[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 784, H.R. 785,
H.R. 1211, AND DISCUSSION DRAFT ON
EMERGENCY CARE REIMBURSEMENT
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
MARCH 3, 2009
__________
Serial No. 111-3
__________
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
48-417 WASHINGTON : 2009
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida HENRY E. BROWN, Jr., South
VIC SNYDER, Arkansas Carolina, Ranking
HARRY TEAGUE, New Mexico CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas JERRY MORAN, Kansas
JOE DONNELLY, Indiana JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
March 3, 2009
Legislative Hearing on H.R. 784, H.R. 785, H.R. 1211, and
Discussion Draft on Emergency Care Reimbursement............... 1
OPENING STATEMENTS
Chairman Michael Michaud......................................... 1
Prepared statement of Chairman Michaud....................... 35
Hon. Cliff Stearns............................................... 2
Prepared statement of Congressman Stearns.................... 35
WITNESSES
U.S. Department of Veterans Affairs, Gerald M. Cross, M.D.,
FAAFP, Principal Deputy Under Secretary for Health, Veterans
Health Administration.......................................... 26
Prepared statement of Dr. Cross.............................. 48
______
American Legion, Joseph L. Wilson, Deputy Director, Veterans
Affairs and Rehabilitation Commission.......................... 13
Prepared statement of Mr. Wilson............................. 44
Disabled American Veterans, Joy J. Ilem, Assistant National
Legislative Director........................................... 12
Prepared statement of Ms. Ilem............................... 37
Herseth Sandlin, Hon. Stephanie, a Representative in Congress
from the State of South Dakota................................. 6
Prepared statement of Congresswoman Herseth Sandlin.......... 36
Iraq and Afghanistan Veterans of America, Todd Bowers, Director
of Government Affairs.......................................... 17
Prepared statement of Mr. Bowers............................. 47
Tsongas, Hon. Niki, a Representative in Congress from the State
of Massachusetts............................................... 3
Prepared statement of Congresswoman Tsongas.................. 36
Veterans of Foreign Wars of the United States, Eric A. Hilleman,
Deputy Director, National Legislative Service.................. 15
Prepared statement of Mr. Hilleman........................... 45
SUBMISSIONS FOR THE RECORD
Filner, Hon. Bob, Chairman, Committee on Veterans' Affairs, and a
Representative in Congress from the State of California,
statement...................................................... 53
Paralyzed Veterans of America, statement......................... 53
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Senior
Analyst for Veterans' Benefits and Mental Health Issues, and
Marsha Four, Chair, National Women Veterans Committee,
statement...................................................... 55
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Hon. Eric K. Shinseki,
Secretary, U.S. Department of Veterans Affairs, letter
dated March 12, 2009, and VA Responses..................... 59
LEGISLATIVE HEARING ON H.R. 784, H.R. 785,
H.R. 1211, AND DISCUSSION DRAFT ON
EMERGENCY CARE REIMBURSEMENT
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TUESDAY, MARCH 3, 2009
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Michael Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Teague, Rodriguez,
Halvorson, Stearns, and Boozman.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I would like to have the hearing come to
order. I want to thank everyone for coming today.
Today's legislative hearing is an opportunity for Members
of Congress, veterans and the U.S. Department of Veterans
Affairs (VA) and other interested parties to provide their
views on and discuss recently introduced legislation within the
Subcommittee's jurisdiction in a clear and orderly process.
I do not necessarily agree or disagree with the bills
before us today, but I believe that this is an important part
of the legislative process and will encourage frank and open
discussion of these ideas.
We have four bills under consideration today. They cover a
wide range of issues, including mental health, women veterans
and reimbursement for emergency care treatment in non-VA
facilities.
The four bills before us today are H.R. 784, sponsored by
Representative Tsongas of Massachusetts; H.R. 785, sponsored by
Representative Tsongas of Massachusetts; a Draft Discussion of
Emergency Care Reimbursement by Mr. Filner from California; and
H.R. 1211, Women Veterans Health Care Improvement Act by
Representative Herseth Sandlin, who is also a Member of this
Committee.
So I look forward to hearing the views of the witnesses on
these bills before us today, and I would like to recognize
Congressman Stearns for any opening statement that he may have.
[The prepared statement of Chairman Michaud appears on
p. 35.]
OPENING STATEMENT OF HON. CLIFF STEARNS
Mr. Stearns. Mr. Chairman, thank you very much.
I am delighted to be here.
I think your opening statement appropriately said it, that
we have four bills before us. You are not saying you agree or
disagree, but you are saying let us listen to the arguments and
hear what they are.
I think, particularly, every Member of Congress should
realize that before we pass legislation, we should consider the
impact of this legislation to the economy, and is it going to
impact States and cause them to spend more money, is it going
to somehow decrease jobs. So I try to look at these four pieces
of legislation in that respect, too.
The first bill, H.R. 784, would require VA to submit
quarterly reports on mental health professional vacancies.
The second bill, H.R. 785, would establish a pilot program
to provide mental health outreach and training on certain
college campuses for Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF) veterans.
The Department of Veterans Affairs has made great
improvements in the past 2 years to reach out to more veterans
and provide better, more effective mental health services.
Mr. Chairman, with a growing number of veterans in need of
mental health care, we must continue to focus on how we can
build on the progress VA has made thus far, and I am very
interested in hearing views on these proposals.
I thank the Chairman, Mr. Filner, for reintroducing his
bill to expand the benefits for veterans related to the
reimbursement of expenses for emergency treatment in the local
non-VA facilities. I am pleased to see that changes have been
made to the bill to clarify the requirements for VA payment
under the program.
I would also like to commend my good friend, Stephanie
Herseth Sandlin, for being a champion of women's veterans. Her
bill, the ``Women Veterans Health Care Improvement Act,''
includes a number of provisions designed to study, improve, and
expand access to care for our courageous women veterans.
The number of women serving in the active-duty Guard and
Reserve, obviously, continues to increase. Today, women
represent almost 8 percent of the total veteran population and
nearly 5 percent of all veterans who use VA health care
services.
VA estimates that the number of women veterans enrolled in
VA health care will more than double over the next decade. So,
obviously, it is essential for us to be making sure that the VA
is providing appropriate programs and services throughout the
country to meet the unique physical and mental health needs of
our women veterans.
As we examine new initiatives, we must also be careful to
ensure that they complement and do not overlap existing VA
efforts in research and programs for women veterans.
So, I look forward to a very productive discussion on these
legislative proposals and want to thank all of our witnesses
for participating in this hearing on a very cold day here in
Washington. Your testimony will help guide us to best serve our
veterans in our Nation.
I thank you, Mr. Chairman. With that, I yield back the
balance.
[The prepared statement of Congressman Stearns appears on
p. 35.]
Mr. Michaud. Thank you very much. I know Representative
Tsongas has another meeting she has to go to, so why don't we
start with Representative Tsongas. If you could explain H.R.
784 and H.R. 785 to us and we will ask you questions if we have
any.
Representative Tsongas.
STATEMENTS OF HON. NIKI TSONGAS, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF MASSACHUSETTS; AND HON. STEPHANIE HERSETH
SANDLIN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF SOUTH
DAKOTA
STATEMENT OF HON. NIKI TSONGAS
Ms. Tsongas. Thank you, Chairman Michaud and Congressman
Stearns for giving me this opportunity to testify.
I have introduced two bills, H.R. 784 and H.R. 785, to
improve the quality and accessibility of mental health services
for our veterans.
Almost one million Operation Enduring Freedom and Operation
Iraqi Freedom veterans have left active duty and become
eligible for VA health care since 2002; 400,304 or 42 percent
of these veterans have obtained VA care, and approximately 44
percent of that number are facing mental disorders. The three
most common diagnoses are post-traumatic stress disorder
(PTSD), depressive disorders and neurotic disorders. These
rates are two to three times that of the general population.
My first bill, H.R. 784, simply requires that the VA report
vacancies in mental health professional positions at VA
facilities on a quarterly basis. With the significant influx of
new war veterans facing mental health wounds, as well as the
already existing veterans' populations from earlier generations
receiving care at the VA, it is incumbent upon us to make sure
that we have the necessary staffing to provide care. This bill
will help this Congress perform our oversight role, and it will
help the VA use its limited resources to effectively care for
our veterans.
The second bill, H.R. 785, will help veterans seeking to
improve their lives through education. The 110th Congress
passed the most sweeping modernization of the Montgomery GI
Bill since the program's creation after World War II. The
purpose of the modernization is to give veterans of Afghanistan
and Iraq access to the education and job training tools that
they will need to achieve the American dream they risked so
much to defend.
As I stated earlier, approximately 44 percent of
Afghanistan and Iraq veterans who have sought treatment at the
VA have demonstrated signs of mental health wounds, including
PTSD. Studies have shown that PTSD can have a negative impact
on an individual's ability to focus and ability to learn.
Returning from a war, separating from service, and then
beginning school can place significant strains on the mental
health of a veteran. It is critical that we provide our
veterans with the assistance they need to manage and recover
from these wounds so that they can take advantage of the
opportunities available to them.
To that end, I have introduced H.R. 785. This bill directs
the Secretary of Veterans Affairs to carry out a pilot program
to provide outreach and training to certain college and
university mental health centers so that they can more
effectively identify and respond to the mental health needs of
veterans of Operation Enduring Freedom and Operation Iraqi
Freedom.
My legislation would not break the continuum of care
provided by the VA. The purpose of this bill is to provide
college counselors and other staff, who come in close contact
with student veterans at their schools, with the tools to
recognize symptoms of combat-related mental health wounds, the
ability to appropriately assist a student veteran in need, and
an understanding of how to effectively refer that student
veteran to the VA for care.
I believe my legislation will actually augment the VA's
continuum of care and bring in veterans who may be hesitant or
apprehensive about seeking care from the VA. The intention of
both bills is to ensure that we have adequate services to
address the mental health care needs of our veterans, and that
we give our veterans the opportunity to build full lives once
they take off the uniform.
Thank you for the opportunity to testify before the
Subcommittee. I look forward to working with you, Chairman
Michaud and the other Members of this Subcommittee, to improve
these bills and to improve the quality and accessibility of the
care we provide our veterans. Thank you.
[The prepared statement of Congresswoman Tsongas appears on
p. 36.]
Mr. Michaud. Thank you very much, Representative Tsongas.
I just have one question on H.R. 784. How would you respond
to potential criticism that the data collection required by
H.R. 784 would be burdensome?
Ms. Tsongas. Well, as we know, data collection is an
essential management tool for the VA and an essential tool for
Congressional oversight. We hear about wait times and staffing
shortages from our veterans. I think any Member of Congress, as
we are out in our districts, often receives that input from
those who have been seeking care. So it is difficult to imagine
how the VA can truly understand what is happening at the local
level without this data. And it will help to provide a baseline
for the VA going forward so that it and we better understand
their capacity to fill and augment the services they provide.
Mr. Michaud. Okay. Thank you very much.
Mr. Stearns, do you have any questions?
Mr. Stearns. Thank you, Mr. Chairman.
Let me just go along with what the Chairman just sort of
alluded to, the fact that these quarterly reports on mental
health vacancies, obviously, I think everybody would agree,
would improve care for veterans. I guess as the Chairman
alluded to, is the fact that it could be duplicative.
Last year, Congress created a grant program for
institutions of higher education to establish ``Center of
Excellence for Veteran Student Success,'' and it was set up to
coordinate services to address the academic, financial health,
and social need of veteran students.
Just a suggestion. Is it possible that within that Center
for Excellence for Veterans Success, where they are
coordinating services dealing with health, rather than perhaps
creating a new separate pilot program, is it possible we could
achieve the same goals under that Center for Excellence that is
already established where they do actually coordinate dealing
with, not only academic, financial, and social needs, but also
health, to improve the mental health outreach? So, in a sense,
coordinating with this existing legislation and just folding it
in, rather than a separate program, I guess, would be a
question.
Ms. Tsongas. Well, we would be happy to work with the VA
and the Committee, Subcommittee, going forward to look at ways
to integrate this. In my former life, I was an administrator in
a community college, and you see how often a very unique role
that counselors in institutions of higher education play with
incoming students.
And so we would be happy to work, as I said, with the VA to
see if there is of way of integrating a program that really
takes advantage of what colleges have to offer, the fact that
they are often those at first--guidance systems are often the
first to really deal with incoming students, and find a way
that we can leverage both.
Mr. Stearns. So you would be receptive, perhaps, to maybe
even allowing a pilot program, using this existing structure to
see how it would work as maybe a possibility of solving this?
Ms. Tsongas. Well, I would be happy to look at that as a
possibility, a way of going forward. But I do think that we
recognize--acknowledge and recognize that there is a need out
there that many returning soldiers will be taking advantage of
the modernized GI bill going on to college and, yet, still
suffering from the impact of their service in war.
So we do want to take advantage of that moment of contact
in these institutions of higher education. And as the bill
says, it focuses on those institutions that are receiving
significant numbers of young people from these wars.
But, again, as I said, I would like to work with the
Committee on that, and the VA.
Mr. Stearns. Okay. Thank you, Mr. Chairman.
Mr. Michaud. Thank you.
Mrs. Halvorson, do you have any questions of Ms. Tsongas?
Mr. Boozman.
Mr. Teague.
Mr. Teague. No, not at this time. Thank you.
Mr. Michaud. Thank you.
Okay. Well, thank you very much, Ms. Tsongas. I really
appreciate your willingness to come today and bring forward
these two pieces of legislation. I will be looking forward to
working with you as we deal with this later on in the year.
Thank you very much.
Ms. Tsongas. And thank you for this opportunity. And I
apologize for----
Mr. Michaud. No, that is totally understandable with all of
our busy schedules. Thank you very much.
I am very pleased to recognize Representative Herseth
Sandlin for her many years working and fighting for veterans'
issues, especially women veterans' health care. I also want to
thank you for your willingness to let Representative Tsongas go
through her testimony so she can get on to her next meeting.
So without any further adieu, Representative Herseth
Sandlin.
STATEMENT OF HON. STEPHANIE HERSETH SANDLIN
Ms. Herseth Sandlin. Well, thank you and good morning, Mr.
Chairman, Mr. Stearns, other Members of the Subcommittee. Thank
you for holding today's hearing, and I certainly appreciate
having the opportunity to be here to discuss the ``Women
Veterans Health Care Improvement Act.''
H.R. 1211, which I introduced on February 26th, 2009,
enjoys original cosponsor support from a number of Health
Subcommittee Members, including Chairman Michaud; the
distinguished Ranking Member of the Economic Opportunity
Subcommittee, Mr. Boozman; and Mr. Moran. The bill will take
important steps to expand and improve Department of Veterans
Affairs Health Care Services for women veterans.
Before I talk more about the bill and the needs of women
veterans, I would also like to take this opportunity to thank
the Disabled American Veterans (DAV) for their continued
leadership and the effort to address the needs of women
veterans and their support for this important legislation.
As your Subcommittee knows, Mr. Chairman, more women are
answering the call to serve and more women veterans need access
to services that they are entitled to when they return. With
increasing numbers of women now serving in uniform, the
challenge of providing adequate health care services for women
veterans is overwhelming. With more women seeking access to
care and for a more diverse range of medical conditions, in the
future these needs will likely be even significantly greater.
