalf of VVA National 
President John Rowan and all of our officers and members, I 
thank you for the opportunity to share our views on pending 
health care legislation for our Nation's veterans and for your 
leadership in holding this hearing today.
    My name is Tom Berger. I am Chair of the National PTSD and 
Substance Abuse Committee for Vietnam Veterans of America. I am 
a Vietnam combat veteran, having served as a Fleet Marine Force 
Navy corpsman, the 3rd Marine Division, 1966 to 1968, in I 
Corps, Vietnam. Obviously, there is a range of issues to be 
considered here today, but VVA will focus on the proposed 
legislation, S. 2573, the Veterans Mental Health Treatment 
First Act that is, to some degree, derived from the Dole-
Shalala Commission's recommendations.
    Although the bill focuses on service-connected disability 
compensation and does not directly address evidence-based 
mental health diagnoses, treatment modalities, or recovery 
programs, the potential impact of this bill, if enacted, on 
veterans suffering from PTSD, TBI, and related mental health 
disorders cannot be overstated. This practice has the potential 
to change virtually everything, but not in a positive 
direction.
    While we are appreciative of Senator Burr's sincere 
motivation to do what is best for all concerned, including 
potentially affected veterans, VVA does not believe that the 
program outlined in the legislation initiative is either the 
best way to address this problem nor is it a productive or 
prudent course in regard to assisting veterans to continue to 
serve our Nation in civilian life as they did in the military.
    VVA remains opposed to S. 2573 principally because it would 
create a two-tiered disability benefit system that would treat 
veterans differently based on their periods of service--that 
is, a system that gives different disability rating awards to 
classes of veterans from different combat eras under the guise 
of saving the VA money. VVA is especially concerned with the 
impact of the so-called ``buy-out'' program of this bill, not 
only on those veterans currently suffering from mental health 
disorders, but also on those who will encounter mental health 
problems later in life as a result of their military service.
    As you know, one of the well-known characteristics of PTSD 
is that the onset of symptoms is often delayed, sometimes for 
decades, despite unfounded assertions to the contrary. This is 
especially applicable to our Nation's largest living veterans 
cohort, Vietnam veterans, who are now aging, retiring, and 
suffering the aftermath of physical and emotional injuries 
incurred as a result of their military service 40 years ago.
    The legitimacy of veterans' claims that they suffer from 
PTSD is apparently again under the gun by a small number of 
media-savvy professional skeptics who have waged a campaign to 
discredit PTSD as a valid diagnosis and whose views, I might 
add, are not generally shared by the mainline PTSD experts, nor 
by the vast majority of mental health professionals, or even by 
the Institute of Medicine of the National Academies. Without a 
shred of evidence, veterans who suffer PTSD are portrayed by 
these skeptics as looking for easy disability payments that 
provide an incentive for staying sick rather than getting well, 
with the implication that sick veterans are welfare cheats. In 
addition to claims of veteran fraud, the skeptics also claim 
the delayed onset of PTSD is rare to nonexistent and that PTSD 
is an acute, not chronic, disease and only rarely should there 
be a need to give long-term disability.
    In fact, there is no data to support these opinions. 
Studies done at the National Center for PTSD confirm the 
delayed onset of PTSD as well as the fact that mental health 
utilization is actually higher for veterans granted disability 
claims than for those who apply and are turned down. VVA would 
also argue that the use of the standardized and validated PTSD 
diagnostic assessment tools in the VA's own best practices 
manual for PTSD would pick up any factious PTSD claims and 
provide for better guidance in developing individualized 
treatment plans.
    Thank you, Senator. I appreciate the opportunity to address 
this issue and I will be glad to answer any questions.
    [The prepared statement of Mr. Berger follows:]
Prepared Statement of Vietnam Veterans of America, presented by Thomas 
 J. Berger, Ph.D., Chair, National PTSD and Substance Abuse Committee; 
with Rick Weidman, Executive Director for Policy and Government Affairs
    Good morning, Mr. Chairman, Ranking Member Burr, other 
distinguished Senators of this Committee, and guests. On behalf of VVA 
National President John Rowan and all of our officers and members, I 
thank you for the opportunity to share our views on pending health care 
legislation for our Nation's veterans and for your leadership in 
holding this hearing today.
    My name is Tom Berger, Chair of the National PTSD & Substance Abuse 
Committee for Vietnam Veterans of America (VVA). I am a Vietnam combat 
veteran, having served as a Fleet Marine Force Navy corpsman with the 
3rd Marine Division, 1966-68, in I Corps, Vietnam.
      s. 2573--the ``veterans mental health treatment first'' act
    Obviously there is a range of issues to be considered here today, 
but VVA wishes to start by focusing on the proposed legislation S. 
2573, the ``Veterans Mental Health Treatment First'' bill that is to 
some degree, derived from the Dole-Shalala Commission's 
recommendations. Although this bill focuses on service-connected 
disability compensation and does not directly address evidence-based 
mental health diagnoses, treatment modalities, or recovery programs, 
the potential impact of this bill if enacted on veterans suffering from 
PTSD, TBI and related mental health disorders cannot be overstated. 
This in practice has the potential to change virtually everything--but 
not in a positive direction.
    I am certain that we're all aware of the independent Rand 
Corporation study released last month showing that 18.5 percent of 
returning OEF/OIF troops meet the criteria for either PTSD or 
depression (i.e., 14 percent for PTSD and 14 percent for depression) 
some 19.5 percent have experienced a probable TBI. Even more 
distressing is the testimony by Colonel Charles Hoge, M.D., before the 
House Veterans' Affairs Health Subcommittee last month in which he 
indicated a 20 percent PTSD rate for troops serving two combat tours 
and a 29.9 percent PTSD rate for those serving three tours--a number 
that is very close to that obtained for Vietnam veterans in the 
original National Vietnam Veterans Readjustment Study conducted in the 
1980's, some years after the end of the war that put PTSD on the 
reality map. Our troops now are seeing both more and longer 
deployments, with at least four Army Brigade Combat Teams (CBCTs) now 
in their fourth deployment cycle. What is beyond argument is that the 
more combat exposure a soldier sees, the greater the odds that soldiers 
will suffer mental and emotional stress that can become debilitating. 
And in wars without fronts, ``combat support troops'' are just as 
likely to be affected by the same traumas as infantry personnel.
    While we are appreciative of Senator Burr's sincere motivation to 
do what is best for all concerned, including potentially affected 
veterans, VVA does not believe that the program outlined in this 
legislative initiative is either the best way to address this problem 
nor is it a prudent course in regard to assisting veterans to continue 
to serve our Nation in civilian life as they did in the military.
    In truth, with no end to the Iraq and Afghanistan wars in sight, 
the true incidence of PTSD among active duty troops may still be 
underreported because of stigma and discrimination. Without proper 
diagnosis and treatment, the psychological stresses of war never really 
end, increasing the odds that our soldiers will suffer mental and 
emotional stress that can become debilitating if left untreated. This 
places them at higher risk for self-medication and abuse with alcohol 
and drugs, domestic violence, unemployment & underemployment, 
homelessness, incarceration, medical co-morbidities such as 
cardiovascular diseases, and suicide.
    VVA remains opposed to S. 2573 principally because it would create 
a two-tiered disability benefits system that would treat veterans 
differently based on their periods of service--that is, a system that 
gives different disability rating awards to classes of veterans from 
different combat eras under the guise of saving the VA money. VVA is 
especially concerned with the impact of the so-called ``buy out'' 
program of this bill, not only on those veterans currently suffering 
from mental health disorders, but also on those who will encounter 
mental health problems later in life as a result of their military 
service. As you know one of the well-known characteristics of PTSD is 
that the onset of symptoms is often delayed, sometimes for decades, 
despite unfunded assertions to the contrary.
    We are not disputing the fact that claims for mental health 
service-connected disability compensation are rising and the 
accompanying costs for such are growing as well. But under S. 2573, 
this problem cannot be resolved unless fewer vets are rated disabled 
and/or fewer disabilities are rated, and/or smaller amounts of 
compensation are awarded. The responsibility of providing service-
connected disability compensation for a veteran's mental health 
injuries must not be trivialized by providing a one-time payment for 
wounds that may take years to heal, if ever.
    This is especially applicable to our Nation's largest living 
veteran cohort, Vietnam veterans, who are now aging, retiring, and 
suffering the aftermath of physical and emotional injuries incurred as 
a result of their military service 40 years ago.
    The legitimacy of veterans' claims that they suffer from PTSD is 
apparently again under the gun by a small number of media savvy 
professional skeptics (some would call them ``hired guns''), who have 
waged a campaign to discredit PTSD as a valid diagnosis, and whose 
views, I might add, are not generally shared by mainline PTSD experts 
nor by the vast majority of mental health professionals nor by the 
Institute of Medicine of the National Academies of Science. (The IOM 
convened several panels at the request of the Department of Veterans 
Affairs relating to this issue of whether PTSD was a legitimate medical 
condition, whether PTSD could be accurately diagnosed, and whether PTSD 
could be effectively treated. (All three of these reports, released on 
June 16, 2006, May 8, 2007, and October 17, 2007, respectively, are 
available at www.iom.edu in the Military & Veterans section.)
    Without a shred of evidence veterans who suffer from PTSD are 
portrayed by these skeptics as looking for easy disability payments 
that provide an incentive for staying sick rather than getting well, 
with the implication that sick veterans are welfare cheats. In addition 
to claims of veteran fraud, these skeptics also claim that cases of 
delayed onset of PTSD ``are rare to non-existent,'' and that ``PTSD is 
an acute, not chronic, disease and only rarely should there be a need 
to give long-term disability.'' In fact, there are no data to support 
these opinions. Studies done at the National Center for PTSD confirm 
the delayed onset of PTSD, as well as the fact that mental health 
utilization is actually higher for veterans granted disability claims 
than for those who apply and are turned down. VVA would also argue that 
use of the standardized and validated PTSD diagnostic assessment tools 
in the ``Best Practices Manual for PTSD'' would pick up any factitious 
PTSD disability claims, and provide for better guidance in developing 
individualized treatment plans.
    VVA's concern is also focused on those veterans suffering from TBI, 
the so-called ``signature wound'' of the war in Iraq, because it 
presents a most puzzling challenge, especially in mild to moderate 
cases. Symptoms can be hidden or delayed, diagnosis is difficult, and 
evidence-based treatments are as of yet largely undetermined. And if 
left untreated over time, even mild TBI can cause epilepsy/seizure 
disorder. Very few medical facilities in the U.S. are capable of 
providing even the most minimal level of specialized care for brain-
injured patients, forcing most survivors to find treatment hundreds of 
miles from home, if they can find it at all--and more than 40 percent 
of our military deployed in Afghanistan and Iraq come from rural 
America.
    In addition, the most commonly utilized current treatment modality 
for epilepsy/seizure disorder is medication. However, we must remember 
that epilepsy/seizure disorder caused by either a concussive or 
contusive brain injury, is never just an isolated incident. Over time 
without proper treatment and care, TBI can affect nearly everything 
associated with the survivor, including one's cognitive, motor, 
auditory, olfactory, and visual skills, perhaps resulting in behavioral 
modifications, not mental illness. Epilepsy/seizure disorder treatment, 
recovery services and programs can also collapse a family and its 
finances. Of all the medically challenging injuries, brain injuries 
require the most involvement and cost over time.
    And so the question then becomes: How can we really expect a 
veteran currently suffering from chronic PTSD or TBI--perhaps even on 
medication for such wounds--to be able to make an informed decision now 
about his/her future mental health care needs and service-connected 
disabilities?
    Last, VVA acknowledges that the culture of the VA mental health 
system itself may play a yet undefined role in this current debate over 
PTSD and VA compensation. For example, the studies of Sayer and Thuras 
(1), as well as Kimbrell and Freeman (2) suggest that VA clinicians had 
a more negative view of the treatment engagement of veterans who were 
seeking compensation and of clinical work with these patients in 
comparison with those veterans not seeking compensation and those 
certified as permanently disabled and thus not needing to reapply for 
benefits. The longer VA clinicians had been working with veterans who 
had PTSD, the more extreme were these negative perceptions.
    What is clear to us is that these so-called clinical 
``researchers'' are not even aware that their patients seek service 
connection so that they will not have to pay for medical treatment for 
a condition that they believe resulted from their military service. 
This, and the sense of validation of the reality of the suffering they 
endure is in fact a result of neuro-psychiatric wounds suffered in 
service are often more important to the individual veteran that any 
compensation payment he or she may derive (and deserve!) as a result of 
this psychiatric wound(s) that are every bit as real as a gunshot 
wound, if properly diagnosed according to the VA's own ``Best Practices 
Manual.''
    VVA would point out that the VA refuses to issue these manuals to 
relevant staff in the Veterans Benefits Administration and in the 
Veterans Health Administration because ``it takes too much time'' and 
to follow the best practices is ``too expensive.'' VVA's rejoinder is 
that if you do not have the time and resources to do it right the first 
time, when are you going to have the time and money to do it over, and 
then do it over yet again? Our veterans deserve better than slapdash, 
simplistic ``fixes'' that in fact do not address their legitimate 
needs, and would actually serve to exacerbate their very real wounds 
incurred in military service.
  s. 2273--the enhanced opportunities for formerly homeless veterans 
               residing in permanent housing act of 2007
    VVA strongly supports this legislation. The crux of the problem 
with transitional housing for homeless veterans (aside from the fact 
that there is not enough of it) is that often there is no available 
permanent housing to which a transition can take place. In other words, 
persons make it off the street into a transitional housing unit, but 
then have no permanent affordable housing to go to when their time in 
the transitional supportive housing is done. What is needed are both 
affordable permanent housing, and supportive services that are 
available and focused on the needs of these persons to help them 
maintain a stable life situation. It is very important that the VA 
provide grants to fund such services, as HUD is increasingly cutting 
back on program dollars and focusing on ``bricks and mortar.'' (Whether 
that is a smart public policy move on the part of HUD is certainly 
debatable, but the fact remains that this is the direction in which 
they seem to be heading.)
    The pilot program as outlined in this proposal is solid, but we 
would suggest that you consider both enlarging the size of the pilot, 
provide for regular reporting to Congress at regular intervals (at 
least once per year), and after evaluation of the experience of what 
works and what does not work, provide for moving beyond the pilot in 
short order should the model(s) prove to be as successful as we think 
they will be if the VA implements them correctly. VVA has no doubt that 
Pete Dougherty (who coordinates homeless programs at VA nationally) 
will do a sterling job of the implementation and running this 
additional needed aspect of the VA homeless program(s), if he is given 
the resources and the backing.
 s. 2377--a bill to amend title 38, united states code, to improve the 
quality of care provided to veterans in department of veterans affairs' 
 medical facilities, to encourage highly qualified doctors to serve in 
   hard-to-fill positions in such medical facilities, and for other 
                               purposes.
    VVA endorses passage of this bill. We do, however, have some 
suggestions that we hope you will consider. First, the Chief of Staff 
and the top medical officer of each VA Medical Center need s to be 
written into the chain of reporting in this bill. Similarly, so does 
the clinical director of each Veterans Integrated Services Network 
(VISN and the Under Secretary for Health of the Department of Veterans 
Affairs. While the principal ones to carry out the activities mandated 
by this bill may in fact be as described, it is the chief medical 
officer at each level who does have, and should have, ultimate 
responsibility for the overall quality of medical care delivered to 
veterans by that unit. While the mechanism prescribed in this 
legislation will be another tool toward that end, it is only part of 
the puzzle of how to maintain the highest quality of care for our 
Nation's veterans.
    VVA also strongly favors additional financial and other incentives 
to attract and keep high-quality physicians and other vitally needed 
clinicians and medical specialists in the VA.
    Last, although it is not at the high professional credential level 