I would like to share just a few statistics with you that
highlight the need for a comprehensive update of VA services
for women veterans. As of October 2008, there were more than 23
million veterans in the United States. Of this total, women
veterans made up 1.8 million, or as Mr. Stearns noted, 8
percent of the total veteran population.
There are increasing numbers of women veterans of
childbearing age. For example, 86 percent of OEF/OIF women
veterans are under the age of 40.
The VA notes that OEF/OIF female veterans are accessing
health care services in large numbers. Specifically, 42.2
percent of all discharged women have utilized VA health care at
least once. Of this group, 45.6 percent of them have made
visits two to ten times.
Finally, according to the VA, the prevalence of potential
PTSD among OEF/OIF women veterans treated at the VA from fiscal
year 2002 to 2006 grew dramatically from approximately 1
percent in 2002, to nearly 19 percent in 2006. So the trend is
clear, but not surprising. More women are answering the call to
serve, and more women veterans need access to health services.
Clearly, we must do everything we can from a public policy
standpoint to meet this new challenge. To address some of these
issues, the ``Women Veterans Health Care Improvement Act''
calls for a study of barriers to women veterans seeking health
care, an assessment of women health care programs at the VA,
enhancement of VA sexual trauma programs, enhancement of PTSD
treatment for women, establishment of a pilot program for
childcare services, care for newborn children of women
veterans, and the addition of recently separated women veterans
to serve on advisory committees.
The VA must ensure adequate attention as given to women
veterans program so quality health care and specialized
services are available equally for both men and women.
I believe my bill will help the VA better meet the
specialized needs and develop new systems to better provide for
the health care of women veterans, especially those who return
from combat, who are sexually assaulted, who suffer from PTSD
or who need childcare services.
Mr. Chairman, thank you, again, for inviting me to testify
here today. I look forward to answering any questions you or
other Members of the Subcommittee may have.
[The prepared statement of Congresswoman Herseth Sandlin
appears on p. 36.]
Mr. Michaud. Thank you very much. Once again, thank you for
all your work in dealing with veterans' issues during your
tenure here as a Member of Congress.
I just have one question. As you know, the Senate actually
introduced a companion bill. Reading that companion bill, there
is one difference and that is dealing with newborn care. I
believe the Senate version allocates 7 days. Your version
allocates 14 days for newborn care. Is there any rationale for
the difference?
Ms. Herseth Sandlin. Well, importantly, the 14-day
provision, in my bill, that was recommended by the Women's
Advisory Committee, but I am more than happy to further discuss
with you, as we look at differences with the Senate bill,
visiting with those women on the Women's Advisory Committee, as
to the purpose of their recommendation for 14 days versus 7
days. But, certainly, I think that we can find a way to
negotiate the appropriate duration of the care following birth.
Mr. Michaud. Do you know what the Congressional Budget
Office (CBO) has scored this provision?
Ms. Herseth Sandlin. We have requested a cost estimate from
CBO. Unfortunately, we haven't received an official cost
estimate yet.
As you know, much of what is in the bill requires studies,
pilot programs, updated procedures, so those provisions we
anticipate the cost will be relatively small. Although I do
think, as it relates to the additional provision that we have
included this year in the bill that we didn't include last
year, as it relates to a duration of care for newborn children,
that that would probably be the largest item as it relates to
the cost estimate. And as soon as we get it from CBO, we
obviously--I think the Health Subcommittee has requested the
score as well.
Mr. Michaud. Thank you very much.
Mr. Stearns.
Mr. Stearns. Thank you, Mr. Chairman. I thank the
gentlelady for her bill and for her testimony.
Generally, I think my purpose is just to clarify so that we
understand things.
I think you know that the VA is currently undergoing its
own national survey of women veterans, which they expect to
complete this fiscal year. I guess, their concern, and perhaps
our concern would be, do you think we should give the VA,
perhaps, some flexibility here and let them complete their own
comprehensive assessment first, and let them analyze it and
find the results, perhaps, before entering into a study that is
mandated in this bill? It is just a consideration of what you
feel.
Ms. Herseth Sandlin. Well, thank you for the question.
In the VA's testimony during the 110th Congress when they
testified on that version of this bill, the VA acknowledged the
need for such a study, but indicated that they don't have the
resources, the staff or the budget needed to carry out such a
study. So, while they may have undertaken that, I think it is
very important that, with the authorization and, of course,
with the resources that would go along with that, that we don't
in any way delay.
There are other studies going on that are a little bit more
narrow. They are sort of peer-reviewed studies that would occur
in just one publication.
But I think that it is important now, at the beginning of
this Congress, in light of the statistics that I cited, that
you as well cited, Mr. Stearns, that we acknowledge that they
have, perhaps, undertaken a study, but we want it to be as
comprehensive as possible. And we think the provisions
authorized in this bill, particularly with the input from the
Women's Advisory Committee, we don't want to be duplicative at
the end of the day either.
And I think it is important to add to their efforts, thus
far, to make sure they understand what this Committee is
looking for as they do an overall assessment of the need for
women veterans and their health care services.
Mr. Stearns. When this assessment is done under your bill,
is it your intent that the contract or entity that is
conducting this comprehensive assessment of women's health care
programs? Would they also be required to develop the follow-up
plan?
Ms. Herseth Sandlin. We haven't anticipated if that same
contractor would be responsible for doing the follow-up. I
think that is something that I can discuss with Secretary
Shinseki, working with Mr. Michaud, working with you, working
with Mr. Brown on this Subcommittee.
But I think, for continuity's sake, if that is what has
been done in the past, when they have done, worked with a
contractor, do a study, that it makes the most sense to utilize
the same entity for follow-up, that that is something that we
would likely want to pursue for continuity purposes.
Mr. Stearns. My last question, Mr. Chairman. How would the
requirements to provide graduate medical education, training
certification and continuing medical education for mental
health professionals under this Section 202 of the bill
actually work towards helping the training that VA is already
providing?
Ms. Herseth Sandlin. Well, I think that the VA has done a
remarkable job in many instances, given some of the Medical
Centers that I have had a chance to visit, not just in my own
district, but in other parts of the country, including
Virginia, including up in New Hampshire, of being very creative
as it relates to identifying those individuals who may be
suffering from PTSD and what type of follow-up is going to be
most aggressive and effective, given the individuals that they
are working with.
But I think that they are, while their current training
efforts are excellent, they fall short because they don't
address the depth of education needed, as you state, for both
the graduate medical education or continuing medical education,
including clinical supervision, mentoring and skills testing to
master the several commonly used evidence-based treatment
protocols.
So H.R. 1211 authorizes that needed training, resources and
certification. And I think it is important, building on the
efforts of some of the Medical Centers, but they have been
doing it, I think, based on the leadership at each of the
Medical Centers. And I think, again, this provides more
comprehensive training and needs with the graduate medical
studies and the type of clinical supervision across the system
in the VA, again, building on some of the very effective and
successful programs that have been built and developed
piecemeal among different Medical Centers across the country.
Mr. Stearns. I thank the gentlelady.
And thank you, Mr. Chairman.
Mr. Michaud. Thank you very much.
Mrs. Halvorson.
Mrs. Halvorson. Thank you, Mr. Chairman.
I have a couple of questions. But, first of all, thank you,
thank you so much for bringing this to our attention. I know
that I am very pleased that the Committee is addressing some of
the issues here of the health care for women. We all know that
the increase in women veterans are going to be quite a
challenge, especially in the differences, culturally.
You pointed to a number of existing efforts to train mental
health professionals using the evidence-based practices.
However, the VA has only trained a limited number of
professionals to date. What are the VA's plans, that you know
of, for ensuring that the training reaches all of the mental
health professionals that are practicing in the VA?
I know when Secretary was here, he said that he believes
that there is a woman's outreach person at each one of the 156
centers. What is going on with regards to that?
Ms. Herseth Sandlin. Oh, that is a good question, and I
don't know specifically. Again, I think it has varied, based on
the leadership of the directors at the different Medical
Centers. And, certainly, there is a sharing of information and
best practices.
But as we have seen the explosion of women veterans
accessing care, I think some Medical Centers have been more
aggressive than others. I also think that in the early years of
OEF/OIF, when we were dealing with emergency budget requests,
there was a difficulty in adequately resourcing and fully
funding all of the programs or new developed programs that some
of the Medical Centers were trying to pursue to identify and
effectively treat, both women and men veterans who suffer from
PTSD.
I think as it relates to the proposed budget that we have
seen from the new Administration and the increased resources,
with a focus on breadth in comprehensive care, I don't know
specifically how much of those resources they would dedicate
toward women's programs, specifically those addressed to PTSD
for women veterans, whether it is related to combat experience,
whether it is related to sexual trauma, or other circumstances.
But I do think that this bill is important because it
provides the type of guidance, as well as authorizes the
resources necessary, to make sure that all of those who are
serving veterans and their mental health care needs have the
adequate training, have the adequate education and clinical
supervision necessary to ensure that the evidence-based
research demonstrates can be most effective in caring for these
veterans.
Mrs. Halvorson. Great. And the only other question I have
is--and excuse my ignorance, I am new--what has been done in
the past with regards to newborn care of babies of veterans,
female veterans?
Ms. Herseth Sandlin. Well, I don't believe the VA
facilities have ever provided for newborn care. I remember, and
I think I would need counsel to correct to me if I am wrong, I
recall an early debate when I was--shortly after I was elected
in 2004. I believe we were discussing the level of prenatal
care for women veterans. So just as recently as 5 years ago we
were discussing whether or not the VA should provide a breadth
of prenatal care services.
So, in my opinion, and based on my recent experience, it
seems somewhat unreasonable and an unfair financial burden for
women veterans, if now that we are providing, as I think we
appropriately should for prenatal care for women veterans, that
we wouldn't provide for a set, a duration, whether it is 7, 10
or 14 days, of care for that newborn, which can be quite costly
and could be, again, an unfair financial burden to the woman
veteran.
Mrs. Halvorson. Thank you. Thank you, Mr. Chairman.
Mr. Michaud. Thank you.
Mr. Teague.
Mr. Teague. Yes. Thank you. I really like the bill, but I
do have a couple of concerns because I believe that there may
be a lot of gender disparity occurring.
For instance, if we had a female veteran that requested a
female counselor, female doctor, what are the chances of her
getting that female counselor or doctor?
Ms. Herseth Sandlin. Well, I can't answer that. I don't
have the numbers at my disposal that I could get from the VA in
terms of the number of psychiatrists and clinical psychologists
they currently employ that would be providing--that would be
available to provide care. I don't know if Counsel has those
statistics.
Ms. Wiblemo. Well, I don't have the statistics, but the VA
certainly tries to pair up, if there is a gender issue, say
military sexual trauma (MST) or some type of gender issue where
a female wants to see a female doctor, they try to pair up the
gender-specific requests. I mean, it is not--you know, I don't
know that they have an entire program where they----
Probably a better question for the Department of Veterans
Affairs when they come up, but I know they do try to do that,
as far as gender disparity is concerned.
Mr. Teague. Thank you. And, also, like Congresswoman
Halvorson said, I am new, and a lot of these things you all
probably already plowed through last year and years before. But
I was concerned and curious as to how to get that information
because I will follow up on it and because I do hope that we
are accepting the fact that they are different and that their
needs are different and we need to remove all the barriers that
we can to be sure that they get all of the help that they need.
Ms. Herseth Sandlin. Well, thank you, Mr. Teague. And I
think one of the provisions in the bill, as it relates to the
assessment and the evaluation as to what those barriers are, a
survey of women veterans, asking them if you aren't currently
receiving care, why is it that you aren't. And what we can
anticipate anecdotally is one of the provisions that is
included in the bill, which is a lot of women veterans are the
primary caregivers to their children. And if they don't have
access to childcare services at the time that they are
receiving their care and their counseling, that can be a
barrier. And, so that is included, and we have changed the bill
in this Congress so that, not just women veterans, but male
veterans who also are responsible for the care of their
children can access those services under that pilot program.
But I think that we will be able to find--and, again, I
know that the Department of Veterans Affairs will be testifying
on these bills here today as well--is it a barrier, for
example--and that is what we tried to find out in this survey--
for women who may be suffering from PTSD, if they feel that
their chances of getting, and let us say they are suffering
PTSD from military sexual trauma, is it a barrier to them
accessing services from the VA because they believe that they
are quite unlikely to get a female counselor, versus who they
may be aware are already providing counseling services to some
of their male counterparts.
So, again, I think the bill is trying to get to some of the
concerns that you have as it relates to the first provision,
being one that seeks to address what are the barriers to care,
so that arms the VA with information they need in developing
new programs that can do a more effective outreach.
Mr. Teague. Good. As I thought, you all have already
checked on most of the things that I had questions about. I
appreciate, not only having done that, but of both of you for
giving me time today. Thank you.
Mr. Michaud. Thank you very much, Mr. Teague.
Once again, I want to thank you very much, Congresswoman,
for coming today and bringing forward this very important piece
of legislation. I look forward to working with you as we move
forward in dealing with the legislation. Thank you.
I would like to call up the second panel to come testify.
On the second panel we have Joy Ilem from the Disabled American
Veterans; Joseph Wilson, the American Legion; Eric Hilleman
from the Veterans of Foreign Wars of the United States (VFW);
and Todd Bowers from Iraq and Afghanistan Veterans of America
(IAVA). I want to thank each of you for coming this morning. I
look forward to hearing your testimony, and we will start with
Ms. Ilem.
STATEMENTS OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS; JOSEPH L. WILSON, DEPUTY
DIRECTOR, VETERANS AFFAIRS AND REHABILITATION COMMISSION,
AMERICAN LEGION; ERIC A. HILLEMAN, DEPUTY DIRECTOR, NATIONAL
LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED
STATES; AND TODD BOWERS, DIRECTOR OF GOVERNMENT AFFAIRS, IRAQ
AND AFGHANISTAN VETERANS OF AMERICA
STATEMENT OF JOY ILEM
Ms. Ilem. Thank you, Mr. Chairman and Members of the
Subcommittee. I appreciate the opportunity to offer our views
on the bills under consideration today.
H.R. 784 would require quarterly reports to Congress
regarding clinical mental health vacancies in VA networks by a
medical facility.
We appreciate the intended purposes of the bill, but as
written, we are concerned that enactment would not elicit the
kind of information Congress needs to properly evaluate VA
status and results in achieving its mental health reforms.
Therefore, we ask this Subcommittee to consider expanding the
scope of the bill.
Over the past several years, VA has developed an aggressive
plan for reform through its mental health strategic plan and
uniform mental health services package. Likewise, Congress has
provided significant increases in funding to improve VA mental
health programs and services.
We believe the intended purpose of this bill is to ensure
there is real progress in increasing the number of mental
health staff and programs, specifically to improve access to
these specialized services. To achieve this result, we believe
detailed oversight and monitoring are necessary now and
imperative if ongoing progress in filling critical gaps in
mental health services across the Nation is to be assured and
the goal of recovery fully embraced.
The oversight process we envision in mental health is one
that is data driven and transparent and includes local
evaluations and site visits to factor in local circumstances
and needs. An empowered VA organizational structure is needed
to carry out this task.
Such a structure would require the Veterans Health
Administration (VHA) to collect and report detailed data at the
national, network and Medical Center levels, on the scope of
programs available and on the net increase over time in the
actual capacity to provide comprehensive, evidence-based,
mental health services.
We believe the recommendations further outlined in our
statement would provide the architecture for a truly effective
oversight of VA mental health programs. Again, while DAV
supports the basic intent behind H.R. 784, we ask this
Subcommittee to consider this broader scope of oversight of
VA's mental health programs.
H.R. 785 would establish a 4-year pilot program aimed at
improving outreach to OEF/OIF veterans on the campuses of
colleges and universities.
DAV Resolution 166 supports program improvement and
enhanced resources for VA mental health programs to achieve
readjustment of new combat veterans and continued effective
mental health care for all enrolled veterans needing such
services. Therefore, DAV is pleased to support H.R. 785.
H.R. 1211, the ``Women Veterans Health Care Improvement
Act,'' would expand and improve VA health care services
available to women veterans with a focus on women veterans
returning from Operations Iraqi and Enduring Freedom.
The current number of women serving in active military
service in its Guard and Reserve components has never been
larger, and this trend 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. As a result,
women, too, bear the cost of war.
VA must prepare to receive a significant new population of
women veterans in future years who will present with needs that
VA has likely not seen before in this population.
Mr. Chairman, this comprehensive legislative proposal is
fully consistent with the 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 the DAV.
DAV Resolution 238 seeks to ensure high quality
comprehensive health care services for all women veterans, with
a special focus on the unique post-deployment needs of women
veterans returning from the wars in Iraq and Afghanistan.
Therefore, we fully support H.R. 1211 and urge the Subcommittee
to recommend its enactment.
The final bill under consideration is a draft proposal
aimed at expanding eligibility for reimbursement by VA for
emergency treatment in non-department facilities. This bill's
purposes are in full accord with the mandate from our
membership expressed in DAV Resolution 178. Its intent is also
consistent with the recommendations of the Independent Budget
to improve reimbursement policies for non-VA emergency health
care services for enrolled veterans. For these reasons, Mr.
Chairman, we urge introduction of the bill and we endorse its
enactment into law.
This concludes my testimony on behalf of the Disabled
American Veterans on these important bills, and I would be
pleased to respond to any questions from you or other Members
of the Subcommittee. Thank you.
[The prepared statement of Ms. Ilem appears on p. 37.]
STATEMENT OF JOSEPH L. WILSON
Mr. Wilson. Mr. Chairman, thank you for the opportunity to
present the American Legion's views on these pieces of
legislation.
H.R. 784, which seeks to improve the recruitment of mental
health care professionals by having the Secretary of Veterans
Affairs submit quarterly reports on mental health employment
vacancies at VA Medical Centers nationwide, now Section (a)
requires the Secretary of Veterans Affairs to submit to
Congress a report describing any vacancy in a mental health
professional position at any medical facility of the Department
no later than 30 days after the last day of a fiscal quarter.
Within these reports, the Secretary is to indicate, for each
vacancy, the Veterans Integrated Services Network, or VISN, to
which the facility with the vacancy is assigned.
Now, the American Legion's System Worth Saving Task Force
visits medical facilities throughout the VA medical system--
reports a constant need for additional mental health providers
in almost every medical facility.
As VA continues to screen, identify, and treat veterans
suffering from mental health disorders through VA outreach
coordinators and Vet Center's Global War on Terror, or GWOT,
counselors having the staffing capabilities to treat veterans
after initial intervention is paramount.
The American Legion believes that--also, this is supported
by our Resolution 150 as well. The American Legion believes
that with a quarterly report, mental health care services for
veterans will be more widely available because less time for
recruitment will be needed.
Currently, following the interview process, the hiring
process takes approximately 6 months. During that time, the
competitive private sector at times hired the prospective
mental health provider away from the VA.
The American Legion supports any standard that improves the
mental health capability of VA and its medical facilities, and,
in turn, would like to see the passage of H.R. 784.
To provide our veterans with the most adequate mental
health care, there should be--the proper amount of mental
health providers in the VA Medical Centers, there should be.
The inadequacy of mental health providers gives way to
substandard care and the possibility that veteran mental health
care needs will fall through the cracks.
H.R. 785, this bill establishes a pilot program to provide
outreach and training to certain college and university mental
health centers relating to the mental health of veterans of
OEF/OIF or Operation Enduring Freedom/Operation Iraqi Freedom,
and for other purposes.
Section 1(a) seeks to establish a 4-year program under
which the Secretary shall provide a counseling center, a
student health or wellness center at a college or university
with a large veteran population to increase outreach efforts.
Resolution 150, ``The American Legion Policy on Department
of Veterans Affairs Mental Health Services,'' states that
veterans continue to need increased access to mental health
care.
A RAND Study on the ``Invisible Wounds of War: Addressing
the Mental Health Needs of Returning Soldiers,'' in 2008,
estimated that 300,000 veterans, or 18\1/2\ percent of those
deployed, were diagnosed by VA with PTSD or major depression.
This number continues to rise and efforts to increase access
and quality of care at the universities and colleges are
imperative to ensure assistance is available to these veterans
during a time of crisis. The American Legion supports the
increased outreach efforts at universities or colleges where
many veteran students are not familiar with VA benefits and
services.
H.R. 1211, this bill seeks to expand and improve health
care services available to women veterans, especially those
serving in Operation Enduring Freedom and Operation Iraqi
Freedom, from the Department of Veterans Affairs and for other
purposes.
Approximately 1.7 million women veterans make up
approximately 7 percent of the veteran population, while
240,000 utilize VA health care services. There are currently
approximately a quarter of a million women serving in the U.S.
armed forces. By 2010, the percentage is projected to rise to
14 percent of the total population and 15 percent by 2020.
A National Institutes of Health study suggested several
areas of improving the provision of health care to this
Nation's women veterans to include the availability of needed
services, particularly women-specific services and the
logistics of receiving care, the VA, such as the waiting time
to obtain care and the issues relating to continuity of care.
The study also revealed problems with the ease of access in VA
health care as the most significant barrier to VA Medical
Center use.
We hereby urge Congress to pass this bill to add to the
closing of gaps, as well as building on a more firm
relationship between VA and this Nation's women veterans.
And on the Draft Emergency Treatment at Non-VA Facilities,
this draft seeks to expand eligibility for reimbursement by the
Secretary of VA for emergency treatment furnished in a non-
department facility and for other purposes.
The American Legion believes it is essential for veterans
to receive emergency medical care from non-VA facilities in the
absence of available VA health care or when traveling presents
a hazard or hardship for the veteran in accessing care.
In addition, VA must devise better methods of communicating
and submitting payment to third-party facilities on behalf of
the veteran. Making this so will decrease the stress added to
veterans who have to answer to agencies collecting on behalf of
non-VA facilities.
The American Legion supports the reimbursement of costs
incurred by veterans who must receive emergency care at non-VA
facilities.
Mr. Chairman and Members of the Subcommittee, the American
Legion sincerely appreciates the opportunity to submit
testimony. Thank you.
[The prepared statement of Mr. Wilson appears on p. 44.]
Mr. Michaud. Thank you.
Mr. Hilleman.
STATEMENT OF ERIC A. HILLEMAN
Mr. Hilleman. Chairman Michaud, Members of the
Subcommittee, thank you for this opportunity to present the
Veterans of Foreign Wars views before the Subcommittee.
On behalf of the 2.2 million men and women of the VFW and
our auxiliaries, it is my honor to urge quick passage of the
four bills presented before this Subcommittee today.
First, H.R. 784, a bill to report quarterly on the
vacancies in mental health professional positions in the
Department of Veterans Affairs.
The VFW supports this bill, which would require the
Secretary of the VA to report to Congress for vacancies of
psychiatrists, psychologists, social workers, marriage and
family therapists, and licensed professional mental health
counselors. Reporting vacancies to Congress will elevate the
issue and encourage mental health professionals to seek
employment within the VA. Much needed attention has to be drawn
to this issue. It is an important shortage that impacts all the
lives of our veterans.
Second, H.R. 785, a bill to establish a pilot program from
FY 2010 to 2013 to educate, engage--excuse me--to educate and
engage in outreach to college and university mental health
centers.
The VFW enthusiastically supports this legislation, which
would require--excuse me--which would give the Secretary $3
million in funding to train college and university clinicians,
administrators, and counselors for serving OIF and OEF
veterans. We believe this bill will help combat veteran
stereotypes and destigmatize mental health issues related to
military service.
Through educating the education community, this information
can hopefully be broadly disseminated into the counseling and
social work industry. Not only is this a benefit to schools and
to the community, it directly affects the lives of veterans on
campuses across the Nation.
In a time where more veterans will be seeking use of their
new GI bill, this benefit is crucial to their success for
transition and reintegration.
Third, H.R. 1211, the ``Women Veterans Health Care
Improvement Act.'' The VFW is proud to support H.R. 1211,
legislation that will improve benefits and services to female
veterans, especially those who have served or are serving in
OEF/OIF operations.
As the number of females in uniform grow, so too will the
percentage of females seeking services at VA. VFW is encouraged
by the improvements in this bill, and we remain hopeful this
legislation will ease access to services at VA by female
veterans.
The VFW recognizes the work VA has already done toward
implementing quality health care for all female veterans. Yet,
we have many challenges to overcome. I would like to highlight
three areas of this bill for special focus.
First, extended health care coverage for 14 days to female
veterans' newborns. This is essential to the health care of the
child and the mother, allowing continuity in obstetrics and
gynecological care.
Second, the provision of this bill authorizing VA to
provide graduate level training, certification and continuing
medical education care for military sexual trauma and PTSD.
MST and PTSD are all too common among returning OIF and OEF
female veterans.
Lastly, and most importantly, assessing the impediments to
care were the focus on VA's common practices. The VFW strongly
believes that VA's culture contributes to the barriers faced by
women. With more conscious effort, we can make a fundamental
difference in the lives of female veterans and improve their
quality of care.
Finally, a draft bill to close existing loopholes and law
allow VA to cover unmet emergency room treatment for veterans
in certain cases. The VFW is pleased to offer our support for
this bill, which will allow VA to pay for the emergency care
for veterans enrolled in VHA under certain cases. It closes a
loophole that sticks many veterans unfairly with a large
hospital bill.
Current law unfairly penalizes veterans who receive a
portion of their costs of their care covered from another
source, such as an insurance settlement or judgment. They may
not be eligible for reimbursement, even if the amount is a
fraction of the cost of their care. This bill allows the VA to
be a second payor in those situations, so every veteran will be
covered.
Mr. Chairman, Members of the Subcommittee, I thank you for
this opportunity and I look forward to your questions.
[The prepared statement of Mr. Hilleman appears on p. 45.]
Mr. Michaud. Thank you very much.
Mr. Bowers.
STATEMENT OF TODD BOWERS
Mr. Bowers. Mr. Chairman and Members of the Subcommittee,
thank you for inviting IAVA to testify today regarding this
pertaining legislation. On behalf of IAVA and our 125,000
members and supporters, I thank you for this opportunity and
your unwavering commitment to veterans.
I also need to point out that my testimony today does not
reflect the views or opinions of the United States Marine
Corps, in which I still currently serve as a staff sergeant in
the Reserves. It is my gunny disclaimer so I don't get choked
this weekend, so.
H.R. 784, IAVA is very concerned with the national shortage
of mental health professionals and, in particular, how the
shortage affects access to adequate mental health care for
troops and veterans.
The VA has already been flooded by new veterans seeking
care for psychological injuries. More than 178,000 Iraq and
Afghanistan veterans have been seen at the VA, have been given
a preliminary diagnosis of a mental health problem. That is
approximately 45 percent of new veterans who have visited the
VA.
Although the VA was initially caught unprepared with a
serious shortage, it is important to point out that the
Department has made significant progress in responding to the
needs of new veterans. Thanks to a mental health budget that
has doubled since 2001, the VA has been able to devote $37.7
million to placing psychiatrist, psychologists and social
workers within primary care clinics.
While psychological staff levels were below 1995 levels
until 2006, the VA has recruited more than 3,900 new mental
health employees, including 800 new psychologists, bringing the
VA's total mental health staff to about 17,000 people. The VA
is now the single largest employer of psychologists in the
country.
That being said, access to mental health care, particularly
for rural and female veterans is still an issue, in part
because of the continued shortage of mental health
professionals. As an example, Montana ranks fourth in sending
troops to war, but the State's VA facilities provide the lowest
frequency of mental health visits.
H.R. 784 will establish Congressional oversight over
vacancies in the VA's mental health professional positions, and
the increased transparency will help improve staffing at VA
hospitals and clinics. IAVA fully supports this legislation and
looks forward to seeing its rapid implementation.
H.R. 785, with the passage of the historic Post-9/11 GI
Bill last year, there will be a flood of Iraq and Afghanistan
veterans taking advantage of their new education benefits and
attending universities across the Nation. It is to be expected
that many of these veterans will return to their student health
centers while attending school for their medical care. This is
an opportune time to advertise and extend VA mental health care
services to new veterans.
H.R. 785 helps facilitate this by ensuring that student
health centers and counseling services at universities have the
appropriate support from the VA to provide best services for
our Nation's student veterans.
IAVA is pleased to support H.R. 785 and looks forward to
working with Congress to ensure that this legislation is
enacted in a timely manner and does not contain any technical
deficiencies. It is our hope that the language within the bill
will be modified to clearly define what is termed as ``large
enrollment.'' It is critical that mental health services be
available to all veterans, no matter what school they attend.
Any university with Iraq and Afghanistan veterans should
have the appropriate amount of counselors ready to assist
veterans. If only schools with a high veteran population are
allocated these resources, veterans attending institutions with
smaller veteran populations will continue to fall through the
cracks.
In addition, Section I contains the following language:
``Training for clinicians on treatment for mental illness
commonly experienced by such veterans.'' IAVA would like to see
this language more clearly defined to reduce the risk of
certain illnesses going undiagnosed and/or untreated.
H.R. 1211, IAVA is pleased to see the Subcommittee is
focusing on the unique needs of women veterans. Improvement of
VA health care for women veterans is one of IAVA's 2009
legislative priorities. More than 11 percent of Iraq and
Afghanistan veterans are women, and they deserve the same
access to health care as any other American veteran.
The ``Women Veterans Health Care Improvement Act'' will
help gather critical information on the quality of VA care
provided to women veterans. By identifying the barriers to care
or gaps in services that women veterans are experiencing, the
VA and Congress can better address these shortfalls.
With respect to Title II, Section 202, of what we received
as the discussion draft, IAVA would like to see funding devoted
to the study of the best evidenced-based treatment and care for
veterans suffering from post-traumatic stress disorder as a
result of, both sexual trauma and combat trauma, so that mental
health care providers within the VA can be trained on these
particular treatments.
This combination of traumas has rarely been studied, but
with more females serving in Iraq and Afghanistan, the
possibility of both these traumas occurring in new veterans is
significant. The VA's mental health providers must be prepared.