of the mechanism described in this legislative proposal, the fact is 
that many veterans cannot properly communicate with their clinician, 
nor is their clinician able to effectively communicate with them and 
others in the VA. Language barriers have become an impediment to 
quality care in too many instances. The lack of full command of the 
English language by clinicians and others at the VA is probably the 
most common complaint we hear from our members, their families, and 
other veterans.
    This is a complaint that is founded on frustration voiced by many 
veterans that they cannot understand what their physician is trying to 
say to them, and their physician simply does not understand or 
misunderstands what they are trying to communicate. This can result in 
erroneous medical notes in the veterans' record, or even misdiagnoses. 
In more than a few cases, it would appear that these communication 
barriers impede the delivery of quality medical care. At minimum, it 
detracts from it.
    The reality is that the VA will likely need to continue to hire 
foreign born physicians. So the question is: what can be done to help 
those physicians to be more effective in communicating with their 
patients, and therefore more effective clinically? VVA urges that 
Congress consider mandating the VA to regularly offer basic 
communication skills courses to clinicians and others within the VA, 
and to make it a requirement for a physician or other clinician (no 
matter where they were born or what their native tongue) to pass both 
an oral and written test in English before being made permanent in 
their employment. (The same would hold true for Spanish at the Puerto 
Rico VAMC.)
 s. 2383--a bill to require a pilot program on the mobile provision of 
  care and services for veterans in rural areas by the department of 
               veterans affairs, and for other purposes.
    VVA endorses this proposal.
    As VVA noted in our last appearance before this distinguished 
Committee, the current paradigm for delivery of health care is 
predicated on placing resources where there is a large concentration of 
veterans eligible for service. In other words, the mechanism for 
service delivery of veterans' health care is in or near urban centers. 
However, those fighting our current wars in Iraq and Afghanistan (and 
elsewhere) comprise the most rural army we have fielded since before 
World War I.
    The Department of Defense reports that about 40 percent of the 
current military force comes from towns of 25,000 or less. What this 
means is that we collectively must re-think the paradigm of how we 
deliver medical services to veterans in need.
    The pilot program outlined in this bill is a good start toward 
testing what is going to work in regard to delivering quality health 
care to veterans (including demobilized National Guard and Reserves) 
who live in less populous areas of our country, and deserves to be 
immediately enacted, and implemented as quickly as possible.
       s. 2639--the assured funding for veterans health care act
    Americans have long held that health care for veterans is a 
national obligation, part of the covenant between the American people, 
through our democratically elected representatives and agencies of 
government, and the men and women who have pledged to defend the 
Constitution and the cherished principles of our Nation. Because those 
who render military service pledge not only their loyalty but their 
life, knowing that they may be called to combat, understanding that 
they may give up their life, this covenant is more profound than a 
legal contract. Now, at a time when a new generation of our sons and 
daughters is on the front lines defending America's interests, it is 
our obligation as citizens of a generous and compassionate society to 
ensure that the funding to care for the injuries, illnesses, and 
disabilities they may suffer is assured and not relegated to a 
``discretionary'' appropriation of inadequate proportions.
    Those who serve during times of war or conflict, particularly those 
who are deployed to a war zone, return home changed. Many are seared 
psychologically. Some are wounded or maimed by the weapons of modern 
warfare. Yet just as they have fulfilled their obligation to their 
country--to all of us--it is our collective obligation to do all that 
we can, through the appropriate agencies of government, to restore as 
much as possible to each veteran who has been lessened physically, 
psychologically, or economically; and all that we can individually and 
through our communal and religious institutions to heal each veteran 
who has been lessened spiritually.
    All Americans committed to justice for veterans understand that the 
annual budget battles in Congress do little to inspire confidence that 
we will do right by our veterans. Budgets and appropriations are, of 
course, a reflection of the values and priorities of the administrators 
who design them and the legislators who approve them. What does 
``discretionary'' funding for the care of men and women who defend our 
country say about America? What does the ``temporary'' triage of 
veterans classified as ``Priority 8'' say about our government's 
priority for veterans who want to use the VA health-care system?
    In the last five sessions of Congress, legislation has been 
introduced in both the House and Senate that would drastically re-
engineer the process by which the Administration and Congress fund 
veterans' health care.
    The highest legislative priority of Vietnam Veterans of America is 
the institution of assured funding for veterans' health care, or 
another mechanism that will enable predictable schedules of 
appropriations increases that account for medical inflation and is 
calculated on a truthful per capita basis of projected use of VHA 
services. The Disabled American Veterans have been working on such a 
model that while still not what VVA's ultimate goal is--assured 
funding--is still better that the mess we have now.
    Of all such mechanisms, however, VVA is still committed ultimately 
to the assured funding mechanism as described in Senator Johnson's 
bill.
    VVA also strongly supports immediate reinstatement of eligibility 
for enrollment for Priority 8 veterans. VVA asks that this Committee 
take the first steps toward directing that the VA use numbers for its 
future planning and projection purposes that include provision of 
services for Priority 8 veterans who are not currently enrolled. A 
funding mechanism that annually makes allowances for the growth in the 
beneficiary population and inflation would ensure adequate additional 
funding as needed. Many of these plans offer similar funding mechanisms 
that already exist for the TRICARE for Life program serving the 
Nation's military retirees and their dependents that are also eligible 
for Medicare. The funding mechanism created for this program requires 
annual increments based on health care inflation and growth in the 
number of beneficiaries. Rather than allowing politics to affect 
funding decisions, the Government Accountability Office (GAO) considers 
whether the annual increment determined will be adequate to meet costs. 
This methodology brought stability and predictability to a program 
that, in its infancy, suffered significant problems attributable to 
funding.
    Unfortunately, despite a recommendation from its own Task Force to 
Improve Health Care for Our Nation's Veterans (Final Report, 2003) to 
consider mandatory funding for VA health care, the Administration has 
rejected any meaningful consideration of funding reform. Bills have 
been introduced in both the House and Senate to no avail.
    VVA is grateful to and salutes Senator Tim Johnson of South Dakota 
for his fortitude in not only overcoming his own health crisis, but for 
his extraordinary efforts in continuing to push for real reform in the 
way in which our Nation funds health care for our Nation's veterans.
    Unfortunately the debates regarding funding of veterans' health 
care continue to focus on the year-to-year ``band-aids'' and quick 
fixes needed to keep the health care system afloat. Last year, $3.7 
billion had to be appropriated as emergency supplemental funding in 
order to make progress on restoring both the infrastructure and the 
organizational capacity of the VHA to deal with the needs America's 
veterans.
    It is time to act to ensure a consistent, predictable, and 
responsible level of funding that will give more than lip service to 
the mandates for health care set forth in law, and by the will of the 
American people, for those who have borne the battle in the fertile 
fields of Europe, the islands of the South Pacific, the rice paddies 
and jungles of Southeast Asia, the sands of Kuwait and Afghanistan and 
Iraq, and the peacetime confrontations of the cold war.
    Establishing a method that will ensure the fair, adequate and 
predictable funding of the VA health care system which would better 
ensure timely access to quality care remains the highest legislative 
priority of Vietnam Veterans of America.
    In the 5 years that have followed publication of our original White 
Paper asserting the need for assured funding, the Administration and 
Congress have continued to provide compelling demonstrations of the 
weaknesses of the current funding method.
    VVA is grateful to you, Senator Akaka, and to all Senators on both 
sides of the aisle who have accorded the veterans health care system 
with more increase in the past eighteen months than they have ever had, 
and to your counterparts on the other side of the Hill for all of their 
hard work as well to achieve these record increases.
    However, despite these efforts and progress, the appropriations for 
the VA health care system continue to be inadequate to the degree that 
the VA is still barring eligibility to health care for many working-
class veterans without compensable service-connected disabilities, 
limiting long-term care options, and compromising access to quality 
health care.
    The uncertainty of when and how much funding it will receive wreaks 
havoc upon the VA's ability to make effective planning, policy and 
purchasing decisions. While that has appeared to improve, it will take 
increases of the magnitude of the last calendar year for another 
several years to restore what was lost from the funding base, and the 
overall organizational capacity of the VHA during the ``flat line'' 
years of 1996 to 1999, and several years thereafter when the increase 
in funding did not keep pace with either the increase in veterans 
entering the system, nor rapidly rising costs of medical care, many of 
which are not controllable.
    Recent budget cycles call into question the VA's ability to produce 
a budget that credibly funds its health care system. Even after 
compensating for the savings and foregone revenues that have proven to 
be distasteful to Congress (new enrollment fees and dismantlement of 
the State home program, for example), the VA had to admit it would be 
$1 billion deficient in funding for fiscal year 2005 and also would 
require almost $2 billion more than originally projected for fiscal 
year 2006.
    Critics of the VA continue to call for it to live within its 
budgets by increasing efficiency. While VVA supports much greater 
accountability for VA officials, VA has proven its efficiency by 
actually reducing per user costs in a time of double-digit health care 
inflation. VA users' per capita costs actually decreased by about 6 
percent (without including the eroding effects of inflation), while 
Medicare per capita costs and those of the average American consumer 
will have almost doubled.
    Other federally funded health programs do not annually suffer 
through the funding cycle as the VA does. The Nation's largest health 
care system that serves some of our most deserving citizens--veterans--
should be accorded the same funding assurances as Medicare and TRICARE 
for Life.
    Accordingly, VVA has joined every other major veterans' service 
organization as part of the Partnership for Veterans Health Care Budget 
Reform in calling for assured funding that is indexed for medical 
inflation and accounts for a credible expectation of utilization of 
health care services of all eligible veterans who desire enrollment. 
Without fundamental changes in the VA's budget process, veterans who 
rely upon the VA's health care services will continue to have a system 
plagued by deficiency and unpredictability.
    For the coming fiscal year (FY 2009), VVA testified earlier this 
year that we believe the VA medical care business line will require at 
least $5.24 billion over fiscal year 2008 VHA appropriations. Some 
contend that even adding that amount will not allow VHA the latitude to 
restore access to all veterans.
    As we all are aware, on January 17, 2003, then-Secretary Anthony J. 
Principi decided to ``temporarily'' suspend enrollment to Priority 8 
veterans. While this decision may be reconsidered on an annual basis, 
every budget proposal sent to the Congress by the Administration since 
continues to omit funding for this group, and attempts to discourage 
use and enrollment of ``higher income'' groups--that is, all Priority 7 
and Priority 8 veterans who had enrolled prior to the suspension. The 
Administration has proposed new enrollment fees for these groups in 
addition to imposing higher co-payments for the pharmaceutical drugs 
that are largely responsible for bringing many into the system. These 
proposals are designed to do two things--eliminate services provided to 
higher income veterans and generate additional revenues to partially 
cover the cost of their care.
    Priority 8 veterans--mostly working-class Americans without 
compensable disabilities incurred during their military service--are 
known as ``higher-income'' veterans. ``Higher income'' is a misleading 
label considering the growing rates of uninsured Americans directly 
subjected to spiraling health care costs and the relatively low-asset 
levels of those affected (currently, as low as about $27,000 for a 
veteran with no dependents). Far from redressing what veterans' 
advocates were given to believe was a ``short-term'' panacea, budgets 
for the 5 years since suspension of enrollment have omitted funding to 
restore access to these veterans and have espoused policies--such as 
new enrollment fees and higher co-payments--that are specifically 
designed to discourage these veterans' use of their health care system.
    In last year's proposal, the VA estimated that more than one 
million ``higher-income'' veterans who have not been suspended from 
enrollment would be discouraged from using their health care system 
under their plan. Additionally it has been reported that more than a 
half a million veterans have been excluded from vitally needed services 
of the VHA system since that time. VVA has reason to believe that this 
is too conservative a figure, and the number of those excluded is 
higher still.
    In an era in which health care inflation has regularly outstripped 
increases in wages, it is not surprising that veterans remain attracted 
to the re-engineered VA system. The proliferation of new outpatient 
clinics in addition to the benefits provided to all enrollees, 
including some that are not typically covered by private-sector health 
plans, such as prescription drugs, eyeglasses, and hearing aids, 
continue to encourage veterans' use of VA health care services. Even 
more veterans who are not considered regular users will be enrolled. 
VVA estimates 8.4 to 9 million would enroll if Priority 8 veterans were 
reinstated for enrollment without an enrollment fee).\1\ Enrollment is 
a prerequisite for eligibility for health care services for all but the 
most highly rated service-connected disabled veterans.
---------------------------------------------------------------------------
    \1\ VVA estimated this number by applying the growth in numbers of 
enrollees from 2002-2003 to estimates of enrollees (without the 
proposed enrollment fee) in the Administration's budget submission for 
2006. VVA estimated 70 percent of these enrollees would use VA 
services.
---------------------------------------------------------------------------
    Recent budgets sent to Congress have also attempted to ration 
services for veterans--particularly long-term care. In recent years, 
State homes have overtaken the VA in the long-term care workload they 
provide veterans and these homes are the only VA-sponsored settings 
that continue to support custodial care for veterans whom VA is not 
mandated to treat. Yet in VA's fiscal year 2006 budget request, a 
policy shift was proposed that would have effectively shuttered as many 
as 80 percent of the State veterans homes (as estimated by the National 
Association of State Veterans Homes) with whom the Federal Government 
has been working for more than 100 years. The VA is currently planning 
a study of the law that requires providing nursing home care for 
veterans with a high-level of disability because of military service 
that may result in requests for further curtailments in their 
authority. Over the last decade VA has attempted to shift care as 
quickly as possible from its own settings to the community where 
veterans can be made eligible for the similarly fiscally challenged 
Medicaid program. The folks at OMB just want to shift the cost away 
from the Federal budget, whether the States have the resources to help 
here or not. Frankly, it is easy to get the impression OMB does not 
care whether these veterans get the services they need or not as long 
as the Federal Government does not have to pay.
    The uncertainty of when and how much funding it will receive wreaks 
havoc upon VA's ability to make effective policy (including 
enrollment), personnel, contracting and other purchasing decisions. The 
VA often misses critical windows to hire new physicians and nurses 
because officials do not know when new funding will become available. 
Health care workers are not willing to put off employment indefinitely 
when other--and often more lucrative--opportunities are readily 
available in their communities. In years of relative scarcity, most of 
the VHA 21 regional Veterans Integrated Service Networks (VISNs) 
routinely delay badly needed equipment purchases and repairs to meet 
their operating expenses.
    Since fiscal year 2002, management ``efficiencies'' have 
accumulated, creating a $1.8 billion hole in the VA's medical services 
funds by fiscal year 2006 (or about 8 percent the medical services 
budget). In a February 1, 2006 report to Senator Daniel Akaka, Ranking 
Member of the Senate Veterans' Affairs Committee and Congressman Lane 
Evans, Ranking Member of the House Veterans' Affairs Committee, the 
Government Accountability Office found that VA lacked a methodology for 
producing the management efficiencies projected in budget submissions 
for fiscal year 2003 and fiscal year 2004 and that:

        the management efficiency savings assumed in these requests 
        were savings goals used to reduce requests for a higher level 
        of annual appropriations in order to fill the gap between the 
        cost associated with VA's projected demand for health care 
        services and the amount the President was willing to request.

    From fiscal year 1996 through fiscal year 2006, however, it is 
clear that the VA has had to do ``more with less.'' Although the 
Administration continues to tout increases in the funding for the 
veterans health care system, the VA's resources per veteran user have 
dropped precipitously, particularly in comparison to the per capita 
costs based on national health care expenditures and the costs per 
Medicare enrollee. VA users' per capita costs actually decreased by 
about 6 percent (without including the eroding effects of inflation), 
while Medicare per capita costs will have almost doubled.
    VA's per capita costs for users, once higher than national per 
capita costs and costs per Medicare enrollee, have actually dropped 
below both of these groups and this was not included third party 
collections While national health care expenditures and Medicare 
enrollees' costs have almost doubled over the period of time studied, 
VA's per capita costs have actually decreased. Fiscal year 2006 dollars 
were adjusted for health care inflation they would not have nearly as 
much buying power as the 1996 dollar. The average annual medical care 
inflation for 2001-2004 has been double the growth for the Consumer 
Price Index for all other items (2.2 percent versus 4.4 percent). A 
comparison of per capita costs is particularly compelling since 
national health care expenditures include the costs of all Americans--
many of whom are young and healthy and may not be expected to require 
the same level services as the mostly older and disabled populations 
Medicare and VA serve.
    Without considering the effects of medical care inflation, in sharp 
contrast to the average American's health care expenditures or the 
average Medicare enrollee's costs (both of which almost doubled), VA's 
per capita costs actually drop slightly from 1996 to 2006. This is 
because VA health-care funding is not linked to growth in the 
beneficiary population or medical inflation.
    What led to this drop in funding per VA user during a time when 
other health care consumers' costs doubled? Simply put, the growth in 
the number of veterans who now use their health system has outpaced the 
growth in financial resources the Federal Government has invested in it 
(or, at least the growth has outpaced to willingness of the OMB to 
recommend increases that are needed just to maintain stasis.)
    Still, the effects of deficient budgeting are still being felt in 
many areas, despite the tremendous strides made in the past 2 years. 
The VA estimates that almost half of its obligations for medical 
services in 2006 would be spent on personal services and benefits for 
its 130,000 employees. Decreases in the VA's per user costs have 
clearly translated to fewer doctors and nurses per patient. The most 
likely outcomes of understaffing are adverse effects on the timeliness 
and quality of care. At this time there are still many thousands of 
veterans projected to wait longer than 6 months for an appointment with 
a clinician, even though the ``official'' estimates are much smaller 
than VVA would estimate. The Inspector General report that was released 
research points out that VHA is still often not telling the truth about 
waiting times, and so many clinics are ``gaming'' the system that it is 
hard to figure out what the actual figures might be. In many areas of 
the country, such as Florida, VA has experienced severe problems 
placing even service-connected veterans on waiting lists.
    With funding uncertainties removed, the VA leadership could focus 
on implementing measures to create a true veterans health-care system--
a system in which every veteran that enrolls would be given a full 
physical examination, including a comprehensive military health and 
medical history and a psychosocial evaluation. This history would 
provide an epidemiological baseline to help measure future health 
conditions not only for a particular veteran but potentially for others 
with whom (s)he served. When an extensive epidemiological database is 
finally compiled, it can serve as an invaluable tool for physicians. 
With more information about a patient's military background, a doctor 
would know to test for particular conditions, parasites, and toxic 
exposures that may already be adversely affecting the health of that 
veteran. Such a database could reveal whether others who served in the 
same unit reported similar health effects. It could also serve as a 
tool to identify common exposures that may be related to the incidence 
of conditions that have long latency periods.
    Such findings, combined with better sharing of military records, 
including the location of troops, deployment health, and pre- and post-
deployment health information, could serve as the basis for research 
into the health effects of a particular exposure, occupation or even 
combat or theater experience.
    VVA has long stressed the importance of collecting such 
information, and the results are taking root in the Veterans Health 
Initiative (VHI). This VA endeavor educates providers about certain 
exposures and health effects that are prevalent among veterans or for 
which veterans have been shown to be at unique risk The VA has made 
these training modules available to its providers and should take 
further steps to educate the general medical community from whom most 
veterans seek care.
    VVA still maintains that managerial accountability goes hand-in-
hand with assured or ``mandatory'' funding. To its great credit, the VA 
has implemented a clinical information system which allows it to 
evaluate its success in meeting a variety of clinical and 
administrative goals. However, some managers who have had problems 
overseeing high-investment projects or publicized breaches in 
government protocols, spotty records of adherence to departmental 
directives and law, and cited problems in Government Accountability 
Office and Inspector General reports on their area in negative ways 
continue to be rewarded. Rewards cannot solely be based on achievement 
of certain goals, if there are well documented (and often highly 
publicized) problems that are not rectified. The deposition of the 
Associate Deputy Under Secretary for Health for a recent civil action 
in Federal Court demonstrated (in his own words) that in regard to 
quality assurance for delivery of PTSD and other neuro-psychiatric are 
that ``we do not have metrics in place to measure that.''
    When clearly understood performance standards have been met and 
there are not clear violations in protocol, rewards should be made from 
the top-down. Just as rewards must be provided, the system must also 
sanction those whose performance is inadequate.
    While there is a legitimate need to make significant adjustments in 
the compensation for critical health care workers, the current use of 
``merit bonuses'' has been corrupted. Merit bonuses must be just that: 
bonuses for merit and achievement above and beyond that which is 
required. The current mode does a disservice to the many fine VA 
physicians and administrators who deserve more competitive pay and 
bonuses for truly outstanding performance. The system of rewards and 
punishment must be adjusted to sanction those who do a poor job or are 
not fully open and honest with appointed or elected officials.
    To ensure accountability, the VA must develop adequate training and 
testing tools for personnel at all levels of the organization. Neither 
managers nor their employees can be held responsible for violating 
protocols of which they are not aware. In a constantly evolving health 
care environment governed by a complex array of law, regulations, 
internal guidance and voluntarily imposed guidelines from accreditation 
agencies, compliance is difficult. Without ensuring that management and 
employees receive updates and appropriate training it is impossible.
    We as a nation can and must do better for our veterans. Funding for 
veterans' health care has been woefully inadequate for years. As Dr. 
Linda Spoonster Schwartz, currently Commissioner of Veterans Affairs 
for the State of Connecticut and Chair of the Health Care Committee of 
the National Association of State Directors of Veterans Affairs put it: 
``The lack of a consistent, reliable budget has, in essence, obstructed 
VA's capacity to respond to the changing needs of the health-care 
system, to efficiently grow, to acquire competent personnel and 
maintain a viable service infrastructure.'' And as the President's Task 
Force to Improve Health Care Delivery for Our Nation's Veterans 
concluded:

        Funding provided through the current budget and appropriations 
        process for VA health care delivery has not kept pace with 
        demand, despite efforts to increase efficiencies and focus 
        health care delivery in the most cost-effective manner * * *. 
        Full funding should occur through modification to the current 
        budget and appropriation process by using a mandatory funding 
        mechanism, or by some other change in the process that achieves 
        the desired goal.