In addition to this recommendation, as part of IAVA's 2009
legislative agenda, we have made multiple recommendations to
adequately address the needs of women veterans. In particular,
IAVA supports prioritizing hiring of female practitioners and
outreach specialists, increased funding for specialized
inpatient, women-only, PTSD clinics, and significant expansion
of resources made available to women coping with military
sexual trauma.
At this time, I would take any questions. Thank you.
[The prepared statement of Mr. Bowers appears on p. 47.]
Mr. Michaud. I would like to thank each of the witnesses
for coming today to give your testimony on the four bills that
we have before us.
I just have a couple of questions. In relationship to H.R.
1211, you talked about your support for the bill. Do any of the
witnesses have any recommendations or thoughts on additional
women's focused research that should be included in the bill?
Mr. Wilson. Mr. Chairman, let us see. From January to
present, we have been, the American Legion has been on sight
visits to VA medical facilities, and I, myself, have traveled
this year. And what we have found is that there is a number--VA
is in the spirit of providing that continuity of care, but
there is a fragmentation in care amongst women.
And what that means is that they are receiving care from
one provider, and then care from another provider when it has
to be continuous. And what that does is, it pushes them away.
We are finding that it is pushing them outside the VA system
altogether. So they are choosing not to come or they are going
to one provider, and not going to the other. So we would like
to see that included and keep them in mind.
As I said, they are in the spirit of providing care or
providing a female veteran with a female counselor, but it is a
matter of availability as well.
Mr. Michaud. Thank you.
Ms. Ilem. Mr. Chairman, I noticed that the epidemiological
study that was proposed in the bill last session, H.R. 4107,
was omitted from this. And I know, we have been briefed by VA,
it was some months ago, but Dr. Khan, apparently, they are
conducting an epidemiological study of OEF/OIF veterans. That
includes an oversampling of women veterans.
But it wasn't clear at the time that there was actually, if
the funding had been approved and was, that was actually moving
forward, and I would just encourage the Subcommittee to perhaps
ask that question of the VA, just to ensure that that is, in
fact, moving forward because I think that would be an important
part to ensure, given the changing roles of women in military
today and their roles, especially in Iraq and Afghanistan, to
make sure that we are looking at the medical aspects and impact
of that service.
Thank you.
Mr. Michaud. Thank you.
Mr. Hilleman. Thank for the question, Mr. Chairman.
Given the scope of this Committee, there are a number of
other issues related to awareness among female veterans, I
think, that need to be addressed on a larger scale with regard
to what benefits that they are eligible for, what access they
have. I imagine that some components of this study will touch
on that when surveying the female veterans.
But from a broader perspective, we are concerned that many
female veterans are not aware of the basic services and
benefits they are entitled to.
Mr. Michaud. Okay. Thank you.
Mr. Bowers. Mr. Chairman, under our 2009 legislative
agenda, we make multiple recommendations in ways to help female
veterans as they come back.
One of the ones that I would like to point out, the VA has
made tremendous strides in trying to prevent suicide. One of
these things was the establishment of the suicide prevention
hotline. We would like to see that the counselors, who are on
the other line of those phones, are trained and/or well versed
in dealing with military sexual trauma. We think that this
would be a great advancement to an initiative that the VA has
really been outstanding on pushing.
One of the other recommendations that we have, and I will
just read this straight out under Section 3.3, where we discuss
improvement of access to care: ``We recommend that the VA
mandate uniform services at women clinics. Currently, women
clinics vary in the services that they deliver, from gender-
specific care to general primary care. Women veterans should
have access to female primary care providers when requested.
And if necessary, the VA should contract with local health care
providers to offer this service.''
One of the issues that we found with some our membership is
there are many women veterans who are also rural veterans and
they are falling into this very difficult place to try and find
appropriate treatment.
Thank you, Mr. Chairman.
Mr. Michaud. Thank you. My second question for each of you
is, as you know, the Senate has a bill dealing with women
veterans and the number of days for newborn care is different
between Representative Herseth Sandlin's bill and in the Senate
version. What criteria would you consider important in
determining the appropriate number of days for newborn care?
And we will start with Mr. Bowers.
Mr. Bowers. Throw me right on the spot, aren't they.
This would be something, again, this falls under an issue
where we are continually looking for the appropriate
information to be able to determine what kind of care these
individuals will need. I believe that there will be a
tremendous amount of time that needs to be spent to look into
this, specifically in regards to the amount of National
Guardsmen and Reservists that utilize VA health care, how will
they fall into this, how long with they will be on active
orders in those times?
Specifically, though, I would hope that we would work with
Federal agencies and mirror what other programs are available
to Federal employees and things along those lines, to be able
to come up with a solid determination on how many days they
should have off.
Mr. Michaud. Okay.
Mr. Hilleman.
Mr. Hilleman. Thank you, Mr. Chairman.
Not having great insight into the neonatal care or the
average number of days of neonatal care needed, we would defer
to the common sense factor. If there is research out there that
suggests that 7 days is appropriate versus 14, I know from
having a younger sister with a number of pregnancies, her last
pregnancy after her child spent about a month in the hospital.
So I think it would be something that we would have to view on
a case-by-case basis, giving certain leniency in the law.
Thank you.
Mr. Michaud. Mr. Wilson.
Mr. Wilson. Mr. Chairman, to ensure that my response
satisfies your question, I would like to defer to that for a
later date so I can get the full consensus of the American
Legion.
Mr. Michaud. Thank you.
Ms. Ilem. I would agree with some of the response of my
colleagues. And also, I think Ms. Herseth Sandlin also pointed
out some appropriate information with regard to that question.
I know one of the things that we heard constantly when I was on
the Women Veterans Advisory Committee, in speaking with the
women's veteran program coordinators or program managers, that,
you know, they were responsible as they developed the care for
that, getting ready for that woman to deliver, and especially
if that was for contract care outside the system that was very
difficult for them to develop those contracts with regard to
those private entities when they didn't have any, you know,
care that would be provided for the child.
And I think that VA probably has a good idea, or at least
they should have an idea and perhaps could share that with the
Subcommittee regarding what is the average stay for those that
they have provided so far, and to try to come up with the best,
in the best interest of the veteran so that they would not be
unfairly stuck with some very, very costly bill for them.
Mr. Michaud. Thank you.
My last question goes to Mr. Bowers.
You support H.R. 785, but you recommend the bill clearly
define the terms ``large enrollment'' and ``mental illness
commonly experienced by veterans.'' Can you share with us some
suggestions of how these terms should be defined, if you have
any?
Mr. Bowers. In the past few years since we have been
fortunate enough to be working with the VA on some of their
initiatives. One of the things that we have learned is that
their outreach training to individuals within the VA is
spectacular, whether it be a training initiative that they take
upon themselves, an online training program. Things along these
lines are extremely effective.
It would be interesting to hear how the VA may look at some
of these things and be able to just provide and/or basic
mailings to colleges that may not have a very large enrollment
of Iraq and Afghanistan veterans. If these programs can be
established and have them sort of spun up on the things to deal
with, it would be very easy.
Myself included, 3 years ago when I came back from my
second tour in Iraq, I was attending George Washington
University. My first semester back, I had a real tough time
just getting myself settled, and I went to my student health
center.
After about an hour of me discussing the things that I
faced in Fallujah, she looked at me cross-eyed and just tossed
me a prescription for Methylphenidate and Sonata. After being
duped up for about 2 weeks, I realized this wasn't really
effective, and eventually I had to make my way over to a Vet
Center to find out the best ways to get myself focused on my
schooling again.
I have talked to a lot of folks, and they really do reach
out to their folks at their universities because it is much
easier for them. They are close, they are nearby. There is
almost a comfort level for many individuals who see these
individuals as someone who is separated from the military to an
extent. So, therefore, that stigma in regards to seeking
treatment for mental health is very, very real for them.
I really do think that the VA would be able to identify, if
it is a university that has 2,000 veterans studying there, then
it would be very easy for them to send a team to train these
individuals. But if there is a minimal number, if there is 5 to
10 or what not in a very rural area, that may be difficult for
the VA to have those resources there.
Training programs can be established. There is a lot of
smart folks over there, and I think they can come up with
something.
Mr. Michaud. Great. Thank you.
Mr. Donnelly, any questions?
Mr. Donnelly. Thank you, Mr. Chairman.
For the DAV, you had talked about going beyond the report
and requiring the VA--this is on H.R. 784--to adopt mechanisms,
ensuring that staffing levels are commensurately stated policy.
What kind of mechanisms would you like to see?
Ms. Ilem. Well, we provided some very detailed
recommendations in our testimony, but we thought basically into
two parts, so really we need to have a good handle on because
of the money that has been provided to VA for mental health
services and the infusion of mental health staff, but we still
would like to see some very detailed oversight into the number
of, not only all the number of the staff that are at the
different facilities, the level of those programs would be
absolutely critical so we can just get a better handle on,
what, you know, VA is facing in terms of trying to provide
these forums through its uniform mental services package, its
mental health strategic plan.
Those are some very big initiatives that they have
undertaken. We really applaud the VA, those at the VA Central
Office level that have developed those. But we think now is the
time for oversight. It is very critical period as they are
trying to develop recovery as a goal in terms of their mental
health staff, and that they are trying to really upgrade all of
their programs in substance use disorder, PTSD, and a number of
other issues.
Mr. Donnelly. And this, Mr. Bowers, for our vets coming
back from Iraq and Afghanistan, how do we get them to buy into
mental health screening to making sure that if they have
concerns, that we can meet them because I know some of them
have told me in the past we don't want to participate in this
because we are afraid it might affect us employment-wise, it is
a stigma. How do we get past that?
Mr. Bowers. One of the things that we have called for at
IAVA for years, and though this doesn't fully pertain to this
Committee, as mandatory pre- and post-deployment screening. We
see this as the only way to remove the issue. Right now, we
spend six times as much on dental care than we do mental health
care, yet one-third of Iraq and Afghanistan veterans returning
have a mental health issue. Getting them in the door is the
difficult part.
So by making mandatory pre- and post-deployment screening,
we are allowed to establish a baseline as to where they were
before they deployed and where they are afterward, allowing
proper treatment and also that ability to feel confident that,
while they are speaking with this individual, they will not be
seen by their fellow servicemembers as being weak or anything
along those lines.
Currently, a lot of the screening methods that are used by
the U.S. Department of Defense are woefully inadequate. They
are not effective in identifying what the problems are, making
individuals feel that they can reach out and get some help.
Mr. Donnelly. And you hear so often that, you know, it is
not in the first week or two back home that issues start to
crop up, but a couple of months later. And, I guess, the
question again is, how do we encourage them to come back in and
have another check when they may not have wanted to do the
first one?
Mr. Bowers. By making it mandatory again.
Mr. Donnelly. Okay.
Mr. Bowers. If there is anything the military is good at,
receiving orders and following those orders. We mirrored this
almost very similarly to the way we had mandatory drug testing
in the late 1990s, or excuse me, mid-1990s.
When that was established, that stigma of, oh, he called
into the First Sergeant's office and he is getting busted right
now, that is gone because, now, everybody has to do it.
This is one of the issues that, you know, we have strongly
pushed. And we understand that is a very difficult issue to
overcome, but stigma is a huge issue, so it is going to take
great strides to really try and remove that.
Getting people to come in continually by mirroring some of
the programs that have been established by the National Guard,
specifically even in Maryland, where they require their
servicemembers to come in up to 180 days after their
deployment, we think, would be extremely helpful.
Mr. Donnelly. Would you recommend something like,
obviously, immediately post deployment, but then again, like a
3-month, 6-month, 1-year visit?
Mr. Bowers. Yes, 3 months, 6 months, a year afterward, just
sitting down with an individual and having them kind of go
through everything and make sure you are squared away because
right now, by watching a DVD and filling out a bubble form, it
is not working, and we have seen that after the past 8 years.
Mr. Donnelly. All right. Thank you.
Thank you, Mr. Chairman.
Mr. Michaud. Thank you, Mr. Donnelly.
Mr. Teague.
Mr. Teague. Yes, actually, I would like to make a couple of
comments to different questions that came up and one of them
was about the rural communities and, as you were saying, where
you have a population of 2,000 veterans, it is really easy to
serve them. But my district is larger than the State of
Pennsylvania, so we have a lot of small communities with just
two or three people.
I think one of the things that we need to be able to look
and maybe get some ideas from the panel, also, but you don't
incorporate broadband so that we can do their training just
like we do a lot of other education over the Internet, from the
libraries or different places.
You know, there has been some pro and con here about
reporting the vacancies that are of the mental health
providers, you know. And, I mean, I think that that definitely
has to be done. I think it is the accountability that we have
to have if, for whatever reason, people are trying to hide
the--maybe they think it is a reflection on how they are
running their area if they continually have vacancies in these
mental health places.
But if we have vacancies, then we have people that are not
being served. And the only way that we can improve that is to
have accountability so that everybody everywhere knows what
they are doing with that.
Would anybody like to comment on that?
Ms. Ilem. I would just make mention that in talking with
folks that are in the field, mental health folks that are in
the field, and those that have just recently retired from VA,
but have had decades of experience in understanding the changes
that have occurred over the last several years and the reforms
that VA is undertaking, I think they feel a tremendous amount
of pressure to do what is mandated from the top down, but there
is a lot of other factors involved for them, including the
Veterans Equitable Resource Allocation (VERA) system that, how
these programs are funded, what kind of support they get from
their Medical Center directors and others, you know, that
support the mental health programs.
And once these programs are ramped up and, you know, the
Medical Centers are then required to sustain them. It sounds
like, now, that they are going to be--instead of having fenced
money or particular money dedicated to those programs for the
startup, then those will be required to go into the regular
allocation system through VERA.
And I think that there is, they have been asked to do
different surveys about how many people, how many mental health
specialists it will take to run these programs, how many staff
they will need, how many support staff they will need. And when
they have put those numbers forward, they have shared with us
that, you know, a different number has come back in terms of,
well, this is what you are going to get, or this is what you
need to do make it work, versus them with their expertise and
knowing how long it takes to provide these very specialized
evidence-based treatments, the number of, you know, times that
they need to see these patients over a longer, more extended
period for these mental health evaluations and treatment.
I think all of those things are making them, you know, feel
a lot of pressure at the local level, and I think the oversight
that we have detailed in our testimony would really help
relieve that in terms of really getting a good assessment
because I think everybody is saying the same thing, that they
want to see these mental health programs out there available to
our veterans and have that access. And I think the providers in
the field want to have that, too.
So it is just a good mechanism not to be punitive, but to
really just have, for all of you to have access to that
information and us, as well.
Mr. Teague. I agree because I think that by having it
public and accountable, I think it protects the providers
against demands being put on them and what they produce as well
as protecting the veterans who need to occasionally see the
providers.
One other thing that I wanted to talk about was the pre-
and post-screening being mandatory, and I don't disagree with
that, but I think what we need to do is be sure that we don't--
when we do the post-mandatory interview, is don't make that be
the, necessarily, the last one. Allow that--you know, because
when that man comes back or woman comes back and is getting a
chance to get away from all of this misery and get back to my
family and everything, they are going to give all of the right
answers to get loose. They don't want to be here next week
answering questions still.
So, I think whereas, with the drug test, we do the test,
and it is yes or no. When we do these tests for mental problems
that they have, they are not yes or no, they are maybes and
ifs, ands and buts.
So I think we need to not necessarily close the book on
those people and I don't know if you all have any input on how
to put that in.
Mr. Bowers. I completely agree. What we really would like
to see is ongoing screening for these individuals. It is very
similar to if they receive a back injury to whatever it may be.
The key is going to be destigmatizing mental health and
referring to it as an injury. It is an injury. It is something
that can be treated and it is something that someone can
recover from and do just fine. And that has been a problem for
so many years, is that it is focused on that once you receive a
mental health injury, that you are damaged goods, and that is
not the case, that is not the truth. Many brave men and women
have served nobly overseas and they don't deserve that when
they come home, to be seen that way. And by doing that is
getting themselves in the door, getting themselves the
treatment that they need.
But it is the screening process that once it is made
mandatory, people can go in and receive screenings up to 2
years later, and they may have issues such as sleep apnea,
things along those lines, which does not mean they have full-
blown PTSD. It just means that may have some reintegration
problems. There is nothing wrong with that.
We strongly believe that this is going to be the only way
to really get folks so that they can be established and get the
health care that they need.
As I mentioned before, dental issues, servicemembers always
have issues with their teeth. Well, that's why before every
deployment and after every deployment I have to go see a
dentist and get myself squared away. I don't have the best
grill, but at least it is taken care of. Same thing needs to
happen with my mind.
I just said ``grill,'' didn't I?
Mr. Teague. Thank you. Mr. Chairman, thank you.
Mr. Michaud. Thank you very much. Once again, I would like
to thank the four of you for your testimony this morning. I
look forward to working with you as we move these bills through
the process. Once again, thank you very much.
I would like to call on the third panel which consists of
Dr. Gerald Cross, who is the Principal Deputy Under Secretary
for Health, who is accompanied by Walter Hall, who is Assistant
General Counsel to the Department of Veterans Affairs.
I would like to thank both of you gentlemen for coming this
morning and look forward to your testimony on the bills before
us today.
So without any further adieu, Doctor Cross.
STATEMENT OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY
UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER
HALL, ASSISTANT GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL,
U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF GERALD M. CROSS, M.D., FAAFP
Dr. Cross. Good morning, Mr. Chairman and Members of the
Subcommittee. Thank you for inviting me here today to present
the Administration's views on four bills that would affect VA
programs that provide veterans' health care. Joining me today
is Walter Hall, Assistant General Counsel.
And I would like to request my written statement be
submitted for the record.
Mr. Michaud. Without objection.
Dr. Cross. We appreciate the opportunity to express our
support for several bills that touch on a range of important
issues, including mental health care, outreach, emergency care
and women veterans care.
VA recognizes the important role mental health providers
fulfill with regard to veteran care. VA has been working
diligently to enhance mental health services throughout our
system. We have done this in part by increasing our core mental
staff by 4,000 positions over the past several years, and that
expansion is continuing.
Our commitment to ensuring that veterans receive needed
mental health services necessarily demands that we do our
utmost to ensure that staffing levels at VA points of access
are sufficient. This data is best collected and understood,
however, at the local level, which is why VA does not support
H.R. 784.
The bill would require the Secretary to submit quarterly
reports to Congress on any vacancies in mental health
professional positions by medical facility and by VISN.
Staffing and workloads are dependent on local factors related
to the local veteran population, usage rates, veterans'
particular health care needs and local employment factors.
Oversight is most effectively achieved through the VISN
managers with accountability to senior leadership and through
the use of performance measures.
The current model is effective. The value in creating a
quarterly reporting requirement at the national level is
limited, particularly since it would necessitate the creation
of a data infrastructure to meet the bill's technical
requirements and have no context once removed from the local
factors. We would be pleased to brief the Committee on our
efforts thus far.
VA supports the intent of H.R. 785, which would require VA
to conduct a 4-year pilot program to provide outreach and
training services related to the mental health needs of OEF/OIF
veterans to certain college or university counseling centers,
student health centers and student service centers, but we can
do what the bill proposes and do it more efficiently. VA
already has a number of outreach programs for this population.
We can expand those to include already established training
programs. VA mandates, for instance, a training requirement of
suicide awareness for OEF/OIF veterans. It mandates
participation in this course for certain VHA staff; I took it
myself.
We have shared this module with the Department of Defense,
and will direct each medical facility to offer it to their
local community colleges and 4-year colleges and universities.
VA has produced several public service announcements that also
address the bill's concerns, and we will provide these to
colleges and universities for campus broadcast. We will invite
college staff to attend local conferences on the health care
needs of OEF/OIF veterans and we welcome the opportunity to
meet with Subcommittee staff to discuss this bill further.
VA supports the draft bill expanding the reimbursement
benefits available to veterans for emergency treatment.
Specifically, this bill would provide reimbursement for
treatment VA has not previously approved from a non-VA provider
for a non-service connected disability. This would relieve a
potential burden for veterans.
Currently, VA is a payor of last resort. This means a
veteran who would otherwise be eligible for reimbursement of
emergency medical expenses is ineligible for the benefit if a
third party makes even a partial payment. This leaves veterans
with sizeable medical debts for which they are personally
liable.
VA also supports most of H.R. 1211, the ``Women Veterans
Health Care Improvement Act.'' The bill would require a
comprehensive assessment of all VA health care services and
programs. Also, the bill would require the VA's Advisory
Committees on Women Veterans and on Minority Veterans to
include recently separated veterans of these populations, a
practice that we already follow.
With the clarifications noted in my written statement, we
would support each of these provisions. VA does not consider
section 101 of this bill necessary, as we already have a
similar study underway. The study is expected to be complete in
the next 6 months.
Before we can take a position on Section 201, medical care
for newborn children and women veterans receiving maternity
care, we first need to determine whether the timeframe of 14
days is appropriate. Additionally, we must complete the cost
estimate for this provision. Once we complete these analyses,
we will submit our views and cost estimates for the record.
Similarly, Section 203 would establish a pilot program
where VA would furnish childcare services directly or
indirectly to eligible veterans. We share the Committee's
interest in ensuring appropriate access to care. Once we have
completed our analysis, we will submit our views for the
record.
We do not support Section 202, however. This section would
require VA to carry out a program to provide graduate and
medical education, training, certification and continuing
medical education for mental health professionals who provide
care and counseling for sexual trauma and post-traumatic stress
disorder. We believe this section is unnecessary because our
current training and continuing medical education practices
exceed the requirements of the bill.
We already train our mental health professional on
evidence-based practices for PTSD and associated conditions
that can result from sexual trauma, such as depression and
anxiety. We are conducting two national training initiatives on
cognitive processing therapy and prolonged exposure for PTSD.
Moreover, VA has begun training our mental health
professionals on acceptance and commitment therapy and
cognitive behavioral therapy. Each of these training courses
includes materials and information specifically educating
providers about treating women veterans. My staff have just
informed me, I believe that we train about 1,900 of our staff
already, 1,900.
Finally, I would like to mention the VA has already
established a military sexual trauma support team at the
national level to monitor MST screening and treatment, oversee
MST related educational training and promote best practices for
screening and treatment of the mental and physical health and
consequences of MST. And by the way, the Congressman who asked
a question about the percentage of female providers, 52.85
percent of our psychologists are female.
Mr. Chairman, thank you, again for the opportunity to
discuss these important proposals with you today. This
concludes my prepared statement. I'd be pleased to answer any
questions that you or the Members have.
[The prepared statement of Dr. Cross appears on p. 48.]
Mr. Michaud. Thank you very much, Doctor Cross for your
testimony.
You noted in your testimony regarding H.R. 784 that VA
achieves oversight by holding the VISN managers accountable to
senior leadership. Could you please explain how the VISN
managers are held accountable? For example, does the Central
Office have a mechanism for monitoring what happens at the
local level, and are there any rewards or penalties to the
VISNs based on performance?
Dr. Cross. The answer to that, sir, is yes. We do have a
mechanism in place. An example of that would be a performance
measure that we created approximately a year ago to set for our
new patients a 14-day standard during which they must receive a
comprehensive evaluation.
We monitor that using our electronic health system record
to determine who is meeting that standard and who is not. This
goes beyond the issue of staffing. This is a more effective way
of managing a medical program than focusing on staffing. We
want to measure function. We want to measure what is really
happening. And so we do performance measures and we have
hundreds of them for various programs, one of them being, for
instance, mental health, as I just mentioned.
Furthermore, the analysis that you're requesting in the
bill would not answer the question that is being asked. It does
not include the full scope of mental health services that we
provide. Primary care provides mental health services. Vet
Centers provide mental health service. Fee-basis care provides
mental health services.
I work with over a hundred academic affiliates. We are
reengaged with them and their staff and their residents and
their fellows, who are also involved in this.
So the combination of those things, particularly with the
performance measures is the better way to go.
Mr. Michaud. Could you provide the Subcommittee, if you
don't have it now, with the current state of mental health
vacancies, where they are located and what is being done to
fill those vacancies?
Dr. Cross. I don't have that report, sir. If you request
it, of course, we will get it. But what we do track is the
performance measures and how we are actually doing in seeing
our patients.
I could give you some more information on that. For
instance, on the 14-day standard, we set a 90-percent goal. All
of our visits had achieved that sometime back, so we raised the
goal and made it 95 percent. As of about 2 weeks ago, I believe
15 out of the 21 VISNs had achieved the goal, and the remaining
6 were very close to achieving that and will do so.
Mr. Michaud. Okay. Yeah, I still would like to know what
that vacancy number is and what is being done to fill those
vacancies.
Dr. Cross. Yes, sir. We will issue a report.
[The VA subsequently provided the information in the Post-
Hearing Questions and Responses for the Record, which appear on
p. 58.]
Mr. Michaud. On H.R. 785, what would you recommend to
improve this legislation so that it will not dilute or
duplicate what the VA is currently doing?
Dr. Cross. You must know that my fundamental concern about
this is that are thousands of colleges. And to take our staff
away from patient care to go train the faculty at each local
community college and university, I think, is a noble endeavor,
but my first responsibility is to providing care to our
patients, and that is what my focus is.
So I think that what we were recommending was, what I
believe to be, an alternative and more effective technique.
I have in the audience a copy of the book that we provide
for training, if someone can hold that up. I can provide the
Committee, if they so desire, with copies of that, and it is
very substantial. This could be used by the local faculty
without having to have our staff there. It is self taught. I
took it online. And this particular volume is for suicide
prevention, suicide awareness, detecting those signs which
might indicate an individual is in some distress and doing
something about it.
We like to also work with the local universities to take
some of the wonderful public service announcements that we have
done. We just had one done with Gary Sinise, who was Lieutenant
Dan in the movie ``Forrest Gump.'' Outstanding PSA that he did
for us. Richard Petty is doing one for us on another program
right now, the famous race-car driver. Deborah Norville has
just completed one that we are showing nationwide. We would
like to share those with our colleagues at our local colleges
and universities and ask them to put those out in their own
media or their own stations.
We would like to make contact with them and invite them
over and say, we are having a meeting, can you come over, would
you like to learn more about the care of veterans.
I think those are the healthy effective ways of doing this,
rather than going out and trying to set aside, establish, and
train the faculty at the university and set up a special
program of training.
Mr. Michaud. Thank you.
My last question is, in 2006 the Advisory Committee on
Women Veterans recommended that VA seek legislation to cover
the cost of post-delivery care of all newborn children
delivered to women veterans receiving VA maternity benefits for
up to 14 days. VA had no official position back then, and in
2008 they recommended that VA support legislation regarding
newborn care without a limit on the duration of the benefit. VA
supported this recommendation with modifications so that it
applied only to cases where a covered newborn requires neonatal
care services immediately after delivery, but does not cover
routine well-baby services.
Can you explain what neo-services are and what timeframe
are they to provide these type of services? Also, could you
explain what routine baby services encompasses and the
timeframe for that as well?
Dr. Cross. On that last part, I am a family physician. I
have delivered a lot of babies. And, you know, this is a
subject that the VA staff is very sensitive to and wants to be
very helpful on this issue. Unfortunately, I can't give you an
exact opinion on behalf of the Administration today because we
are still working on the cost estimate.
Secondly, we don't really know where the 14-day requirement
came from. It seems a bit arbitrary.
Most of the patients, the babies that I have delivered, you
know, they were ready to go home in 2 or 3 days. If a child has
certain conditions like neonatal sepsis, a bilirubin problem,
so forth, several days can be, additionally, can be added on.
We need to work through this with the Committee to find out
what the best answer is, and I don't think today I have the
best answer for you.
[The VA subsequently provided the information in the Post-
Hearing Questions and Responses for the Record, which appear on
p. 58.]
Mr. Michaud. Okay. I appreciate that very much, Doctor,
because unlike you, I have not delivered any babies and I look
forward to your expertise in this particular area, as well.
Mr. Rodriguez.
Mr. Rodriguez. Thank you. I have participated on----
[Laughter.]
Mr. Rodriguez [continuing]. On the issue of women's
services, I would hope that we want to be supportive, we want
to do everything we can, and I know you also want to do that,
and I foresee that there will be other pieces of legislation
that are going to require you to do certain things, so I am
hoping that you take, as an agency, take the initiative,
especially on women's services.
You mentioned that there are some things that you are
already doing on sexual trauma, I kind of look at it like this
Congress, when it was nothing but men, and then we had the
first females. They could not find a restroom or anything like
that, or a school turns coed and they continue to have problems
in the near future.
I think we are going to continue to have difficulty, so I
would hope that there is some mechanism throughout the system,
and in each one of these hospitals and clinics that allows an
opportunity to look in terms of not only the facilities, but
also the type of services for women, the type of training that
the people are getting to make sure that happens. And maybe
that is something that you can comment on or we can hope that
the system takes it upon themselves to make that initiative
systemwide and consistent for a good time to come.
Secondly, in the area of mental health services. I have
been a State legislator for 11 years. I have been a school
board member for 12 years. Anyone who comes to Congress all of
the sudden gets bombarded with a great amount of case work. In
that case work, a large number, at least in my district, are
veterans. And the only thing I can say is that I am handling a
lot of your cases that you should be handling. And so, somehow
a case management system would be something that would be
beneficial at this time to try to look at.
We have done legislation to provide you the flexibility to
contract out with community mental health centers,
understanding that you didn't have all the staff that is
required and needs and that you are overwhelmed. Can you report
in terms of how we are doing from that perspective in terms of
mental health services and contracting out that is occurring
right now?
Dr. Cross. Congressman Rodriguez, you ask several very good
questions and I certainly support your sentiments that you
express. In regard to the number of women veterans coming to
see us, I strongly agree with you.
About 5\1/2\ percent of our patients right now are women,
5\1/2\ percent. I think that should be substantially higher. I
want to make sure, and our staff want to make sure, that VA is
the first choice, a place where they will feel most
comfortable.
One of those things, of course, is to make sure that we
have a staff that is well trained and that is sensitive to
their needs. And we also want to make sure that we have the
appropriate number or adequate numbers of female staff.