    It is imperative to enact legislation that would assure funding for 
veterans' health care. An assured, predictable and reliable funding 
stream would enable the VA to concentrate on achieving accountability 
for performance from senior managers and building a system that is not 
only cost-effective and efficient, but contributes to the mission of 
restoring veterans who have been lessened physically through injury or 
illness or the psychic wounds of war, or economically by virtue of 
military service.
    VVA and other VSOs believe it is ultimately disingenuous for our 
government to promise health care to veterans and then fail to provide 
adequate funding. Rationed health care must only be a temporary 
expedient as Congress moves toward an assured funding model. We endorse 
the proposition that ``by including all veterans currently eligible and 
enrolled for care, we protect the system and the specialized programs 
VA has developed to improve the health and well-being of our Nation's 
sick and disabled veterans.''
          a word on the office of management and budget (omb)
     It should be clear to all that the current method of funding 
health care services to veterans has not been working very well for 
some years now, despite some nigh on to heroic efforts by the Congress. 
Some of this is due to the funding for this vital function being 
classified as ``discretionary'' funding. But it needs to be publicly 
noted that much of the difficulty in this being ``discretionary'' 
spending is the difficulty of overcoming the churlish attitude toward 
veterans of the OMB and their willful ignorance of the reality of 
veterans' needs or even of what actually happens in VA facilities.
    The current Deputy Director of OMB and her staff have never visited 
a VA medical center, not even once. The previous permanent ranking 
civil servant permanent employee the veterans unit at OMB had held her 
job for about two decades and never once even entered a VA medical 
facility. We would also point out that the last time we checked, OMB 
less than 10 veterans employed out of more than 970 employees, and 0 
disabled veterans. And yet OMB is theoretically subject to the same 
Veterans' Preference laws as the rest of the government.
    The only way this could happen is in a corps. Just by accident they 
should have had more than 10 veterans and at least SOME disabled 
veterans in their orate culture that condones the conscious and 
deliberate patterns and practices of overt discrimination against 
persons who served our Nation in military service, and particularly 
prejudice against employing disabled veterans.
    If OMB had hired no women, or no African-Americans, or no of 
Hispanic decent, or no Asian Americans would anyone accept their 
contention that could find no qualified candidates from those groups to 
work there? VVA thinks not, and that similarly we should not accept 
this continued illegal pattern and practice by OMB that discriminates 
against veterans, particularly disabled veterans.
    Given OMB's clear attitude toward employing veterans, it should 
come as no surprise to anyone that this lack of respect should be 
reflected in their work and budgets produced in regard to the VA and 
other programs vital to veterans. At least it is now more 
understandable that they always try to give too few resources to 
properly assist veterans, no matter how good the program. That does not 
make it proper or legitimate, but at least we know what we are dealing 
with.
          s. 2796--community-based organization pilot programs
    VVA strongly endorses this bill. The experience of Vietnam veterans 
in the 1970's showed that the most effective, and certainly the most 
efficient, mechanism for serving otherwise ``under-served'' veterans 
was by means of funding community based organizations (CBOs) for 
specific purposes on a pay for performance basis. The experience in the 
past decade has clearly shown that the most cost effective, cost 
efficient means of reaching and properly serving homeless veterans has 
been though funding community based organizations to do this.
    For example, the Homeless Veterans Reintegration Project (HVRP) 
which helps place homeless and formerly homeless veterans in full time 
employment is far and away the most cost effective, cost efficient 
program administered though any branch of the U. S. Department of 
Labor. It is therefore a mystery to VVA as to why this program is not 
funded at the full $50 million that is authorized, as it works and 
works well to move veterans from the welfare dole to the tax rolls, and 
helps them restore their sense of dignity and self worth, in addition 
to helping them lift themselves off of the street and back into 
society, through supporting them in their effort to work their way back 
up.
    A similar program funded by up to $50 million at VA to perform the 
duties as outlined in this proposed legislation would be similarly 
successful. We can cite at least two organizations that are CBOs that 
have been doing this multi-service center work successfully for three 
decades. One is Swords to Plowshares, in San Francisco, California, and 
the other is the Veterans Outreach Center in Rochester, New York. Both 
of these organizations have received funding from various sources over 
the years, some from private donations, some via grants from private 
donations, at times they have received State funding, and sometimes 
local government funding. From time to time their funding sources have 
changed, but their core commitment to serving the whole person, and 
assisting the veteran in all aspects of his or her life to re-construct 
a decent life and a way forward toward a more complete human existence 
has not changed or wavered. Furthermore, they do so and achieve a 
success rate of reaching and substantially assisting veterans to meet 
their recovery goals at a cost per participant that is far less than 
most programs delivered by large agencies. This model already 
demonstrably works.
    Chairman Akaka is to be commended for introducing this legislation, 
but we suggest that you consider giving this pilot an authorized amount 
of funding for at least 3 years, and direct VA to work with already 
existing similar programs in developing the Request For Proposal, as 
well as consulting with the National Coalition for Homeless Veterans 
and the veterans' service organizations who may have knowledge of such 
programs. We also suggest that the VA be directed to report back to you 
within 180 days of enactment their plan for issuing a Request for 
Proposal, and that VA deliver a report and analysis of the pilot to VA 
on a yearly basis thereafter.
                  s. 2797--construction authorization
    VVA has no objection to most of these requests, as most of the 
items requested by the Administration are needed. VVA does believe, 
however that the pace of reconstructing and replacing of the physical 
infrastructure of the Veterans Health Administration needs to be 
quickened. For quite a number of years virtually no construction was 
funded until VA designed a plan that had some sense and rationale to 
it. Even though VVA still has significant reservations in regard to the 
CARES formula, at least there is a comprehensible model to formulate a 
plan for facilities for the future. Therefore, we should get on with it 
at a faster pace, before construction costs soar even higher.
    However, in regard to the medical facility in San Juan, Puerto Rico 
VVA has serious reservations about VA's plan to try and jury rig and 
shore up an outdated and outmoded early 1960's style building that is 
in danger of collapsing in a hurricane currently, as opposed to 
designing and building a new, strong, and modern medical facility. If 
you fix up an outmoded structure that was poorly designed to begin 
with, then you have a poorly designed facility that still is inadequate 
to meet the needs of the future.
    Frankly, one has to question whether some other factor was 
operating here that Denver gets a $2 billion state-of-the-art beautiful 
facility that will not even be fully owned by VA, but San Juan gets 
some leftovers and an as cheap as possible retrofit of an outmoded and 
energy inefficient structure that even when the projected work is 
finished will not even approach being the ``best,'' nor will it be able 
to withstand a direct hit of the likely stronger storms that we will 
experience in the coming decades. VVA understands that if the money is 
authorized and appropriated to do this retro-fit in San Juan, then the 
possibilities of a proper new building will be slim to none.
    Therefore, VVA strongly encourages the Committee to take a very 
strong look at Puerto Rico as to every aspect of services provided 
there, from medical services to claims adjudication to the State of the 
cemetery which will be full in a relatively short time. The 
construction plans for parking, the medical facility, and additional 
space for proper burial of veterans there all seem to be less than one 
would expect, or certainly less than accorded other areas in the United 
States. The veterans in Puerto Rico performed no less well, and fought 
no less valiantly, and in fact served in a higher than average 
percentage in the combat arms than those from elsewhere, and so should 
not be relegated to cut rate facilities or service. The veterans of San 
Juan deserve no less consideration than the veterans of Denver.
      s. 2799--women veterans health care improvement act of 2008
    VVA salutes Senator Murray for introducing this much needed 
legislation, which should be enacted as soon as possible.
    Women comprise the fastest growing segment of the Armed Forces, and 
therefore as they leave the military, the fastest growing sub-set of 
the veterans' population. Thousands have been deployed to Iraq and 
Afghanistan. This has particularly serious implications for the VA 
health care system because the VA itself projects that by 2010 more 
than 14 percent of all veterans utilizing its services will be women.
    Women's health care is not evenly distributed or available 
throughout the VA system. Although women veterans are the fastest 
growing subset, there remains a need for increased focus on health care 
and its delivery to women, particularly the young women coming home 
today. What is needed are real women's medical clinics that are 
separate places within each hospital, and ensure that the women get the 
privacy and the ``comfort level'' needed for them to seek assistance 
for the full range of maladies from which they may suffer, including 
Military Sexual Trauma (MST).
    Although women veterans are the fastest growing population within 
the VA, there remains a need for an increased focus on health care and 
its delivery for women, particularly the new women veterans of today. 
Although VA Central Office may interpret women's health services as 
preventive, primary, and gender-specific care, this comprehensive 
concept remains ambiguous and splintered in its delivery throughout all 
the VA medical centers. Many at the VHA appear (unfortunately and 
wrongly) to view women's health as only a GYN clinic. It certainly 
involves more than gynecological care. In reality, women's health is 
viewed as a specialty unto itself as demonstrated in every University 
Medical School in the country.
    Furthermore, some women continue to report a less than 
``accepting,'' ``friendly,'' or ``knowledgeable'' attitude or 
environment both within the VA and/or by third party vendors. This may 
be the result, at least in part, of a system that has evolved 
principally (or exclusively) to address the medical needs of male 
veterans. But reports also indicate that in mixed gender residential 
programs, women remain fearful and unsafe.
    The nature of the combat in Iraq and Afghanistan is putting 
servicemembers at an increased risk for PTSD. In these wars without 
fronts, ``combat support troops'' are just as likely to be affected by 
the same traumas as infantry personnel. They are clearly in the midst 
of the ``combat setting''. No matter how you look at it, Iraq is a 
chaotic war in which an unprecedented number of women have been exposed 
to high levels of violence and stress as more than 160,000 female 
soldiers have been deployed to Iraq and Afghanistan * * *. This 
compared to the 7,500 who served in Vietnam and the 41,000 who were 
dispatched to the Gulf War in the early `90's. Today, nearly one of 
every 20 U.S. soldiers in Iraq/Afghanistan is female. The death and 
casualty rates reflect this increased exposure.
    With 15-18 percent of America's active-duty military being female 
(20 percent of all new recruits) and nearly half of them have been 
deployed to Iraq and/or Afghanistan, there are particularly serious 
implications for the VA health care system because the VA itself 
projects that by 2010, more than 14 percent of all its veterans will be 
women, compared with just 2 percent in 1997. Although the VA has made 
vast improvements in treating women since 1992, returning female OIF 
and OEF veterans in particular face a variety of co-occurring ailments 
and traumas heretofore unseen by the VA health care system.
    There have been few large-scale studies done on the particular 
psychiatric effects of combat on female soldiers in the United States, 
mostly because the sample size has heretofore been small. More than 
one-quarter of female veterans of Vietnam developed PTSD at some point 
in their lives, according to the National Vietnam Veterans Readjustment 
Survey conducted in the mid-`80's, which included 432 women, most of 
whom were nurses. (The PTSD rate for women was 4 percent below that of 
the men.) Two years after deployment to the Gulf War, where combat 
exposure was relatively low, Army data showed that 16 percent of a 
sample of female soldiers studied met diagnostic criteria for PTSD, as 
opposed to 8 percent of their male counterparts. The data reflect a 
larger finding, supported by other research that women are more likely 
to be given diagnoses of PTSD, in some cases at twice the rate of men. 
Matthew Friedman, Executive Director of the National Center for PTSD, a 
research-and-education program financed by the Department of Veterans 
Affairs, points out that some traumatic experiences have been shown to 
be more psychologically ``toxic'' than others. Rape, in particular, is 
thought to be the most likely to lead to PTSD in women (and in men, 
where it occurs). Participation in combat, though, he says, is not far 
behind.
    Much of what we know about trauma comes primarily from research on 
two distinct populations--civilian women who have been raped and male 
combat veterans. But taking into account the large number of women 
serving in dangerous conditions in Iraq and reports suggesting that 
women in the military bear a higher risk than civilian women of having 
been sexually assaulted either before or during their service, it's 
conceivable that this war may well generate an unfortunate new group to 
study--women who have experienced sexual assault and combat, many of 
them before they turn 25.
    Returning female OIF and OEF troops also face other crises. For 
example, studies conducted at the Durham, North Carolina Comprehensive 
Women's Health Center by VA researchers have demonstrated higher rates 
of suicidal tendencies among women veterans suffering depression with 
co-morbid PTSD. And according to a Pentagon study released in March 
2006, more female soldiers report mental health concerns than their 
male comrades: 24 percent compared to 19 percent.
    VA data showed that 25,960 of the 69,861 women separated from the 
military during fiscal years 2002-06 sought VA services. Of this 
number, approximately 35.8 percent requested assistance for ``mental 
disorders'' (i.e., based on VA ICD-9 categories), of which 21 percent 
was for Post Traumatic Stress Disorder or PTSD, with older female vets 
showing higher PTSD rates. Also, as of early May 2007, 14.5 percent of 
female OEF/OIF veterans reported having endured military sexual trauma 
(MST). Although all VA medical centers are required to have MST 
clinicians, very few clinicians within the VA are prepared to treat co-
occurring combat-induced PTSD and MST. These issues singly are ones 
that need address, but concomitantly create a unique set of 
circumstances that demonstrates another of the challenges facing the 
VA. The VA will need to directly identify its ability and capacity to 
address these issues along with providing oversight and accountability 
to the delivery of services in this regard. All of these issues, 
traumas, stress, and crises have a direct effect on the women veterans 
who find themselves homeless. Early enactment of Senator Murray's bill 
on women veterans currently pending in the Senate will do much to 
rectify this situation, and VVA commends her for her leadership in this 
and other matters of vital interest to veterans.
    Although veterans make up about 11 percent of the adult population, 
they make up 26 percent of the homeless population. Of the 154,000 
homeless veterans estimated by the VA, women make up 4 percent of that 
population. Striking, however, is the fact that the VA also reports 
that of the new homeless veterans more than 11 percent of these are 
women. It is believed that this dramatic increase is directly related 
to the increased number of women now in the military (15 percent-18 
percent). About half of all homeless veterans have a mental illness and 
more than three out of four suffer from alcohol or other substance 
abuse problems. Nearly forty percent have both psychiatric and 
substance abuse disorders. Homeless veterans in some respects make use 
of the entire VA as do any other eligible group of veterans. Therefore 
all delivery systems and services offered by the VA have an impact on 
homeless veterans. Further, the failure of the Department of Labor 
system to provide needed employment assistance in a nationwide 
accountable manner to many veterans means they lose their slim purchase 
on the lower middle class, and therefore end up homeless. Once 
homeless, it becomes very difficult for these veterans to find 
employment for a multiplicity of reasons.
    The VA must be prepared to provide services to these former 
servicemembers in appropriate settings.
    VVA thanks Senator Patty Murray for her leadership on the issue of 
ensuring that women veterans get proper health care and services that 
is different but equal to me. This bill warrants speedy passage and 
prompt full implementation.
 s. 2824--a bill to amend title 38, united states code, to improve the 
   collective bargaining rights and procedures for review of adverse 
  actions of certain employees of the department of veterans affairs.
    VVA supports collective bargaining rights, and commends Senator 
Rockefeller for his leadership in introducing this bill.
 s. 2889--veterans health care act of 2008, sections 2, 3, 4, 5, and 6
                          (akaka, by request)
    VVA generally supports Sections 3, 4, 5, and 6 of this proposed 
legislation. In regard to Section 2, VVA suggests you consider revising 
to say Global War on Terror, which is generic enough to cover anyone 
who experiences such deficits due to Traumatic Brain Injury wherever 
they might be serving in the world in the United States Armed Services. 
Further, VVA suggests that a clause be added to the effect ``and other 
such veterans who may be eligible for and in need of this type of 
care.''
    As you know, VVA's founding principle is ``Never again shall one 
generation of veterans abandon another generation.'' VVA continues to 
try and live up to that principle in regard to both our fathers who 
served in World War II and toward the young people serving today and 
who have already come home, all too often wounded. However, the 
disturbing trend in much of what the Administration proposes would 
divide the generations. We suggest that by adding ``and other such 
veterans as may be in need of this type of care'' that this 
distinguished Committee can avoid the slippery slope of dividing the 
generations, no matter whether that is intended or not.
s. 2899--a bill to direct the secretary of veterans affairs to conduct 
                   a study on suicides among veterans
    VVA generally favors anything that will produce reliable data 
regarding the thorny question of suicide among veterans of every 
generation. Any suicide is a terrible thing that leads almost all who 
know the person to question themselves: what could I have done better 
to have saved him or her? Good data on suicides is a very scarce 
commodity. Suicide has been a topic of much (often quite animated and 
passionate) debate and discussion about and among Vietnam veterans for 
30 years, for instance.
    However, since VA refuses to obey the law and complete the National 
Vietnam Veterans Readjustment Study replication, thus producing a 
longitudinal study of Vietnam veterans utilizing a statistically valid 
random sample, we do not have any idea of why Vietnam veterans and, we 
suspect young veterans are dying by their own hand in disproportionate 
numbers.
    Given their poor track record in regard to telling the whole truth 
on this and other sensitive subjects (particularly regarding suicides), 
VVA does not feel that VA can be trusted to do such a study on its own, 
as most people would have doubts as to the credibility of almost any 
statistics on suicide they advance at this time.
    Therefore we urge that this bill be modified so as to prescribe the 
protocol to be used and direct VA to contract it out to a nationally 
respected research institution after first consulting with the VSOs, 
entities such as the American Psychiatric Association, the American 
Psychological Association, and others as appropriate to produce a 
Request for Proposal (RFP) that is supplied to the Committees on 
Veterans Affairs for review prior to publishing said RFP.
            s. 2921--caring for wounded warriors act of 2008
    VVA generally favors this proposal. As VVA has pointed out in 
numerous forums, soldiers are surviving initial wounds that would have 
killed them in previous wars, and therefore are suffering really 
grievous wounds in larger percentages than previous conflicts. When we 
came home from Vietnam, when you were in the hospital, you were 
literally in the hospital for many months or even years while 
undergoing treatment. That is just not the case today, as the 
overwhelming majority of health care delivery is on an outpatient 
basis, even for those with really severe multiple wounds, or wounds 
that would preclude them being able to drive a car or function on 
public transport (where there is such public transportation).
    The treatment model currently being used for these veterans with 
severe conditions is all predicated on having an intact nuclear family 
akin to Ozzie & Harriet, where a parent or the spouse can be full time 
chauffeur and caregiver for many months or even years. This has placed 
terrible strains on many young marriages that were already stressed by 
the absence of one member of the couple in a war zone, and then the 
swift change of reality for the soldier or marine (and by extension his 
or her family) in one terrible instant.
    For starters, many spouses or other family members have to work to 
help provide additional income to keep the family together and the 
bills paid. This proposal would allow spouses, mothers, or other family 
members to receive remuneration and training to provide these essential 
services that are necessary for the best possible recovery and 
rehabilitation of these fine servicemembers. Further, this proposal 
would allow graduate students to be trained to provide respite care, 
which is necessary so that the primary care giver does not suffer from 
utter exhaustion and compassion fatigue. VVA suggest that you consider 
opening this up further to nursing students, students in other medical 
and helping professions (particularly veterans who are attending 
institutions of higher education after return from military service), 
and possibly undergraduates, if they are more than 21 years old and/or 
they are returning veterans themselves that have completed at least 1 
year or more of study in their field.
    This proposal is a practical one, and meets a real need.
    s. 2926--veterans nonprofit research and education corporations 
                        enhancement act of 2008
    VVA does not have objection to this legislation. However, we do 
urge that there be much more disclosure of the activities of each of 
these corporations as may be established, both to the Secretary of 
Veterans Affairs and to the Congress. We also urge that public posting 
on the Internet of who are on the Boards of Directors of these 
corporations, what their profession and or business interests are, and 
regular summaries of any and all funds accepted and the source(s), all 
funds spent on research for each purpose, and other information 
regarding governance or what research is being funded by what source of 
funds, producing what results toward what end?
    There is already a disturbing trend in the Veterans Health 
Administration toward excessive secrecy, e.g. conducting the Secretary 
of Veterans' Affairs Advisory Committee on PTSD in total secrecy, with 
not even a minimal publication of the work of this Committee. 
Similarly, the decision of the previous Undersecretary and which the 
current Undersecretary continues to intransigently insist on keeping 
the sunshine of daylight and public or consumer advocates off of much 
of the proceedings of the Advisory Committee on Serious Mental Illness.
    It will certainly take action by the Congress and probably a new 
President who is committed to open and honest government of the people 
by the people to change this ``We know best, and if you only knew what 
we know'' current mentality of some in VHA that is unworthy of a 
constitutional democracy.
    Until then, the attitude at VHA apparently will continue to be one 
of ``SHHHhhhh!!!!''
    This attitude does a great disservice to veterans who depend on 
this system for quality medical care, and a great disservice to the 
many thousands of fine clinicians across the country in VA who just 
want to do a good job of helping veterans heal, and who do in fact 
manage to do outstanding work, no matter how much some of them are 
punished for doing right by the veterans we all serve.
     s. 2937--a bill to provide permanent treatment authority for 
 participants in department of defense chemical and biological testing 
 conducted by deseret test center and an expanded study of the health 
impact of project shipboard hazard and defense, and for other purposes.
    VVA favors making permanent the right of all participants in 
chemical, biological, and pharmacological testing by the military 
services or any other Federal Government entity to be able to receive 
medical care without charge from the VA.
    VVA is very supportive of the right that those who participated in 
the Shipboard Hazards and Decontamination (Project SHAD).
    However, Project SHAD was just one part of Project 112, which 
includes many more individuals than served in Project SHAD tests, per 
se. VVA urges this Committee to broaden the group covered by this part 
of the bill.
     VVA also urges the Committee to consider the proposed legislation 
being advanced in the House of Representatives by Congressman Mike 
Thompson of California, which would go further in that it would create 
a commission to study all of Project 112, and possibly other tests that 
took place of a chemical, biological, or pharmacological nature during 
that same time period of 1963 to 1973.
    Last, there is a real need for further study of the adverse health 
effects due to exposure of servicemembers in Project SHAD that focuses 
on the crews of the light tugs, and others who were not properly 
covered by the previous IOM study. VVA will be pleased to work with 
Senator Tester and with staff to make the changes briefly outlined here 
to produce a bill that we can enthusiastically support.
s. 2963--a bill to improve and enhance the mental health care benefits 
   available to members of the armed forces and veterans, to enhance 
counseling and other benefits available to survivors of members of the 
           armed forces and veterans, and for other purposes.
    Vietnam Veterans of America is grateful to Senator Bond for his 
leadership on this and other issues of medical care and treatment of 
returning war fighters, both while they are still in the Armed Forces, 
and once they become veterans. The work and thinking that went into 
this proposal is both laudable and solid.
    In regard to Section 1 of S. 2963, VVA has favored and advocated 
such scholarships for the education and training of behavioral health 
specialists for Vet Centers operated by the Readjustment Counseling 
Service of the VHA for 26 years, ever since VVA made the motion that 
led to the very first recommendation of the then brand new 
Administrator's Advisory Committee on the Readjustment of Vietnam 
Veterans (now the Secretary's Advisory committee on the Readjustment of 
Combat Veterans) that called for such scholarships to be created. VVA 
does urge that preference be accorded to veterans for receipt of these 
scholarships, especially those who have served in a combat theater of 
operations.
    In Section 2 of S. 2963, VVA recommends that the wording be changed 
to veterans of the Global War on Terror (GWOT) who have served in a 
theater of combat, or have experienced combat situations. Those who 
have and are serving in the southern Philippines or the horn of Africa, 
and elsewhere should be covered by this provision as well.
    Further, VVA strongly believes that the Vet Centers are the ones 
who have the mind set, training, and the treatment models to best help 
the still on active duty troops and their families. However, the VA 
must be mandated to add to the credentialed professional counseling 
staff in significant numbers before we can fully support this title. 
The Congress gave VA an additional $20 million specifically to add at 
least another 250 counseling staff members to the Vet Centers as part 
of the Emergency Supplemental War Appropriation bill signed by the 
President on March 7, 2007. The VA did not release the money to the 
Readjustment Counseling Service until past the mid-August, which was 
far too late to spend any of these funds on personnel before the fiscal 
year ended. Therefore the VA bought much needed computers and computer 
software upgrades in addition to purchasing vehicles for outreach into 
rural and other hard to reach areas where veterans currently were not 
being served.
    Since that time the RCS has only hired another 62 professional 
counselors in the pre-existing centers (to wit, separate and apart from 
the staff being hired to staff the more than two dozen new Vet Center 
sites that have already or will be opening by the end of this year.).
    The problem is that the existing Vet Centers (or at least the 
majority of them) are virtually over-run with more veteran clients than 
they can effectively serve. The reason they have so many clients is 
that they are generally very good at what they do. So, what already is 
happening in regard to basically pushing aside earlier generations of 
veterans will be accelerated if the centers are opened to active duty 
personnel and their families.
    The solution is to add the resources beginning immediately so that 
the Vet Centers are not forced into a situation of forced ``Triage'' 
that leaves some older veterans who depend on their local Vet Center to 
keep them alive, help them keep it together to successfully continue in 
their job, and veterans of previous conflicts who need the Vet Center 
to help them deal with relationship and family problems, to keep 
families together, are not pushed out into the cold (both figuratively 
and in some instances literally).
    The simple solution is for them to start adding more staff 
immediately. For the VHA to say they do not have enough money to do so 
is simply disingenuous, as the Congress gave them more than $3 Billion 
for the current fiscal year more than they said they needed to provide 
all services to all legally entitled to service.
    VVA very much wants to support this section, but the VA must be 
compelled to add another 250 to 350 staff members to serve the needs of 
those whom they are already seeing, as well as to be ready to 
effectively serve those active duty servicemembers who will seek their 
services once they know of the Vet Centers, and understand they can go 
there with no potentially bad effect on their military career. That way 
these fine young war fighters will be able to enhance their career as 
they learn to better cope with their symptoms, and overcome their 
neuro-psychiatric wounds.
    In regard to Section 3 of S. 2963, VVA favors this provision, and 
recommends in addition that all former members of the Armed Services 
who were separated from the military for reason of ``personality 
disorder'' after having served in a combat theater of operations be 
accorded full rights under the law to utilize any and all services of 
the VA Vet Centers.
    In regard to Section 4 of S. 2963, VVA strongly supports this 
provision.
    Further VVA asks that the Committee considers adding the phrase 
``died by their own hand'' so as to include those who take their lives 
via single car accidents and one person ``hunting accidents'' and the 
like to this category. Coroners are often loath to list these formally 
as suicides in many cases, even though we have good reason and 
experience to suspect that many of these so-called ``accidents'' within 
the first 2 years after return from a combat situation are really 
suicides.
    In regard to Section 5 of S. 2963, VVA strongly favors utilizing 
the services of not for profit organizations to provide services to 
veterans in hard to reach communities and too hard to reach 
constituencies whether they are located in rural or in urban areas. As 
one example, perhaps the most effective way to reach veterans who live 
in the Bedford-Stuyvesant or Fort Green sections of Brooklyn is through 
contracting with the ``Black Veterans for Social Justice'' organization 
that has been amassing credibility with veterans and their families, 
and delivering quality services to veterans in a way in which they will 
accept that help for thirty years.
 s. 2969--veterans' medical personnel recruitment and retention act of 
                                  2008
    VVA has no objection to this proposed legislation.
    We do have some concerns, however. In regard to ``nursing 
assistants'' VVA hopes that there will continue to be an emphasis on a 
career track for nursing assistants to acquire needed education to 
become vocational nurses or registered nurses if they so desire. VVA 
also urges the Committee to consider including a special scholarship 
program for returning Army medics and Navy Medical Corpsmen/women to 
become Physician Assistants, and to require VA to have a range of 
practice for PAs in the VA that is comparable to the range of practice 
for PAs in the military services.
    VVA has long favored competitive salaries for top VA personnel and 
managers. Thus we support the proposed increases to enhance recruitment 
and retention of top professionals to run the VA health care system. 
However, with increased pay must come much greater accountability. For 
someone in the VA to make just a bit less than the Nation pays the 
Commander in Chief does seem to be pushing the limits. Therefore, VVA 
will ask on behalf of all veterans (and all other tax payers as well), 
what are the mechanisms/means in place for evaluation to ensure that we 
are getting our money's worth?
    VVA suggests that the VA will pay attention to this crying need for 
holding these same highly paid employees more accountable for 
performance or non-performance by VA officials if the Congress takes 
steps to require them to pay attention to measuring and evaluating the 
value that the Nation gets for expenditures made.
         s. 2984--``veterans benefits enhancement act of 2008''
    At first blush VVA has no objection to this bill, although we do 
recommend that Committee study the provisions pertaining to the 
elimination of certain reporting requirements very carefully to assess 
what if any impact this will have on the already most inadequate 
transparency of the workings of the VA.
    This concludes our testimony. I shall be glad to answer any 
questions you might have. Again, all of us at VVA thank you for the 
opportunity to provide our thoughts and hopefully useful suggestions 
regarding these proposed legislative initiatives. VVA thanks you and 
your distinguished colleagues for your fine efforts on behalf of 
America's veterans.
References
1. Sayer, N.A. and Thuras, P. 2002. The influence of patients' 
        compensation-seeking status on the perception of veteran's 
        affairs clinicians. Psychiatry. Serv. 53:210-212.
2. Kimbrell, T.A. and Freeman, T.W. 2003. Clinical care of veterans 
        seeking compensation. Psychiatry. Serv. 54:910-911.