I pointed out before, 52.85 percent of our psychologists
now are female; 84 percent of our nurses are female; 82 percent
of our occupational therapists are female; 62 percent of our
physical therapists are female; 58 percent of our pharmacists
are female, on and on. I could go down the list.
We are very sensitive to this issue. We are doing a good
deal. We want to do a good deal more and, as I said, make sure
that we are their first choice and that those numbers increase.
We do case management. We have women's coordinators at each
of our Medical Centers and we do outreach, and we are trying
desperately to do better outreach, more effective outreach so
that women veterans understand that there is a place that they
can go that will welcome them and provide the services they
need.
In terms of fee-basis care, we do it where we need to, and
we are doing billions of dollars' worth of fee-basis care per
year. I believe the last number I heard was about $3 billion in
fee basis.
Mr. Rodriguez. I have a district similar to my colleagues
next to me, West Texas, which is at least 650 miles long. And
in my district I know we just did a contract with one physician
in one area. Other than that, the others, in West Texas, there
is a big gap in those rural communities. I would hope that
somehow we reach out to some of those community mental health
centers that provide those kind of services to do some of that
work.
What do you attribute the number of cases that our
Congressional Members have with your clients?
Dr. Cross. I can tell you that we do everything we can to
work with our Congressional Members in our local communities to
make sure that if they do get an inquiry, that we provide an
efficient pathway to immediately resolve whatever that we can
resolve.
We want to be a welcoming home for these individuals, and
we are doing our absolute best to be that home.
Mr. Rodriguez. Let me encourage you to be forthright with
us in terms of what you might need in terms of services because
we want to do the right thing, but what I foresee is additional
types of legislation for additional types of reporting if the
complaints continue. As you well know, that usually occurs.
No one hates more bureaucratic stuff than I do, and at the
same time I would really hope that maybe the agency comes up
with an aggressive program, not only reaching out to women, but
looking at all of the types of things that might need to occur
in each one of those facilities, as well as doing what we can
to make sure that suicide numbers drop, as well as reaching out
to a lot of the other ones that suffer from mental health.
I know that mental health is a real difficult area where
you can have just a few individuals are bogging down the
system. I don't mean to be rude in that area, but they are a
difficult clientele to deal with, because of the fact that they
suffer from mental health.
But there is also the problem that the ones that suffer
from mental health, because of the mental health problem
itself, do not seek it out and so there needs to be outreach
that needs to occur and needs to happen by the agency.
Otherwise, we are going to continue to have problems out there.
And I am hoping that that can happen.
Now, case management, what do we have now that you say that
we have a case management system?
Dr. Cross. Sir, we have case managers for OEF/OIF, for
women veterans, for MST, Federal recovery coordinators,
transition patient advocates. We have a whole range, depending
on the needs of the individual that we are serving.
And let me say, sir, satisfaction is something that we take
very seriously. We track it, we measure it, we get third
parties to do it with us. We also do mystery shoppers to make
sure. Our satisfaction levels are very good and have continued
to be good out here for some time.
And in regard to where we send out cases in the community,
we also have to make sure that those facilities that we send
them to, that we refer them to will achieve certain standards.
For instance, we do screening for MST. We do screening for
PTSD, for depression, for substance abuse. We have people that
are specially trained in PTSD. As I mentioned, the hundreds and
hundreds that we trained in special techniques, we don't want
to send them somewhere where they don't have those advantages,
so we are sensitive to that issue as well.
Mr. Rodriguez. Thank you for all the good work that you do
do.
Dr. Cross. Thank you, sir.
Mr. Rodriguez. Thank you.
Mr. Michaud. Mr. Boozman.
Mr. Boozman. Thank you, Mr. Chairman.
I want to apologize for running in and out to you and the
panel. I have had two or three things that have just kind of
cropped up that I am sure they were emergencies.
But I really do not have any questions. What I would like
to do, though, is reserve the right to go ahead and submit some
in writing for the future.
And it is good to be back on the Health Subcommittee. We
appreciate your leadership and look forward to having a really
productive Congress.
Mr. Michaud. Thank you very much, and we are very fortunate
to have you back on the Subcommittee and look forward to
working with you as we move forward, not only on these pieces
of legislation, but throughout the next 2 years.
I understand that Members have a lot of other competing
emergency needs as well, so you don't have to apologize. I
really appreciate your willingness to participate in the
process.
Mr. Teague.
Mr. Teague. Yes, thank you. And I also need to apologize
for running in and out. I am going to have to learn how to
manage my time, I think. I am going to take advice from some
people that have been here longer.
But I did want to touch on one thing and that is the fee-
based services that I heard you talking a little bit about, you
know, and I think we have to do more fee-based services and be
sure that when we are doing them, that we are doing them for
the benefit of the veteran and not for internal reasons that we
are doing them.
And the reason that I am bringing that up, and I am sure
that we all have scary stories and everything, but we had a
gentleman that was actually a World War II veteran, that he
could have gotten that service in town, but they required him
to go to a VA Center. It was 285 miles. And as the young man,
the Vietnam veterans, who were hauling him back and forth 3
days a week, said, we are killing him hauling him back and
forth because they needed his number to justify their services
at the VA Center, instead of letting him have----
So I know that we have dealt with numbers, we have to work
with numbers and that, but I would like for us to also to look
at the individuals so that we do take care of the people that
need help and not fill our numbers. Thank you.
Dr. Cross. Thank you, sir.
Mr. Michaud. Once again, I would like to thank you very
much, Doctor Cross for your continued efforts to make sure that
our veterans get the benefits that they have earned and
deserve, and for the commitment of both you and your staff, Mr.
Hall, and the entire staff at the VA. You do a phenomenal job
and hopefully Congress will be able to provide a budget that
will reflect the needs of taking care of our veterans. And as
you mentioned earlier, Doctor Cross, it is more or less making
sure that we get the work done. The numbers are good to have,
but the services must be provided.
I want to thank you and all the previous witnesses for
coming today. Thank you.
This hearing is adjourned.
[Whereupon, at 11:48 a.m. the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud, Chairman,
Subcommittee on Health
I would like to thank everyone for coming today.
Today's legislative hearing is an opportunity for Members of
Congress, veterans, the VA and other interested parties to provide
their views on and discuss recently introduced legislation within the
Subcommittee's jurisdiction in a clear and orderly process.
I do not necessarily agree or disagree with the bills before us
today, but I believe that this is an important part of the legislative
process that will encourage frank discussions and new ideas.
We have four bills before us today. Each of the bills address
important issues affecting our veterans today. They cover a wide range
of important issues including mental health; women veterans; and
reimbursement for emergency care treatment in non-VA facilities.
I look forward to hearing the views of our witnesses on these bills
before us.
Prepared Statement of Hon. Cliff Stearns
Thank you, Mr. Chairman.
At our hearing today we will examine four bills that have been
referred to our Subcommittee.
The first bill H.R. 784 would require VA to submit quarterly
reports on mental health professional vacancies. The second, H.R. 785,
would establish a pilot program to provide mental health outreach and
training on certain college campuses for Operation Iraqi Freedom and
Operation Enduring Freedom veterans. The Department of Veterans Affairs
(VA) has made great improvements in the past 2 years to reach out to
more veterans and provide better, more effective mental health
services. With a growing number of veterans in need of mental health
care we must continue to focus on how we can build on the progress VA
has made thus far and I very interested in hearing views on these
proposals.
I thank our Chairman, Bob Filner, for reintroducing a bill to
expand the benefits for veterans related to the reimbursement of
expenses for emergency treatment in a local, non-VA facility. I am
pleased to see that changes have been made to the bill to clarify the
requirements for VA payment under the program.
I would also like to commend my good friend Stephanie Herseth
Sandlin for being a champion of women veterans. Her bill, the Women
Veterans Health Care Improvement Act, includes a number of provisions
designed to study, improve and expand access to care for our women
veterans.
The number of women serving in the active duty, guard and reserve
continue to increase. Today, women represent almost 8 percent of the
total veteran population and nearly 5 percent of all veterans who use
VA health care services. VA estimates that the number of women veterans
enrolled in VA health care will more than double over the next decade.
It is essential for us to make sure that VA is providing appropriate
programs and services throughout the country to meet the unique
physical and mental health needs of our women veterans. However, as we
examine new initiatives, we must also be careful to ensure that they
compliment and do not overlap existing VA efforts in research and
programs for women veterans.
I look forward to a very productive discussion on these legislative
proposals and want to thank all of our witnesses for participating in
today's hearing. Your testimony will help guide our actions to best
serve our Nation's veterans.
Prepared Statement of Hon. Niki Tsongas
Chairman Michaud, Ranking Member Brown, Members of the
Subcommittee, thank you for giving me this opportunity to testify.
I have introduced two bills, H.R. 784 and H.R. 785, to improve the
quality and accessibility of mental health services for our veterans.
Almost 1 million (945,423) Operation Enduring Freedom and Operation
Iraqi Freedom veterans have left active duty and become eligible for VA
health care since 2002.
Four hundred thousand three hundred four (42 percent) of these
veterans have obtained VA care and approximately 44 percent of that
number are facing mental disorders (178,483). The three most common
diagnoses are PTSD (92,998), depressive disorders (63,009), and
neurotic disorders (50,569). These rates are two to three times that of
the general population.
My first bill, H.R. 784, simply requires the VA to report vacancies
in mental health professional positions at VA facilities on a quarterly
basis.
With the significant influx of OEF and OIF veterans facing mental
health wounds, as well as the already existing veterans populations
from earlier generations receiving care at the VA, it is incumbent upon
us to make sure that we have the necessary staffing to provide care.
This bill will help this Congress perform our oversight role and it
will help the VA use its limited resources to effectively care for our
veterans.
My second bill, H.R. 785 will help veterans seeking to improve
their lives through education.
The 110th Congress passed the most sweeping modernization of the
Montgomery GI bill since the program's creation after World War II. The
purpose of the modernization is to give veterans of Afghanistan and
Iraq access to the education and job training tools that they will need
to achieve the American dream they risked so much to defend.
As I stated earlier, approximately 44 percent of Afghanistan and
Iraq veterans who have sought treatment at the VA have demonstrated
signs of mental health wounds, including PTSD.
Studies have shown that PTSD can have a negative impact on an
individual's ability to focus and ability to learn.
Returning from a war, separating from service and then beginning
school can place significant strains on the mental health of a veteran.
It is critical that we provide our veterans with the assistance
they need to manage and recover from these wounds so that they can take
advantage of the opportunities available to them.
To that end, I have introduced H.R. 785.
My bill directs the Secretary of Veterans Affairs to carry out a
pilot program to provide outreach and training to certain college and
university mental health centers so that they can more effectively
identify and respond to the mental health needs of veterans of
Operation Enduring Freedom and Operation Iraqi Freedom.
My legislation would not break the continuum of care provided by
the VA. The purpose of this bill is to provide college counselors and
other staff who come in close contact with student-veterans at their
schools with the tools to recognize symptoms of combat related mental
health wounds; the ability to appropriately assist a student-veteran in
need; and an understanding of how to effectively refer that student-
veteran to the VA for care.
I believe my legislation will actually augment the VA's continuum
of care and bring in veterans who may be hesitant or apprehensive about
seeking care from the VA.
The intention of both H.R. 784 and H.R. 785 is to ensure that we
have adequate services to address the mental health needs of our
veterans and that we give our veterans the opportunity to build full
lives once they take off the uniform.
Thank you for the opportunity to testify before the subcommittee. I
look forward to working with you Chairman Michaud, Congressman Brown
and the other Members of this Subcommittee to improve these bills and
to improve the quality and accessibility of the care we provide to our
veterans.
Thank you.
Prepared Statement of Hon. Stephanie Herseth Sandlin
Good morning Chairman Michaud and Ranking Member Brown. Thank you
for holding today's hearing. I appreciate having the opportunity to be
here to discuss the ``Women Veterans Health Care Improvement Act.''
The ``Women Veterans Health Care Improvement Act,'' which I
introduced on February 26, 2009, along with the original cosponsor
support of Health Subcommittee Members Representatives Boozman and
Moran, will take important steps to expand and improve Department of
Veterans Affairs health care services for women veterans. Before I talk
more about the bill and the needs of women veterans, I also would like
to take this opportunity to thank the DAV for their continued
leadership in the effort to address the needs of women veterans and
their support for this important legislation.
As your Subcommittee knows, more women are answering the call to
serve, and more women veterans need access to services that they are
entitled to when they return. With increasing numbers of women now
serving in uniform, the challenge of providing adequate health care
services for women veterans is overwhelming. With more women seeking
access to care, and for a more diverse range of medical conditions, in
the future, these needs will likely be even significantly greater.
I would like to share just a few statistics with you that highlight
the need for a comprehensive update of VA services for women veterans.
As of October 2008, there were more than 23 million
veterans in the U.S. Of this, women veterans made up 1.8 million or 8
percent of the total veteran population.
There are increasing numbers of women veterans of
childbearing age. For example, 86 percent of OEF/OIF women veterans are
under age 40.
The VA notes that OEF/OIF female veterans are accessing
health care services in large numbers. Specifically, 42.2 percent of
all discharged women have utilized VA health care at least once. Of
this group, 45.6 percent have made visits 2 to 10 times.
Finally, according to the VA, the prevalence of potential
PTSD among new OEF/OIF women veterans treated at VA from fiscal year
2002-2006 grew dramatically from approximately one percent in 2002 to
nearly 19 percent in 2006.
So the trend is clear, but not surprising: More women are answering
the call to serve . . . and more women veterans need access to services
that they are entitled to. Clearly, we must do everything we can from a
public policy standpoint to meet this new challenge of women veterans.
To address some of these issues, the ``Women Veterans Health Care
Improvement Act'' calls for a study of barriers to women veterans
seeking health care, an assessment of women health care programs at the
VA, enhancement of VA sexual trauma programs, enhancement of PTSD
treatment for women, establishment of a pilot program for child care
services, care for newborn children of women veterans, and the addition
of recently separated women veterans to serve on advisory committees.
The VA must ensure adequate attention is given to women veterans'
programs so quality health care and specialized services are available
equally for both women and men. I believe my bill will help the VA
better meet the specialized needs and develop new systems to better
provide for the health care of women veterans--especially those who
return from combat, who were sexually assaulted, suffer from PTSD, or
who need child care services.
Chairman Michaud and Ranking Member Brown, thank you again for
inviting me to testify. I look forward to answering any questions you
may have.
Prepared Statement of Joy J. Ilem, Assistant National Legislative
Director, Disabled American Veterans
Mr. Chairman and other Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this legislative hearing of the Subcommittee on Health. DAV
is an organization of 1.2 million service-disabled veterans, and
devotes its energies to rebuilding the lives of disabled veterans and
their families.
We appreciate the opportunity to offer our views on the bills under
consideration by the Subcommittee--specifically two bills focused on
mental health care services provided by the Department of Veterans
Affairs (VA), a measure focused on women veterans health, and one draft
measure--related to expansion of eligibility for reimbursement for
emergency treatment in non-VA facilities. Our comments related to the
four measures are expressed in numerical sequence of the bills.