    Chairman Akaka. Thank you very much.
    Dr. Satel?

  STATEMENT OF SALLY SATEL, M.D., RESIDENT SCHOLAR, AMERICAN 
 ENTERPRISE INSTITUTE, AND LECTURER, YALE UNIVERSITY SCHOOL OF 
                            MEDICINE

    Dr. Satel. Thank you, Mr. Chairman. I am speaking as a 
psychiatrist and a former VA clinician. The purpose of my 
remarks today is to endorse the premise of the Veterans Mental 
Health Treatment First Act, that premise, of course, being that 
veterans with PTSD and other mental illnesses are best served 
when they first pursue treatment with the goal of recovery 
before assuming that they will be chronically incapacitated and 
thus candidates for full and total disability status.
    I am thinking of a real case: a 22-year-old young man who 
was discharged from the military a few months ago. He is 
flooded with terrible memories, classic PTSD symptoms. He can't 
concentrate. He is agitated. He is depressed. He is certain he 
will never be able to work again, that he will never be able to 
develop intimate relationships or have a family or even fully 
function in society. So, he naturally thinks, why even bother 
with treatment? My situation is hopeless. So, he applies for 
permanent and total disability.
    I understand this perfectly, but I also believe that 
permanent and total disability status is the last thing a 22-
year-old needs. It confirms his worst fears--that, in fact, he 
will be a psychiatric invalid. In fact, what receipt of 
disability compensation would say to him is, yes, you are 
right, there is no hope of significant recovery. We wouldn't 
dream of doing this to someone with a spinal cord injury--that 
is, tell him forget it, you will never work again. First, 
obviously, he would have surgery. He would have intensive 
physical therapy. These kinds of things come first.
    Let me say that there is much more at stake than granting 
disability to someone who actually has good prospects for 
recovery. The problem to me is that the very act of granting 
full disability can actually diminish those prospects of 
recovery. But let me say right here that I am not claiming 
compensation, per se, is harmful. In fact, it is a Godsend for 
people who need it. But what I am saying is that the timing of 
granting disability compensation is critical.
    For one thing, granting full disability too quickly sends a 
powerful negative message of enduring disablement when what 
this young man or woman needs to hear about hope and recovery. 
This optimism I am talking about, it is not just a feel-good 
strategy, it is a well-established clinical truth: that a 
person's perceptions of his or her capabilities and 
expectations for the future is critical to improvement after 
trauma. These truths are data from the National Center for 
PTSD, in fact.
    Also, giving full disability status first, before 
treatment, naturally leads a patient to assume he won't be able 
to work, and given that work is one of the best therapies we 
know, puts him at a real disadvantage. He loses the sense of 
purpose and confidence that one derives from work--even the 
daily structure it affords, the opportunity for socializing it 
creates. Being deprived of these virtues before--and I 
emphasize before--there is good reason to believe he is truly 
and permanently totally disabled is a very high price to pay.
    In closing, a ``treatment first'' approach is by far the 
most clinically rational way to manage young veterans with war-
related mental illnesses. This has nothing to do with 
curtailing access to disability compensation, but everything to 
do with making these young men and women healthy enough so that 
they won't need it in the first place.
    Thank you very much.
    [The prepared statement of Dr. Satel follows:]
  Prepared Statement of Sally Satel, M.D., Resident Scholar, American 
   Enterprise Institute, Lecturer, Yale University School of Medicine
    Mr. Chairman, thank you for the invitation to appear before the 
Committee. I am a psychiatrist who formerly worked with disabled 
Vietnam veterans at the West Haven VA Medical Center in Connecticut 
from 1988-1993. Currently, I am a resident scholar at the American 
Enterprise Institute (and work, part-time, at a local methadone 
clinic). I have been interested in applying the lessons we learned in 
treating Vietnam veterans to the new generation of service personnel 
returning from Iraq and Afghanistan.
    The purpose of my remarks today is to endorse the concept behind S. 
2573 Veterans' Mental Health Treatment First Act.
    The animating idea behind the legislation is that young men and 
women who are suffering from military-related mental illness service 
will benefit most when they pursue treatment with the goal of recovery 
before labeling themselves beyond hope of improvement--and thus a 
candidate for total and permanent service-connected disability status.
    As a clinician I agree wholeheartedly with the premise of the bill 
that the most appropriate sequence begins with treatment, moves to 
rehabilitation, and then--if necessary--goes on to assessment for 
disability status.
    The following vignette underscores the intrinsic wisdom of the 
bill.
                           clinical scenario
    Imagine a young soldier wounded in Iraq. His physical injuries heal 
but his mind remains tormented. He is flooded with memories of bloody 
firefights, he can't concentrate, and sudden noises make him jump out 
of his skin.
    He is 22 years old and was discharged from the military a few 
months ago. He is certain he'll never again be able to hold a job, 
tolerate being around people, develop an intimate relationship, go on 
to have a family, and fully function in society. ``Why even bother with 
treatment,'' he thinks, ``The situation is hopeless.'' Convinced he is 
facing life as a psychiatric invalid and worried about financial 
security he applies for total and permanent disability from the 
Department of Veterans' Affairs.
    Yet the last thing this 22-year-old man needs is confirmation of 
his fearful pessimism. Unfortunately, that will be precisely the 
message he gets if his claim is approved for full permanent and total 
disability: ``You're right, there is no hope of significant recovery. 
You are irreparably damaged.''
How can we make a responsible determination about an individual's life-
        long psychiatric incapacitation before he or she has even 
        allowed himself to be helped?
    Implications--Judging an individual doomed to a life of invalidism 
before he has even had a course of therapy and rehabilitation is 
drastically premature. This is particularly so when the young soldier 
is being evaluated for mental disability status while still on active 
duty.
    Full disability status may actually undermine the possibility of 
recovery; its implicit message is that the beneficiary has a very small 
likelihood of improvement. As a result, the status itself can become a 
self-fulfilling prophecy for the patient.
    Without question, some patients will remain severely and 
irretrievably impaired by their war experience. Treatment will help 
them, almost surely, but return to the workforce may not be possible. 
These men and women deserve generous disability compensation.
    Yet, so many others do have the potential to resume work, greater 
family participation, and engagement in their community. The problem is 
that once a patient receives a monthly check because he is diagnosed 
with (a treatable) psychiatric illness, his motivation to hold a job 
can diminish. Full disability would naturally lead him assume--often 
incorrectly--that he is no longer able to work, and then, the longer he 
is unemployed, the more his confidence in his ability to work erodes 
and his skills atrophy.
    At home on disability, he adopts a ``sick role'' that ends up 
depriving him of the estimable therapeutic value of work. Lost are the 
sense of purpose and competence work gives (or at least the distraction 
from depressive rumination it provides), the daily structure it 
affords, the occasion for socializing it creates, and the opportunity 
to reach for goals. That work serves as a prophylactic against 
psychological distress is especially evident among veteran retirees.
    This is a good place to mention remission rates of PTSD. According 
to the National Vietnam Veterans' Readjustment Study (NVVRS, 1988) 
fifty percent of those who develop the diagnosis of PTSD will recover 
fully over time. A recent re-analysis of the NVVRS (Science, vol. 313 
18 August 2006), found the lifetime rate of PTSD to be 18.7 percent vs. 
point prevalence (current) of 9.1 percent. Notably, those with a 
lifetime history of PTSD but not current PTSD exhibited virtually no 
lingering functional impairment at the time of assessment. Thus, to 
grant total disability compensation in light of a fifty percent chance 
of total remission (and a much higher chance of achieving partial or 
near-total remission) makes little sense.
       is disability compensation a barrier to seeking treatment?
    In 2006 the Veterans' Disability Benefits Commission asked the 
Institute of Medicine (IOM) to evaluate the evidentiary basis for 
various influences of compensation on treatment and recovery. The IOM 
panel concluded that ``PTSD compensation does not, in general, serve as 
a disincentive to seeking treatment.''
    Healthy skepticism surrounding this conclusion is warranted, not 
least because there are so few studies on the subject. Moreover, the 
IOM conclusion is based on studies of Vietnam veterans. I will 
elaborate presently on why the IOM report does not justify dismissing 
the importance of a ``treatment first'' approach for young veterans 
from Iraq and Afghanistan.
    First, let us briefly review the data they interpreted. The IOM 
committee reviewed six studies of veterans claiming combat-related 
PTSD.
    Longitudinal studies--Three of the six examined data from the 
phases before and after disability status was granted.
    The best known is a 2005 study conducted by the Inspector General 
of the DVA. Ninety-two cases were examined and revealed that most 
veterans' self-reported symptoms of PTSD become steadily worse over 
time until they reached the 100 percent disability level--at which 
point there is an 82 percent drop in use of VA mental health services 
(but no change in VA medical health service use).
    These findings are contradicted by two studies from the Minnesota 
VAMC which found increased attendance at treatment after receipt of 
disability compensation. Samples sizes were 452 and 102, respectively. 
Authors reported an increase in the number of sessions attended and in 
the percentage of patients who used services. Patient drop out after 
receipt of disability compensation is not a problem, they concluded.
    Comparison of compensation-seeking patients versus non-seeking 
regarding service use--A 2004 study from the Charleston VA reported the 
study of 68 veterans as having found that compensation-seeking veterans 
were more likely to use PTSD services compared to non-seekers. Yet, 
notably, the actual paper itself denies any significant difference in 
PTSD service utilization between the two groups.
    Comparison of compensation-receiving patients and non-recipients 
regarding symptom reduction--This 2006 study found an equivalent degree 
of symptom reduction among 54 veterans at the Boston VAMC with chronic 
PTSD irrespective of their receiving disability compensation.
    Comparison of compensation-seeking patients versus non-seeking 
regarding symptom reduction--Researchers at the West Haven VAMC 
published a 1998 study of 1,000 compensation-seeking veterans 
undergoing either outpatient or inpatient treatment. Symptom reduction 
was observed among the outpatient cohort but not among the inpatients. 
Notably, despite amelioration of symptoms, employment was low at 1 year 
following treatment initiation: outpatient subjects had worked, on 
average, almost 7 days per month (an increase of less than a full day 
compared to pre-treatment) and inpatient subjects worked just under 2 
days per month (a decline from slightly over 2 days pre-treatment).
    Limited relevance to today's situation--Many features of these 
studies limit their relevance to the subjects of today's hearing, 
namely young veterans returning from Iraq and Afghanistan who (1) 
suffer new-onset PTSD symptoms (2) seek or receive total and permanent 
disability status, and who (3) have not received sustained, quality 
treatment.
    By contrast, the studies examined by the IOM examine involve almost 
exclusively Vietnam veterans with chronic PTSD who are already in 
treatment.
    These are two very different populations. Most veterans of the 
Vietnam War who came to the attention of VA psychiatrists were neither 
diagnosed with PTSD, nor treated, until over a decade after 
experiencing combat trauma. Presenting for treatment so many years 
later typically means a diagnostic picture is very complex (e.g. 
overlaid with substance abuse problems, long-term employment 
difficulties, and diagnoses such as depression). At this advanced 
stage, responsiveness to treatment is usually compromised.
    Consider, also, the age of most of the Vietnam veterans who were 
subjects of the studies. They were in their forties and fifties when 
seeking disability and had been ill for many years; for most, the 
struggles with long-standing psychiatric conditions were an 
acknowledged aspect of daily life and personal identity. By comparison, 
veterans from Iraq and Afghanistan have not been ill for such a long 
time. They are in a different, earlier phase of life, still configuring 
what their post-service lives will be. Within this vulnerable period 
their perceptions of their capabilities and futures are being formed; 
so are the meanings they give to their symptoms.
    In short, this is a highly impressionable stage; a time to offer 
untreated veterans a message of promise and hope, not enduring 
disablement.
    Finally, bear in mind that the studies reviewed by the IOM reveal 
very little about real-world functioning. In fact, the take-home lesson 
from the single study that measured change in occupational functioning 
(West Haven) was that symptom reduction is a poor proxy for overall 
improvement. Recall, the study found post-treatment employment rates of 
only two to 7 days of work per month among disability-seekers. True, 
attendance at treatment sessions and measurable reductions in symptoms 
may be a sign of engagement with the VA, but this is only a part of the 
picture: the major goal of treatment is social reintegration and re-
entry, especially into the workplace community.
Studies of treatment utilization among compensation seeking Vietnam 
        veterans tell us little to nothing about the potential for 
        functional improvement/recovery in young, never-treated 
        veterans returning from Iraq.
    Note, also, that the studies' observations are consistent with the 
well-established finding within civilian populations that individuals 
who receive disability compensation are less likely to work when 
compared to their counterparts who do not receive compensation but 
exhibit the same degree of mental illness severity (see p. 6-3, IOM).
Disability doesn't necessarily inhibit treatment seeking, but it 
        inhibits recovery. Not only does full disability status signify 
        dysfunction, it presents a basic disincentive to recovery.
               making treatment work first and work well
    We must think of PTSD and other war-related mental conditions as a 
treatable and time-limited affliction. We must treat it early when 
symptoms are most responsive to treatment.
    There are excellent treatments for the component parts of PTSD 
(e.g., the phobias, anxiety, depression, existential dislocation). 
Treatments include desensitization protocols (such as Virtual Iraq), 
cognitive-behavioral therapy, psychotherapy, and medication. There is 
often a period in which treatment and rehabilitation overlap.
    Rehabilitation is critical to psychiatric recovery and familial and 
community reintegration. And the most effective efforts capitalize on 
the well-established finding that patients' prognoses depend on what 
transpires in the ``post-trauma'' phase. One element of this is the 
patient's self-image. How does he view himself ``post-event?'' Is his 
expectation one of recovery? Does he view himself as in control? Is he 
hopeful?
    In addition to the importance of a forward-looking stance is the 
extent to which problems of reintegration are managed. This is why 
quality rehabilitation addresses marital discord, readjustment to 
civilian life as well as to being a parent, vocational training, and 
financial concerns. Some veterans will need help with skills in 
relating to family, friends, neighbors, colleagues, and bosses.
    When daily life can be made more manageable, the patient feels more 
in control. Not only can he tolerate some symptoms better (sleep 
problems, distressing memories), those symptoms will fade faster. He 
will be less likely to ascribe morbid interpretations to symptoms and 
to less apt to feel discouraged. Demoralization is not a formal 
diagnosis, but in my experience, it can be the difference between 
someone who throws in the towel and someone who prevails. The virtue of 
rehabilitation is that it can turn risk factors for a prolonged course 
of illness into protective factors.
                               conclusion
    Veterans who are afflicted with PTSD or other mental disorders in 
the wake of their military experience deserve the best treatment. But 
it is imperative that we pair concern over the quality of care with 
serious consideration of the philosophy guiding the timing of that 
care. Imagine giving young men and women permission to surrender to 
their psychological wounds without first urging them to pursue 
recovery. Imagine even trying to make an accurate determination of 
one's potential for recovery before he or she has even received 
therapy. For many young veterans, a ``treatment first'' approach could 
mean the difference between a rich civilian life and withdrawal into 
disability.
                                 ______
                                 
    Response to Written Questions submitted by Hon. Richard Burr to 
Dr. Sally Satel, M.D., Resident Scholar, American Enterprise Institute, 
            and Lecturer, Yale University School of Medicine
    1. In a 2007 report the Institute of Medicine (IOM) examined 
available research on the link between veterans seeking, or in receipt 
of, disability compensation and their propensity to obtain mental 
health treatment. IOM made the final finding and conclusion: ``Research 
reviewed by the committee indicates that PTSD compensation does not, in 
general, serve as a disincentive to seeking treatment.''

    Question. Please comment on the IOM finding. Should the IOM's 
conclusion preclude VA from adopting a treatment first focus? Why or 
why not?
    Response. The IOM finding has very little relevance to the question 
of the VA's establishing treatment-first as a focus. To rely on the IOM 
as justification for the VA's rejection of the treatment first focus is 
a mistake as the report offers a flawed interpretation of the research.
    First, the studies included in the IOM report concern Vietnam 
veterans who have experienced PTSD symptoms for years, if not decades, 
and who are already in treatment. This is not relevant to young 
veterans returning from Iraq and Afghanistan who: (1) suffer new-onset 
PTSD symptoms, (2) seek or receive total and permanent disability 
status, and (3) have not received sustained, quality treatment.
    These are two very different populations. Most veterans of the 
Vietnam War who came to the attention of VA psychiatrists were neither 
diagnosed with PTSD, nor treated, until over a decade after 
experiencing combat trauma. Presenting for treatment so many years 
later typically means a diagnostic picture is very complex (e.g. 
overlaid with substance abuse problems, long-term employment 
difficulties, and diagnoses such as depression). At this advanced 
stage, responsiveness to treatment is usually compromised.
    Also, keep in mind that the studies reviewed by the IOM reveal very 
little about real-world functioning. In fact, the take-home lesson from 
the single study that measured change in occupational functioning (West 
Haven) was that symptom reduction is a poor proxy for overall 
improvement. Recall, the study found post-treatment employment rates of 
only two to 7 days of work per month among disability-seekers. True, 
attendance at treatment sessions and measurable reductions in symptoms 
may be a sign of engagement with the VA, but this is only a part of the 
picture: the major goal of treatment is not simply attending sessions, 
it is making use of them to achieve greater levels of social 
reintegration and re-entry into the workplace community.
    Thus, even if we can conclude that disability payments do not 
necessarily inhibit treatment seeking, they often inhibit recovery. And 
that is the key outcome.
    A more detailed analysis can be found in my written statement for 
the May 21 hearing.

    2. The 2005 VA Inspector General report found that most veterans' 
PTSD symptoms gradually worsened until 100 percent disability is 
achieved. You noted that the Vietnam veterans you worked with had 
incorporated their disorders as part of their identities.

    Question. Do you believe an early, more holistic approach that 
emphasizes recovery before resignation to disability could reverse this 
trend? How can we change the mindset that results from the label of a 
disability rating?
    Response. Most definitely, the emphasis must be on recovery. That 
is not falsely optimistic; it is simply a reflection of the natural 
course of PTSD. Yet, it will be hard to change the mindset because of 
the pattern established with the Vietnam generation wherein PTSD was 
believed to be a lifelong affliction.
    Furthermore, all troubling symptoms and behaviors were attributed 
to PTSD, no matter how many years post-war they manifested. When 
patients, abetted by clinicians, understand themselves in that way, 
therapy suffers greatly as the search for the true basis of distress is 
abandoned and treatment is targeted at the wrong problem.
    However, many mental health professionals at individual VAMC's 
realize that the most effective way to treat young veterans is to 
regard the condition as temporary and to reassure them that the chances 
are excellent that they will recover and resume full lives with their 
families and communities.
    I believe that no veteran should be eligible for total and 
permanent disability until we (and they) have evidence that they are 
refractory to treatment. Perhaps disability status should not even be 
available to them for at least 2 years post separation.
    However, the equivalent of treatment scholarships (similar to the 
Burr bill) should be available so that they have a safety net while 
pursuing intense treatment with an emphasis on vocational 
rehabilitation and family therapy.
    The image of PTSD as a diagnosis must change from a chronic problem 
to a temporary one (based on the data we have amassed within the past 
decade and more). Psychiatrists and psychologists who work in VA 
environments are more attuned to this than they were years ago (though 
some of those in leadership positions at the National Center for PTSD 
seem too willing, in my view, to perpetuate the traditional model of 
PTSD as it emerged during the Vietnam era).
    Perhaps the biggest obstacles to reform are some of the veterans 
groups--in particular the Vietnam Veterans of America. Unfortunately, 
these groups are so single-mindedly focused on preserving entitlements 
to veterans that they perceive any innovation, no matter how clinically 
beneficial it might be, as a grave threat. If reform is to be made, in 
my opinion, there needs to be political will to resist the urgent 
lobbying efforts of some advocacy groups.

    Question. Reflecting on the veterans you worked with, and based on 
your professional knowledge, do you believe early rehabilitative 
intervention would have helped in their readjustment to civilian life?
    Response. I worked with the veterans who never received early 
intervention. These men described having difficulties readjusting when 
they returned from Vietnam. They did not receive formal assistance. 
Some went to Vet Centers which tended to entrench their bitterness 
about the political dimensions of the war. Many were suspicious about 
going to a VAMC, considering it an agent of the government that failed 
them as soldiers.
    Keep in mind that the large majority of Vietnam veterans went on to 
lead full, productive lives (as the National Vietnam Veterans 
Readjustment Study shows). But the patients who came to us never 
regained their civilian footing: they did not work regularly or at jobs 
with advancement potential, they abused alcohol or other drugs, they 
had tumultuous marriages, and they often had run-ins with the law.
    The longer they lived chaotic lives, the more entrenched they 
became in those habits, and the harder it was to change themselves or 
their circumstances. I believe that early intervention would have 
changed the trajectories of the lives of many of them.

    Question. If so, should we therefore apply the treatment first 
concept to recently separated combat veterans as a first priority in 
order to avoid the mistakes we made with the Vietnam generation of 
veterans?
    Response. Most assuredly. This is a new generation of young 
veterans. They have much promise and we must not repeat with them the 
clinical errors made during the Vietnam era. I must add, though, that 
the errors to which I refer (including lengthy, regressive inpatient 
stays, incessant rehashing of war stories at the expense of forward-
looking rehabilitation, and an expectation of disability) were made in 
good faith. We now have sufficient data to guide us in a different 
direction. And we have effective exposure therapies and CBT.
    One of the most important strategies is to ``front load'' help to 
the veterans so they can readjust to civilian life as quickly as 
possible. The other is to transform the image of PTSD so that it is 
understood as a time-limited condition. Also, the VA should have a high 
threshold for granting full and total disability status.
    3. Recent studies suggest that full or partial remission of PTSD 
should be the norm and not the exception for the vast majority of PTSD 
cases.

    Question. Please comment on the risks of labeling individuals as 
disabled (especially totally and permanently disabled) through the 
disability compensation process. In your view, does such labeling 
potentially hinder the recovery process for many?
    Response. Full disability status and compensation--unless applied 
appropriately to the small minority of severely afflicted veterans--
paradoxically suppresses recovery by (a) suggesting to the patient that 
his condition is hopeless, (b) depriving him of the world of work, (c) 
eroding his confidence in his ability to work, (d) creating a perverse 
incentive to remain ill because payments stop when he recovers. For 
someone who hasn't worked in years, the prospect of losing the safety 
net is understandably anxiety-provoking.

    Chairman Akaka. Thank you. I want to thank all of you for 
your testimonies.
    Dr. Luke, in your statement, you mentioned that Helping 
Hands Hawaii seeks to identify eligible veterans and assist 
them with navigating the VA system. Can you please provide the 
Committee with some more specific examples of how an 
organization such as Helping Hands Hawaii reaches out to 
returning veterans, especially those in rural areas or minority 
populations, to let them know what services are available to 
them?
    Mr. Luke. As already mentioned in the previous panel, there 
is a stigma regarding mental health services and we have 
noticed also in the various ethnic groups in Hawaii, including 
the Native Hawaiians, the stigma is particularly strong. You 
see that in the normal and the general population, as well. So, 
when people do present for treatment, usually it is out of 
desperation, because nothing else has worked for them.
    What we do is we use a very open and very engaging process 
to welcome people into our office, to engage with our case 
manager and also our psychologist--and both of them have 
previously worked for the VA, such as myself. And what we do is 
we try to encourage them not to drop out of treatment and not 
to drop out of the disability application process. Long lines, 
long wait time, the paperwork is so overwhelming for the 
veterans that they often give up and decide it is not worth the 
process. So, we try to encourage them not to disengage from the 
VA and the disability application process.
    Chairman Akaka. Thank you. This question is for Mr. Cox and 
Ms. McVey. You have both presented numerous suggestions that 
would strengthen hiring and retention of nurses in VA and I 
appreciate your support of S. 2969, the Veterans Medical 
Personnel Recruitment and Retention Act of 2008. In your view, 
what are the two most important steps VA can take to attract 
and retain a greater number of highly qualified nurses? Mr. Cox 
or Ms. McVey?
    Mr. Cox. Well, Senator, I believe probably the first thing 
that I would say today, to be able to recruit and retain the 
best qualified nurses in the world, is to give them full 
collective bargaining rights in the VA and to support the 
legislation that Senator Rockefeller has introduced. Because, 
you know, the Congress of the United States said the public's 
best interest is served through collective bargaining, and for 
those nurses to have a way to be treated properly in the 
worksite, to be able to deal with the workplace issues, you 
would recruit those nurses and retain those nurses.
    And the other issue, I would say, you have got to pay them 
and pay them properly. The nurse pay is a very big issue in the 
VA. It is a very secretive issue in the VA. It needs to become 
transparent, an open book; and pay those nurses properly, treat 
them well, give them their collective bargaining rights.
    Chairman Akaka. Thank you, Mr. Cox. Ms. McVey?
    Ms. McVey. I think, as I stated in the testimony, several 
of the provisions in the bill, if they were to be addressed, 
would go a long way to enhancing both recruitment and retention 
for VHA, such as education and implementation of what exists in 
locality pay law. That would be one way to do that. It would be 
an important thing.
    And I think also in the pay issues that Mr. Cox testified 
on, as well, streamlining some of the human resource issues 
that exist still--outdated classification systems, hiring 
processes that are cumbersome--need to be addressed in order to 
facilitate. That is more actually on the recruitment end of it, 
but will go a long way also to facilitating the recruitment and 
then retention for VHA nurses.
    Chairman Akaka. Ms. McCartney, thank you for your testimony 
in support of S. 2926, the Veterans Nonprofit Research and 
Education Corporation Enhancement Act of 2008. As you 
discussed, the recent Inspector General report raises a number 
of concerns about NPCs. How will this legislation facilitate VA 
oversight of NPCs?
    Ms. McCartney. VA has always had the power to oversee these 
nonprofit corporations, which are inextricably linked to VA, 
and that has not changed at all. One of the things that this 
bill does, and a very important component, is that it does 
provide the capacity for small corporations to merge with 
larger corporations. So, in terms of oversight, that would 
lessen the number of institutions that VA would have to oversee 
and it would also strengthen the operation of these 
institutions by having, as Mr. Hall testified earlier, critical 
mass and enough resources for the local institutions to manage 
them.
    The nonprofits welcome this oversight. We are happy to work 
closely with VA in developing any kind of standards; and would 
be very willing to work with them to make sure that the 
oversight is there, that the standards are clear, and that we 
are in full compliance with these standards.
    Chairman Akaka. Thank you, Ms. McCartney.
    Dr. Berger, do you believe that veterans in receipt of 
compensation for mental health conditions are the targets of 
recurring scrutiny? Does such scrutiny exist for veterans with 
physical conditions?
    Mr. Berger. Sir, are you asking me about mental health 
conditions or physical conditions? Obviously----
    Chairman Akaka. This is mental health conditions.
    Mr. Berger. OK. Yes, that is true. There are people who 
undergo periodic review.
    Chairman Akaka. I see. And does such scrutiny exist for 
veterans with physical conditions, as well?
    Mr. Berger. I am not aware of any, although I could not 
answer across the board.
    Chairman Akaka. Dr. Berger and Dr. Satel, I share the 
concern noted by VA in testimony about the potential conflict 
that would arise for health care practitioners if S. 2573 were 
enacted as introduced. Do either of you see a problem with 
health care practitioners who are furnishing health care 
services being pressured by their patients to grant requests 
for extensions of treatment in order to maximize the amount of 
money patients would receive under the program?
    Dr. Satel. My understanding of the Treatment First Act is, 
first, that it is completely voluntary, and second, that the 
critical period ends either at a year or when treatment ends. 
Certainly in my experience, which I admit was a while ago, I 
always felt completely insulated from any kind of financial 
pressures. We did our clinical work and our focus was the well-
being of the patient. I have no reason to think that this has 
changed.
    Chairman Akaka. Yes. I would like to thank all of you for 
your testimony. This will be helpful to us, and I want to thank 
all the witnesses who have appeared today. We appreciate your 
views on this legislation. Your input on these issues will be 
valuable to the Committee as it moves forward, and I thank you 
so much for your help to the Committee.
    This hearing is adjourned. Thank you.
    [Whereupon, at 12:01 p.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


 Prepared Statement of David A. Butler, Ph.D. and Frederick Erdtmann, 
   M.D., M.P.H., on Behalf of the Institute of Medicine and National 
             Research Council, National Academy of Sciences
        s. 2573, ``veterans mental health treatment first act''
    The National Academies were asked by Committee staff to provide 
testimony for the record on issues raised by the ``Veterans Mental 
Health Treatment First Act'' (S. 2573) that are addressed in the 2007 
report PTSD Compensation and Military Service (hereafter referred to as 
PTSD Compensation). This report contains the results of a study 
conducted by the Members of the Committee on Veterans' Compensation for 
Post Traumatic Stress Disorder. The committee was convened under the 
auspices of the Institute of Medicine and National Research Council 
(IOM/NRC). These institutions are operating arms of the National 
Academy of Sciences, which was chartered by Congress in 1863 to advise 
the government on matters of science and technology.
    The IOM/NRC committee was charged with evaluating how veterans with 
PTSD are compensated for their mental health condition and assess how 
that compensation might influence attitudes and behavior in ways that 
might serve as barriers to recovery. Their work was requested by the 
Department of Veterans Affairs, which provided funding for the effort. 
The report results were also presented to and used by the 
congressionally-constituted Veterans Disability Benefits Commission.
    Our testimony is limited to this topic. The Committee--which is now 
disbanded--did not examine the ``Veterans Mental Health Treatment First 
Act'' and The National Academies have no opinion on the Act. Our role 
is to provide independent, non-partisan scientific advice to the 
government and we wish to make it clear that we are neither for nor 
against this legislation. Neither of us is an authority on mental 
health treatment and we are therefore not qualified to offer personal 
expert opinion on the proposals put forward in the Act.
    The ``Veterans Mental Health Treatment First Act'' touches on two 
topics that are addressed in the PTSD Compensation report. The first of 
these is the imposition of a requirement to pursue treatment as a 
condition for receiving compensation. The report notes that, in 
civilian disability-compensation systems in the US, ``[p]eople who 
qualify for compensation may be required to follow prescribed medical 
treatment and to participate in rehabilitation in order to continue 
receiving payment'' (p. 53). It later observes that ``[m]ost [workplace 
long-term disability] plans require that a person be receiving 
appropriate medical treatment for the disabling condition'' (p. 61). 
However, the report also states--in a section entitled ``Philosophy of 
U.S. Disability Systems''--that society does not apply civilian-program 
standards to veterans' benefits:

          VA disability benefits, including compensation, reflect a 
        somewhat different set of principles of social justice. * * * 
        One of the reasons that societies form is to provide safety and 
        security for their members, so when individuals put themselves 
        at risk to preserve a society's security, social justice 
        implies that they should be compensated for losses resulting 
        from taking that risk. (p. 52)

    The second topic is the possible effects of compensation on 
treatment-seeking, which is dealt with in Chapter 6 of the Committee's 
report. The sections entitled ``Disability Compensation and the Use of 
VA Mental-Health Care Services'' and ``Disability Compensation and 
Treatment Outcome'' (pages 178-184) are particularly relevant.
    PTSD Compensation cites a 2005 report from the VA's Office of the 
Inspector General that found that when VA PTSD disability ratings were 
increased to 100 percent, veterans sought less treatment for the 
conditions. Quoting the VA report:

          In a judgment sample of 92 PTSD cases, we found that 39 
        percent of the veterans had a 50 percent or greater decline in 
        mental-health visits over the 2 years after the rating 
        decision. The average decline was 82 percent, and some veterans 
        received no mental-health treatment at all. While their mental-
        health visits declined, non-mental-health visits did not. 
        (Department of Veterans Affair, 2005, p. 52)

    The IOM/NRC report states that, although the OIG analysis has 
received some attention ``it is clearly limited by the selective nature 
of the sample and the lack of supporting data'' and that ``[t]his is 
unfortunate because other scientific evidence does not support the OIG 
findings'' (p. 179). The report's review of that evidence, detailed on 
pages 179-182, indicates that disability compensation does not in 
general serve as a disincentive to seeking treatment. While some 
beneficiaries will undoubtedly understate their improvement in the 
course of pursuing compensation, the scientific literature suggests 
that such patients are in the minority, and there is some evidence that 
disability payments may actually contribute to better treatment 
outcomes in some programs. The literature on recovery indicates that it 
is influenced by several factors, and the independent effect of 
compensation on recovery is difficult to disentangle from these.
    The report concludes that ``in spite of concerns that disability 
compensation for PTSD may create a context in which veterans are 
reluctant to acknowledge or otherwise manifest therapeutic gains 
because they have a financial incentive to stay sick, the preponderance 
of evidence does not support this possibility'' (p. 184). It goes on to 
state that ``[t]he committee's review of the literature on misreporting 
or exaggeration of symptoms by PTSD claimants yielded no justification 
for singling out PTSD disability for special action and thereby 
potentially stigmatizing veterans with the disability by implying that 
their condition requires extra scrutiny'' (p. 187).
    The report also offers a recommendation to address the concern that 
the current system creates an incentive to stay sick. It notes that 
PTSD--along with multiple sclerosis, lupus, and many mental disorders 
including depression--may exhibit a relapsing and remitting course (p. 
141). The report recommends that VA ``consider instituting a set, long-
term minimum level of benefits that would be available to any veteran 
with service-connected PTSD at or above some specified rating level 
without regard to that person's state of health at a particular point 
in time after the [compensation and pension] examination'' (p. 185). It 
states:

          Regulation already specifies an analogous approach for other 
        disorders, including conditions whose symptoms may remit and 
        relapse over time. Multiple sclerosis, for example, has a 
        minimum rating of 30 percent without regard to whether the 
        condition is disabling at the moment that the subject is 
        evaluated. However, rather than being limited to a particular 
        minimum rating, the committee suggests that the VA consider 
        what minimum benefits level--where ``benefits'' comprise 
        compensation and other forms of assistance, such as priority 
        access to VA medical treatment--would be most likely to promote 
        wellness. It is beyond the scope of the charge to the committee 
        to specify the particular set of benefits that would be most 
        appropriate or the level[s] of impairment that would trigger 
        provision of these benefits. This would require a careful 
        consideration of the needs of the population, of the new 
        incentives that the policy change would create, of the possible 
        effects on compensation outlays and demand for other VA 
        resources, and of how to maintain fairness with respect to 
        other conditions that have a remitting/relapsing nature.

          Providing a guaranteed minimum level of benefits would take 
        explicit account of the nature of chronic PTSD by providing a 
        safety net for those who might be asymptomatic for periods of 
        time. A properly designed set of benefits could eliminate 
        uncertainty over future timely access to treatment and 
        financial support in times of need and would in part remove the 
        incentive to ``stay sick'' that some suggest is a flaw of the 
        current system. (p. 185-186)

    The IOM/NRC committee also reached a series of other 
recommendations regarding the conduct of VA's compensation and pension 
system for PTSD that are detailed in the body of its report. We 
previously provided a copy of this report to the Committee and would be 
happy to submit additional copies upon request. The report is also 
freely accessible on-line at the URL listed in the references below.

                                    David A. Butler, Ph.D.,
     Senior Program Officer, Board on Military and Veterans Health,
            Institute of Medicine, National Academy of Sciences and
      Study Director, Committee on Veterans' Compensation for Post 
                                                          Traumatic
      Stress Disorder, Institute of Medicine and National Research 
                                                           Council.

                                            and    

                          Frederick Erdtmann, M.D., M.P.H.,
                Director, Board on Military and Veterans Health and
                                Director, Medical Follow-up Agency,
               Institute of Medicine, National Academy of Sciences.
References cited in this testimony
Department of Veterans Affairs. 2005. Review of State Variances in VA 
            Disability Compensation Payments. Report No. 05-00765-137. 
            Washington, DC: VA Office of the Inspector General. 
            [Online]. Available: http://www.va.gov/oig/52/reports/2005/
            VAOIG-05-00765-137.pdf.
Institute of Medicine/National Research Council. 2007. PTSD 
            Compensation and Military Service. Washington, DC: National 
            Academies Press. [Online]. Available: http://www.nap.edu/
            catalog.php?record_id=11870.
                                 ______
                                 
          Statement of the Brain Injury Association of America
            s. 2921--caring for wounded warriors act of 2008
    The Brain Injury Association of America (BIAA) and its nationwide 
network of State affiliates representing survivors of Traumatic Brain 
Injury (TBI), their families, researchers, clinicians and other 
professionals, strongly endorses S. 2921, and urges the U.S. Senate 
Committee on Veterans' Affairs to approve this important legislation in 
a timely manner.
    The Caring for Wounded Warriors Act of 2008 (S. 2921) would 
significantly improve support for family caregivers of returning 
servicemembers with Traumatic Brain Injury (TBI). This important bill 
proactively acknowledges the reality that a brain injury happens to an 
entire family, not just the individual survivor.
    Importantly, this legislation acknowledges the critical role played 
by family caregivers in facilitating recovery from brain injury and 
addresses the pressing need to increase support for these caregivers 
through pilot programs providing access to training, certification and 
financial compensation.
    The Brain Injury Association of America also applauds the bill's 
introduction of innovative pilot programs to leverage existing 
partnerships between Veterans Affairs facilities and the Nation's 
leading universities through the training of graduate students in 
related fields to provide respite care for wounded warriors with TBI.
    Family care is the most important source of assistance for people 
with chronic or disabling conditions, including people with brain 
injury. Yet, research has found that all too often, the Traumatic Brain 
Injury of a spouse or close relative places extreme stress on family 
caregivers, frequently resulting in negative physical and emotional 
outcomes for the caregivers themselves. Unfortunately, despite these 
documented physical hardships and psychological stress, family 
caregivers receive little support.
    Specifically, stress reaction is known to occur in situations where 
the demands of the environment exceed an individual's resources. One 
critical component which has been found to be related to caregiver 
burden is whether or not the caregiver perceives the effects of the 
injury to exceed the caregiver's resources to manage the situation. In 
other words, perceived stress ha s consistently predicted negative 
outcomes for the caregiver.i A lack of financial resources 
and social supports are some of the common perceived stresses impacting 
family caregivers of loved ones with TBI.
    One longitudinal study found that 47 percent of family caregivers 
of individuals with TBI had altered or given up their jobs at 1 year 
postinjury, and 33 percent at 2 years postinjury, and decreases in both 
employment and financial status were reported over a 2-year time period 
postinjury. ii Particularly in light of the fact that 
caregivers often report severe financial strain and frequently must 
give up their jobs in order to take care of their loved one with TBI, 
increased financial support and access to respite care for family 
caregivers of returning servicemembers with TBI is vital and long 
overdue.
    Again, the Brain Injury Association of America enthusiastically 
endorses the ``Caring for Wounded Warriors Act of 2008,'' and strongly 
encourages the Committee to approve this legislation.
            Sincerely,
                                          Susan H. Connors,
                                                     President/CEO,
                               Brain Injury Association of America.

    i Chwalisz, Kathleen. ``Perceived Stress and Caregiver 
Burden after Brain Injury: A Theoretical Integration.'' 
[p1]Rehabilitation Psychology, Vol. 37, No. 3, 1992. pp 189-203.
    ii Hall KM , Karzmark P, Stevens M, Englander J, O'Hare 
P, Wright J. Arch Phys Med Rehabil. 1994 Aug;75 (8): 876-84.
                                 ______
                                 
   Prepared Statement of the National Coalition for Homeless Veterans
    The National Coalition for Homeless Veterans (NCHV) appreciates the 
opportunity to submit written testimony to the Senate Veterans' Affairs 
Committee regarding S. 2273, the Enhanced Opportunities for Formerly 
Homeless Veterans Residing in Permanent Housing Act of 2007, a bill 
that would authorize the Secretary of Veterans Affairs to conduct pilot 
programs of grants to coordinate the provision of supportive services 
available in the local community to very low income, formerly homeless 
veterans residing in permanent housing.
    The homeless veteran assistance movement NCHV represents began in 
earnest in 1990, but like a locomotive it took time to build the 
momentum that has turned the battle in our favor. In partnership with 
the Departments of Veterans Affairs (VA), Labor, and Housing and Urban 
Development (HUD)--supported by funding measures this committee has 
championed--our community veteran service providers have helped reduce 
the number of homeless veterans on any given night in America by 38 
percent in the last 6 years.
    This assessment is not based on the biases of advocates and service 
providers, but by the Federal agencies charged with identifying and 
addressing the needs of the Nation's most vulnerable citizens.
    To its credit, the VA has presented to Congress an annual estimate 
of the number of homeless veterans every year since 1994. It is called 
the CHALENG project, which stands for Community Homelessness 
Assessment, and Local Education Networking Groups. In 2003 the VA 
CHALENG report estimate of the number of homeless veterans on any given 
day stood at more than 314,000; in 2006 that number had dropped to 
about 194,000. We have been advised the estimate in the soon-to-be 
published 2007 CHALENG Report shows a continued decline, to about 
154,000.
    Part of that reduction can be attributed to better data collection 
and efforts to avoid multiple counts of homeless clients who receive 
assistance from more than one service provider in a given service area. 
But in testimony before this committee in 2006, VA officials affirmed 
the number of homeless veterans was on the decline, and credited the 
agency's partnership with community-based and faith-based organizations 
for making that downturn possible.
             addressing prevention of veteran homelessness
    The reduction in the number of homeless veterans on the streets of 
America each night proves the partnership of Federal agencies and 
community organizations--with the leadership and oversight of 
Congress--has succeeded in building an intervention network that is 
effective and efficient. That network must continue its work for the 
foreseeable future, but its impact is commendable and offers hope that 
we can, indeed, triumph in the campaign to end veteran homelessness.
    However, the lessons we have learned and the knowledge we have 
gained during the last two decades must also guide our Nation's leaders 
and policymakers in their efforts to prevent future homelessness among 
veterans who are still at risk due to health and economic pressures, 
and the newest generation of combat veterans returning from Operations 
Iraqi Freedom (OIF) and Enduring Freedom (OEF).
    The lack of affordable permanent housing is cited as the No. 1 
unmet need of America's veterans, according to the VA CHALENG report. 
Last year, Public Law 110-161 included $75 million in fiscal year 2008 
for the joint HUD-VA Supported Housing Program (HUD-VASH), which 
allowed HUD and VA to make up to 10,000 HUD-VA supportive incremental 
housing vouchers available to veterans with chronic health and 
disability challenges. NCHV is pleased HUD has requested another 
increase in equal measure in fiscal year 2009 and hope this new funding 
will be approved by the Congress.
    The affordable housing crisis, however, extends far beyond the 
realm of the VA system and its community partners. Once veterans 
successfully complete their Grant and Per Diem (GPD) programs, many 
formerly homeless veterans still cannot afford fair market rents, nor 
will most of them qualify for mortgages even with the VA home loan 
guarantee. They are, essentially, still at risk of homelessness. With 
another 1.5 million veteran families living below the Federal poverty 
level (2000 U.S. Census), this is an issue that requires immediate 
attention and proactive engagement.
    Many homeless veterans receiving services today are aging and the 
percentage of women veterans seeking services is growing. Moreover, OIF 
and OEF combat veterans, both men and women, are returning home and 
suffering from war related conditions that may put them at risk for 
homelessness.
    Veterans who graduate from 2-year GPD programs often need 
supportive services while they continue to build toward economic 
stability and social reintegration into mainstream society. Those who 
will need permanent supportive housing--the chronically mentally ill, 
those with functional disabilities, families impacted by poverty--may 
be served by the HUD-VASH program. But the majority of GPD graduates 
need access to affordable housing with some level of follow-up services 
for up to 2 to 3 years to ensure their success.
    Many community-based organizations are already providing that kind 
of ``bridge housing,'' but resources for this purpose are scarce. At 
present, the VA cannot meet the range of housing and resource needs of 
currently homeless and at-risk returning veterans. While the agency can 
provide homeless veterans with primary care and mental health services, 
along with transitional housing, it lacks the authority and funding to 
provide supportive services for the growing number of veterans who will 
need long-term affordable permanent housing.
    To meet these current and future needs, NCHV urges this Committee 
to support S. 2273, a measure that would authorize the Secretary of 
Veterans Affairs to establish several pilot programs that would provide 
grants to public and non-profit (including faith-based and community 
organizations) to provide local supportive services to very low-income, 
formerly homeless veterans residing in long-term or permanent housing. 
The programs would be conducted at former military properties or 
installations in addition to properties where permanent housing is 
provided to formerly homeless veterans.
    Homeless and at-risk veterans need a community-based, coordinated 
effort that provides secure housing and nutritional meals; essential 
physical health care, substance abuse aftercare and mental health 
counseling; and personal development and empowerment. Veterans also 
need job assessment, training and placement assistance. NCHV believes 
all programs to assist homeless and at risk veterans must focus on 
helping veterans reach the point where they can obtain and sustain 
employment and live independent lives in their community. Passage and 
implementation of S. 2273 would be a giant step toward helping these 
veterans have a higher chance of becoming productive citizens again.
                              in summation
    NCHV believes it is now time to take the next step in the campaign 
to end veteran homelessness. Developing solutions that address the 
health and economic challenges of veterans who served in Viet Nam and 
other conflicts as well as OEF/OIF veterans--before they are threatened 
with homelessness--and provide the necessary funding and resources 
should be a national priority. Never before in U.S. history has this 
Nation, during a time of war, concerned itself with preventing veteran 
homelessness. For all our collective accomplishments, this may yet be 
our finest moment.




                                  