H.R. 784--To amend title 38, United States Code, to direct the
Secretary of Veterans Affairs to submit to Congress quarterly
reports on vacancies in mental health professional positions in
Department of Veterans Affairs medical facilities.
This bill would require the Secretary of Veterans Affairs to report
quarterly to Congress to describe each mental health professional
vacancy in every medical facility in the Department, and to indicate to
which Veterans Integrated Services Network (VISN) the facility is
assigned. The bill would define mental health professionals to include
psychiatrists, psychologists, social workers, marriage and family
therapists, and licensed professional mental health counselors. While
we appreciate the intended purposes of this bill, we ask the
Subcommittee to expand its scope to better account for the current
situation in VA mental health services, and to consider our
recommendations for an enhanced means of achieving better oversight and
accountability in that program.
We recognize the unprecedented efforts made by VA over the past
several years to improve the consistency, timeliness, and effectiveness
of mental health care programs for disabled veterans. We are especially
pleased that VA has committed through its national Mental Health
Strategic Plan (MHSP) to reform VA mental health programs, moving from
the traditional treatment of symptoms to embrace recovery potential in
every veteran under VA care. We also appreciate the will of Congress in
continuing to insist that VA dedicate sufficient resources in pursuit
of comprehensive mental health services to meet the needs of veterans.
One key part of improving mental health services and increasing access
to those specialized services is through sufficient staffing levels.
The DAV supports the intent of this measure (H.R. 784) that would
attempt to verify the current vacancies in mental health positions in
VA facilities and thus the gap in mental health professionals needed to
provide timely, high quality mental health services to veterans who
need them. DAV is concerned, nevertheless, that the intended goal of
the bill will be unfulfilled unless Congress goes beyond requiring VA
to provide simply the number of vacancies but rather requiring VA to
adopt and enforce mechanisms to assure its policies at the top are
reflected as results in the field. As written, we are concerned that
enactment of the bill would not surface the kind of information
Congress needs to conduct proper oversight of VA's results and status
in achieving mental health reforms.
The development of the MHSP and the new Uniformed Mental Health
Services (UMHS) policy (detailed in VHA Handbook 1160.01, dated
September 11, 2008) provide an impressive and ambitious roadmap for
VHA's transformation of its mental health services. However, we have
expressed continued concern about oversight of the implementation phase
of these initiatives. The VA MHSP was developed before the impact of
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) was
evident, and we believe a pressing need is emerging for Congress to
ramp up the monitoring of VA's strategies, policies, and operating
plans being implemented to deliver on the promise of the current
strategic plan. We believe VHA must also conduct accurate annual needs
and gap assessments to take into account the changing needs of the
veteran population, including the newest generation of combat veterans.
Historically approximately one fifth (20 percent) of veterans
receiving any kind of VA care consumed a mental health service. This
use rate in general is well above the rate for the private sector.
According to VA, the needs of OEF/OIF veterans for mental health
services are even greater, with almost 45 percent having been evaluated
for, or having received, a possible diagnosis of a mental health
disorder. Based on past experience and confirmed in the scientific
literature, it is clear that the needs and greater demand for mental
health services continue for 5 to 10 years following combat exposure.
In a recent compilation of screening data for servicemembers returning
from deployments in Iraq, nearly 40 percent of active duty soldiers and
more than 30 percent of active duty Marines screened positive for a
psycho-social problem. The rates for reservists were even higher--over
45 percent for Army reserve, 50 percent for Army National Guard and
nearly 45 percent for Marine reserves. On all surveys of psychological
concerns among OEF/OIF servicemembers, these rates rise as they
experience repeated deployments. For some, the pressures become
unbearable. While the wars continue and the number of deployments per
servicemember climbs, rates of suicide in the military are rising.
Given these findings, easily accessible, high quality VA mental health
and substance-use disorder treatment is essential to address the post-
deployment mental health needs of combat veterans early on, before
symptoms become chronic. Today, VA is challenged to meet these needs,
and without meaningful oversight that challenge will grow as time goes
along.
VA has been chronically plagued with wide variation among medical
centers on the adequacy of the continuum of care of mental health
services offered. Wide unexplainable variations were documented every
year from 1996 when Congress first mandated that VA track whether it
was maintaining its capacity to provide mental health services, until
the final report from that expired mandate was delivered to Congress.
In February 2004 the VA Capital Asset Realignment for Enhanced Services
(CARES) Commission included a special section on mental health services
underscoring its assessment that the breadth of services and access to
mental health care were unacceptably variable across the system. In
June 2004, a VA mental health task force again documented wide
variation in the availability of and access to a full continuum of
mental health care services, particularly in substance-use disorder
treatment, and in use of evidence-based approaches to the care of post-
traumatic stress disorder (PTSD) and other mental disorders.
In response to the 2003 New Freedom Commission's call for action,
VA developed a national strategic plan for mental health services which
was finalized in November 2004. In showing sensitivity to VA's
commitment to reform, Congress allocated new funds to enhance mental
health services and required VA to spend these funds in pursuit of that
reform. Despite these efforts, in May 2007 the VA Inspector General
again criticized the consistency and adequacy of mental health services
throughout the system.
To address these concerns VA has been provided with targeted mental
health funds in more recent years' appropriations to augment mental
health staffing across the system. This funding was intended to address
widely recognized gaps in the access and availability of mental health
and substance-use disorder services that existed prior to the
development of the MHSP, to address the unique and increased needs of
veterans who served in OEF/OIF and to create a comprehensive mental
health and substance-use disorders system of care within VHA that is
focused on recovery--a hallmark goal of the New Freedom Commission. In
addition, VHA developed its UMHS policy so that veterans nationwide can
be assured of having access to the full range of high quality mental
health and substance-use disorder services in all VA facilities and at
the time that they are most needed. Timely, early intervention services
can improve veterans' quality of life, prevent chronic illness, promote
recovery, and minimize the long-term disabling effects of undetected
and untreated mental health problems. These funds have been dispersed
as part of special initiatives, with a clear mandate that they would be
used to augment current mental health staffing, not merely replace
older positions as they become vacant.
While the specialized mental health augmentation funding has
significantly improved mental health services across VHA, a recent gap
analysis conducted by VHA, resulting in the UMHS plan, underscores how
much still needs to be done to assure equity of access for all
veterans. Furthermore we understand that this analysis (one that VA has
not released to the Congress or the veterans service organization
community) does not fully take into account many important factors such
as the cost and effort required to provide newer evidence-based
treatments for priority conditions such as PTSD.
Supplementary mental health funds were allocated as time-limited,
annual ``special purpose'' funding allocations that occurred outside of
the usual Veterans Equitable Resource Allocation (VERA) process.
Although there was a clear expectation by Congress that the services
based on these funds would be maintained into the foreseeable future,
within VA the continued medical center funding has not been promised or
assured. It is critical that these programs and the UMHS package be
maintained, since, as was learned tragically after the Vietnam War, the
needs for mental health services are not time-limited, since many
veterans of that era first sought care long after the conflict ended.
We understand that VHA now proposes to move funding for these programs
into the VERA process. We are concerned that if all mental health funds
moved into VERA and mixed with other medical care funds allocated to
the medical centers, mental health and substance-use disorder programs
will be again at great risk for erosion. In fact this has been the case
in the past when mental health and substance-use disorder funds were
allocated under VERA and were required to compete directly with other
acute care programs.
VHA is a large integrated health care system with national policy
and program mandates but today is characterized as a largely
decentralized management system. While local flexibility has many
strengths, the budgetary discretion granted at the Network and local
medical center levels for the use of funds allocated through VERA could
have unwarranted consequences for vulnerable veteran populations who
have special needs. Comprehensive and detailed oversight and monitoring
is imperative if ongoing progress in filling critical gaps in mental
health services across the Nation is to be assured and recovery is to
be fully embraced.
We believe the solution to this pressing problem would need two
major components: an attentive oversight process, and an empowered
organizational structure to inform that oversight responsibility.
The oversight process we envision in mental health would be a
constructive one that is helpful to VA facilities, rather than
punitive. It should be data-driven and transparent, and should include
local evaluations and site visits to factor in local circumstances and
needs. Such a process could assure that ongoing progress is made in
achieving the goal of the VA MHSP and UMHS package to provide easily
accessible and comprehensive mental health services equitably across
the Nation.
Mr. Chairman, the second component necessary to make the first one
meaningful would be putting in place an empowered VA organizational
structure to assure that this oversight process is robust, timely and
utilizes the best clinical and research knowledge available. Such a
structure would require VHA to collect and report detailed data, at the
national, network and medical center levels, on the net increase over
time in the actual capacity to provide comprehensive, evidence-based
mental health services. Using data available in current VA data
systems, such as VA's payroll and accounting systems, supplemented by
local, audited reports where necessary, could provide information down
to the medical center level on at least the following for the period
fiscal year 2004 to the present fiscal year:
The number of full-time and part-time equivalents of
psychiatrists and psychologists;
The number of mental health nursing staff;
The number of social workers assigned to mental health
programs;
The number of other direct care mental health staff (e.g.
counselors, outreach workers);
The number of administrative and support staff assigned
to mental health programs;
As a basis for comparison, the total number of direct
care and administrative full-time employee equivalents (FTEE) for all
programs, mental health and others; and
The number of unfilled vacancies for mental health
positions that have been approved, and the average length of time
vacancies remain unfilled.
The current practice of reporting only the number of offers made to
prospective new mental health staff members, and not the number who are
actually on board, should be immediately halted, since we know there
are lags of several months in actually bringing these new clinicians on
board.
Mr. Chairman, we believe VA should be required to establish a web-
based clinical inventory instrument to gather information from the
field about existing mental health programs (i.e., PTSD, substance-use
disorder, etc.) in each VA facility including hours of operation,
caseloads and panel sizes, staffing levels and current capacity to
provide evidence-based treatments as specified in published VA/DoD
Evidence-Based Practice Guidelines.
VA should also develop an accurate demand model for mental health
and substance-use disorder services, including veteran users with
chronic mental health conditions and projections for the needs of OEF/
OIF veterans. This model development should be created parallel to the
VA mental health strategic planning process. This model should include
estimated staffing standards and optimal panel sizes for VA to provide
timely access to services while maintaining sufficient appointment time
allotment.
Assuming the creation of these resource tools, Congress should also
require VA to establish an independent body, a ``VA Committee on
Veterans with Psychological and Mental Health Needs,'' with appropriate
resources, to analyze these data and information, supplement its data
with periodic site visits to medical centers, and empower the Committee
to make independent recommendations to the Secretary of Veterans
Affairs and the Congress on actions necessary to bridge gaps in mental
health services, or to further improve those services. Membership of
the Committee should be made up from VA mental health practitioners,
veteran users of the services and their advocates, including veterans
service organizations and other organizations concerned about veterans
and VA mental health programs. The site visit teams should include
mental health experts drawn from both within and outside of VA. These
experts should consult with local VA officials and seek consensual,
practical recommendations for improving mental health care at each
site. This independent body should synthesize the data from each of the
sites visited and make recommendations on policy, resources and process
changes necessary to meet the goals of the MHSP.
In addition to these changes, VA should be directed to conduct
specialized studies, under the auspices of its Health Services Research
and Development Program and/or by the specialized mental health centers
such as the Mental Illness Education, Research and Clinical Centers
(MIRECCs) in several sites, the Seriously Mentally Ill Treatment,
Research Education and Clinical Center (SMITREC) in Ann Arbor; and the
Northeast Program Evaluation Center in West Haven, among others, on
equity of access across the system; barriers to comprehensive substance
use disorders rehabilitation and treatment; early intervention services
for harmful/hazardous substance use; couples and family counseling; and
programs to overcome stigma that inhibits veterans, particularly newer
veterans, from seeking timely care for psychological and mental health
concerns.
As an additional validation, we believe that the Government
Accountability Office (GAO) should be directed to conduct a follow-on
study of VA's mental health programs to assess the progress of the
MHSP, the UMHS, and to provide its independent estimate of the FTEE
necessary for VA to carry out the above-noted initiatives. Congress
should also require GAO to conduct a separate study on the need for
modifications to the current VERA system to incentivize its fully
meeting the mental health needs of all enrolled veterans.
While DAV supports the basic intent behind H.R. 784, we ask the
Subcommittee to consider a broader scope of oversight of VA's mental
health program than envisioned by the bill. We believe the ideas
above--ideas that we have gleaned from a number of mental health and
research professionals in and out of VA, and from the literature, are
necessary to fully ensure VA is moving its mental health policy and
program infrastructure in a proper direction. Also, we urge the
Subcommittee, which would be the major recipient of this new approach
to reporting true VA mental health capacity, to continue its strong
oversight to assure VA's mental health programs and the reforms it is
attempting to meet all their promise, not only for those coming back
from war now, but for those already here.
H.R. 785--To direct the Secretary of Veterans Affairs to carry out a
pilot program to provide outreach and training to certain
college and university mental health centers relating to the
mental health of veterans of Operation Enduring Freedom and
Operation Iraqi Freedom (OEF/OIF).
The intent of this bill is to establish a 4-year pilot program
aimed at improving outreach to OEF/OIF veterans on the campuses of
colleges and universities. The measure would require VA to provide
training to clinicians, administrative and other relevant individuals
at the selected pilot sites for the purpose of improving access to
mental health treatment and services for returning war veterans from
Iraq and Afghanistan. H.R. 785 would require VA to report on the
selected pilot sites, the number of OEF/OIF veterans enrolled in each
university or college, a description of the services to be made
available under the program and assessment and effectiveness of the
program. The bill would authorize appropriations of $3 million annually
to carry out its intent for each fiscal year 2010 through 2013.
Current research findings indicate that combat veterans from OEF/
OIF are at higher risk for post traumatic stress disorder (PTSD) and
other post-deployment mental health problems. VA reports that veterans
of the current wars have sought care for a wide range of medical and
psychological conditions, including depression, anxiety, PTSD and
substance-use disorders.
The VA has a unique obligation to meet the health care and
rehabilitative needs of veterans who have been wounded during military
service or who may be suffering from post-deployment readjustment
problems as a result of combat exposure. The VA and Congress must
remain vigilant to ensure that Federal programs aimed at meeting the
needs of the newest generation of combat veterans are sufficiently
funded and adapted to meet them, while continuing to address the
chronic health maintenance needs of older veterans who served and were
injured in earlier military conflicts.
DAV Resolution 166, adopted in general session by our members at
DAV's National Convention assembled in Las Vegas, Nevada, August 9-12,
2008, supports program improvement and enhanced resources for VA mental
health programs to achieve adjustment of new combat veterans and
continued effective mental health care for all enrolled veterans
needing such services. Therefore, DAV is pleased to support H.R. 785, a
bill that would offer an appropriate outreach effort and would attempt
to better inform academic centers about VA services and the unique
needs our newest generation of war veterans--and specifically about
their post-deployment mental health needs.
H.R. 1211--Women Veterans Health Care Improvement Act
This measure seeks to expand and improve health care services
available to women veterans from the Department of Veterans Affairs
(VA); especially those serving in Operations Iraqi and Enduring Freedom
(OIF/OEF).
Title I, section 101 would require VA to enter into a contract with
an outside entity or organization to perform a comprehensive study and
report on the existing barriers that impede or prevent women from
accessing health care and other services from VA. This study would
build on the work of the National Survey of Women Veterans in FY 2007-
2008, to ensure sufficient sample size and include reporting on such
barriers as perceived stigma with seeking mental health services, child
care, distance to and availability of care, acceptability of integrated
primary care, perception of personal safety and gender sensitivity
during care, and effectiveness of outreach.
The VA would be required to internally review the results of the
study and submit findings with respect to the study to specified
divisions within VA, and would be further required to submit two
reports to Congress. The report to Congress would include
recommendations for administrative and legislative action by the VA
Secretary as deemed appropriate. The bill would authorize
appropriations of $4 million to carry out the purpose of this section.
Section 102 would require VA to contract with an outside entity or
organization to perform a comprehensive assessment of existing health
care programs for women veterans and report the findings to Congress.
This would include assessment of specialized programs, including those
for women with post traumatic stress disorder (PTSD), those who are
homeless, require substance-use disorder or mental health treatment,
and for women who require obstetric/gynecological care. The assessment
would rate the effectiveness of the VA's programs based on the
frequency with which the services are provided, the demographics of
women using these services, the locations of the services, and whether,
and to what extent, waiting lists, distance to care, and other factors
affect the receipt of services.
After the assessment is completed, and no later than 1 year after
the enactment of this Act, the Secretary would be required to provide a
report to Congress on a plan to improve health care services to women
veterans, and project future health care needs to include mental health
needs of OEF/OIF women veterans. The report would also include a list
of services available at every medical center in the Department and
include recommendations for administrative and legislative action that
the VA Secretary deems appropriate. Within 6 months of this report, GAO
would be required to submit a report to Congress based on the
Secretary's report. The bill would authorize $5 million to be
appropriated to carry out the purposes of this section.
Title II, section 201 would amend subchapter VIII of chapter 17 of
title 38, United States Code, to authorize hospital care and services
for newborn children of women veterans receiving maternity care at a
Department facility or through contract care at VA expense, for a
period of 14 days beginning on the date of birth of the child.
Section 202 would improve VA's ability to assess and treat veterans
who have experienced military sexual trauma (MST) who exhibit symptoms
of PTSD by requiring a new tailored training and certification program
to ensure VA health care providers develop competencies in caring for
these co-occurring conditions. Section 202 would also mandate that
professionals be trained in a consistent manner to include the
principles of evidence-based treatment and care for MST and PTSD.
Under this authority, the Secretary would also be required to
provide Congress an annual report covering a number of areas including
the number of mental health professionals, graduate medical education
trainees, and primary care providers who have been certified under the
program, along with the amount and type of continuing medical education
that they complete for the required certification; in addition, the
report would include the number of graduate medical education,
training, certification and continuing medical education (CME) courses
that were provided by the program. The report would also detail the
number of veterans who received counseling, care and services from
these certified professionals, trainees and other providers, and the
number of trained full-time employee equivalents needed to meet the
needs of veterans treated for MST and PTSD. Finally, the report would
contain any recommended improvements for treating veterans with co-
occurring MST and PTSD.
Section 203 would authorize a 2-year pilot program, in at least
three VISNs, of reimbursement for the expenses of child care services
for certain qualified veterans receiving mental health, intensive
mental health or other intensive health care services, whose absence of
child care might prevent them from obtaining these services. The term
``qualified veteran'' would be defined as a veteran with the primary
caretaker responsibility of a child or children. Following the
completion of the pilot, the Secretary would be required to report on
the program, including recommendations to Congress for continuing or
expanding the program. The bill would authorize appropriations of $1\1/
2\ million for each of fiscal years 2010 and 2011 to carry out the
pilot program under this section.
Section 204 would require recently separated women veterans and
minority veterans to be appointed to certain VA advisory committees.
Women veterans are a small but dramatically growing segment of the
veteran population. The current number of women serving in active
military service and its reserve and Guard 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, artillery, 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.
Mr. Chairman, this comprehensive legislative proposal seeking to
access, improve and expand VA services for women veterans, 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 Resolution 238 seeks to ensure high quality comprehensive VA health
services for all women veterans, with a special focus on the unique
post-deployment needs of women veterans returning from OEF/OIF. DAVs
resolution notes that VA needs to undertake a comprehensive review of
its women's health programs, and seek innovative methods to address
barriers to care for women veterans to ensure they receive the
treatment and specialized services they need and deserve. Therefore, we
fully support H.R. 1211 and urge the Subcommittee to recommend its
enactment.
We note with regard to section 202 of the bill that it specifically
references ``women'' a couple of times. VA MST and mental health
specialists have reported to us that veterans currently under care for
MST in VA programs are nearly equally divided by gender. While we fully
support the purposes of the bill, and have no objection to the purposes
of section 202 being included in the bill, we would recommend any
references in section 202 to ``women'' be made gender neutral.
Alternately, the bill could be amended to sub-divide the required
report for each gender.
Draft Bill--To amend title 38, United States Code, to expand veteran
eligibility for reimbursement by the Secretary of Veterans
Affairs for emergency treatment furnished in a non-Department
facility.
This bill would amend subparagraph (b)(3)(C) of section 1725 of
title 38, United States Code, by striking the words ``or in part''
where they appear in current law. In subsection (f)(2) the bill would
strike subparagraph E. The bill would also add new language to clarify
Congressional intent that VA would be required to assume responsibility
as a secondary payer in a case in which an otherwise eligible veteran
has private insurance coverage that pays a portion or part of the cost
of an episode of emergency care in a private facility. Under the bill,
VA would pay the remainder of the veteran's obligation, less any
required copayments under the associated private insurance coverage.
DAV supports the purposes of this draft bill and appreciates the
sensitivity of the Subcommittee leadership in developing an effective
solution to a nagging problem plaguing both service-connected and
nonservice-connected veterans who rely on VA to meet their primary
health care needs.
In 1999, Congress enacted the Veterans Millennium Health Care and
Benefits Act, Public Law 106-117. That Act provided the authority
sought by VA at the time to complete its role as a comprehensive health
care system for all veterans who are enrolled, by giving VA authority
to reimburse costs of emergency private care under certain
circumstances. Prior to passage of the Millennium Act, VA was
essentially without authority to pay emergency expenses in private
facilities for its own patients, unless generally they were service-
connected veterans. Under prior law VA was authorized to pay for non-VA
emergency treatment for a veteran's service-connected disability, a
nonservice-connected disability aggravating a veteran's service-
connected condition, any condition of a veteran rated permanently and
totally disabled from a service-connected condition(s), and a veteran
enrolled in a VA vocational rehabilitation program.
The intent of this bill would enable a veteran, enrolled in VA
health care, who otherwise is eligible for VA reimbursement of certain
private emergency health care expenses under the Millennium Act
authority but for the existence of coverage ``in part'' by a form of
private health insurance (no matter how major or minor such private
coverage might be), to be reimbursed as otherwise authorized under the
Millennium Act's emergency care reimbursement program. Rescission of
the words ``or in part'' in section 1725, accompanied by the striking
of subparagraph E of subsection (f)(2) of that section, would provide
VA a clearer authority. For a VA-enrolled veteran with minimal
insurance coverage (such as a small medical rider on a state-mandated
automobile insurance plan) to secure VA reimbursement for emergency
care under the intended authority, would be an exceedingly helpful new
benefit.
Today, a number of enrolled veterans routinely are being denied
reimbursement, because they are covered ``in part,'' even if all other
eligibility requirements are met. The bill would be effective as of
October 8, 2007, presumably to take into account the circumstances of
any individuals who may have recently been denied VA reimbursement
because of the current ``in part'' restriction.
DAV supports the intent of this draft bill. This bill's purposes
are in full accord with the mandate from our membership expressed in
DAV Resolution No. 178, adopted at our National Convention assembled in
Las Vegas, Nevada, August 9-12, 2008. Its purposes are also consistent
with the recommendations of the Independent Budget to improve
reimbursement policies for non-VA, emergency health care services for
enrolled veterans. We urge the Subcommittee Chairman to introduce this
bill, to gain its further consideration by the Full Committee, and we
endorse its enactment into law. The DAV thanks those involved for their
efforts to ensure this essential emergency relief benefit originally
contemplated in the Millennium Act, and its improvements from this
bill, are properly implemented.
With regard to this bill, we note the current renewed discussion of
the need for national health reform, a major stated goal of this
Administration. Emergency hospitalization of the uninsured is one of
the driving forces for reform in the private sector. One of the
unintended consequences of such reform might well impact on the VA
health care system. In that regard, we ask the Subcommittee for
vigilance to ensure that whatever shape reform may ultimately take,
that veterans' rights be protected for continuation of reimbursement of
their emergency health care services as authorized by section 1725,
title 38, United States Code.
Mr. Chairman, this concludes the testimony of Disabled American
Veterans on these important bills. I would be pleased to respond to
questions from you or other Members of the Subcommittee on these
matters.
Prepared Statement of Joseph L. Wilson, Deputy Director, Veterans
Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for the opportunity to present The American Legion's
views on these two important pieces of legislation.
H.R. 784, Quarterly Reports on Vacancies in Mental Health Professional
Positions
H.R. 784 seeks to improve the recruitment of mental health care
professionals by having the Secretary of Veterans Affairs submit
quarterly reports on mental health employment vacancies at VA Medical
Centers nationwide.
Section (a) requires the Secretary of Veterans Affairs to submit to
Congress a report describing any vacancy in a mental health
professional position at any medical facility of the Department, no
later than 30 days after the last day of a fiscal quarter. Within these
reports, the Secretary is to indicate, for each vacancy, the Veterans
Integrated Services Network (VISN) to which the facility with the
vacancy is assigned.
The American Legion's ``System Worth Saving'' Task Force visits
medical facilities around the country and reports a constant need for
additional mental health providers in almost every Medical Facility. As
VA continues to screen, identify, and treat veterans suffering from
mental health disorders through VA outreach coordinators and Vet
Center's Global War on Terror Counselors, having the staffing
capabilities to treat veterans after initial intervention is paramount.
Resolution 150, ``The American Legion Policy on Department of Veterans
Affairs Mental Health Services,'' states that VA now has more mental
health patients seeking treatment with fewer mental health providers.''
The American Legion believes that with a quarterly report, mental
health care services for veterans will be more widely available because
less time for recruitment will be needed.
The American Legion supports any standard(s) that improve the
mental health capabilities of VA and its medical facilities, and in
turn would like to see the passage of H.R. 784. To provide our veterans
with the most adequate mental health care, there needs to be the proper
amount of mental health providers in the VA Medical Centers. The
inadequacy of mental health providers gives way to substandard care and
the possibility that veteran mental health care needs will fall through
the cracks.
H.R. 785, Pilot Program on Outreach and Training Relating to Mental
Health of Veterans of Operation Iraqi Freedom and Operation
Enduring Freedom
This bill establishes a pilot program to provide outreach and
training to certain college and university mental health centers
relating to the mental health of veterans of Operation Iraqi Freedom
(OIF) and Operation Enduring Freedom (OEF), and for other purposes.
Section 1(a) seeks to establish a 4-year program under which the
Secretary shall provide a counseling center, student health or wellness
center at a college or university with a large veteran population to
increase outreach efforts.
Resolution 150, ``The American Legion Policy on Department of
Veterans Affairs Mental Health Services,'' states that veterans
continue to need increased access to mental health care. A RAND Study
on the `Invisible Wounds of War: Addressing the Mental Health Needs of
Returning Soldiers' in 2008 estimated that 300,000 veterans, or 18\1/2\
percent of those deployed, were diagnosed by VA with Post Traumatic
Stress Disorder or major depression. This number continues to rise and
efforts to increase access and quality of care at the universities and
colleges are imperative to ensure assistance is available to these
veterans during a time of crisis. Additionally, training is needed to
ensure college and university staff is prepared in the case of a
veteran's mental health crisis. Moreover, The American Legion supports
the increased outreach efforts at universities or colleges where many
veteran students are not familiar with VA benefits and services.
Mr. Chairman and Members of the Subcommittee, The American Legion
sincerely appreciates the opportunity to submit testimony and looks
forward to working with you and your colleagues on the abovementioned
matters. Thank you.
Prepared Statement of Eric A. Hilleman, Deputy Director, National
Legislative Service, Veterans of Foreign Wars of the United States
MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
On behalf of the 2.2 million men and women of the Veterans of
Foreign Wars of the U.S. (VFW) and our Auxiliaries, I would like to
thank you for the opportunity to provide our views on the bills under
consideration at today's hearing. These bills would make meaningful
changes in the law, improving the quality of health care this Nation's
veterans receive at the Department of Veterans Affairs (VA). We urge
quick passage of all four.
H.R. 784, a bill to report quarterly on vacancies in mental health
professional positions in the Department of Veterans Affairs
(VA)
The VFW supports, this bill would require the Secretary of VA to
report to Congress, no later than 30 days from the end of the quarter,
each vacancy for: psychiatrists, psychologists, social workers,
marriage and family therapists, and licensed professional mental health
counselors. Each report would be required to state the Veterans
Integrated Services Network (VISN) or region in which the vacancy
existed. The date of termination for these quarterly reports would be
December 31, 2014.
Currently, reporting on vacancies for mental health professionals
is not shared with Congress. Reporting vacancies to Congress will
elevate the issue of the health care professional shortage and draw
much needed attention to developing these professions nationally. In
breaking out the data by VISN, Congress and the VA can address regional
shortages and/or barriers to employing these essential health care
professionals. Fully understanding the shortages and need for mental
health care professionals may also aid in creating incentives for their
employment.
VFW is proud to support this legislation.
H.R. 785, a bill to establish a pilot program from FY 2010 to 2013 to
educate and engage in outreach to college and university mental
health centers
The VFW enthusiastically supports this legislation, which would
give the VA Secretary the authority to train college and university
clinicians, administrators, and counselors to serve veterans returning
from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF).
The VA would highlight illnesses common to veterans, resources
available, and any other service the Secretary determined necessary for
this program. The reporting component of the program would require the
Secretary to report to Congress not later than 2 years after enactment
of this Act. The Authorization for Appropriations of this Act would be
$3 million.
This legislation follows the prevailing trend of engagement of and
on behalf of OEF/OIF veterans. We believe this bill will help to combat
stereotypes of veterans in the community, de-stigmatizing mental health
issues related to military service. Through educating the education
community this information can hopefully be broadly disseminated into
the counseling and social work industry. Not only is this a benefit to
schools and the community, it directly affects veterans on campuses
across the Nation and eases their transition/reintegration.
The timing of this bill is especially important due to the New GI
Bill the VA anticipates an increase of veterans on college campuses in
the coming years. Many veterans will encounter an entirely new culture
and bureaucracy not designed to support older students with unique
needs. It is for these reasons that the VFW enthusiastically supports
this bill.
H.R. 1211, ``Women Veterans Health Care Improvement Act''
VFW is proud to support H.R. 1211, legislation that would improve
benefits and services to female veterans, especially those who have
served or are serving in OEF/OIF operations. Recent data collected by
VA's Center for Women Veterans reports that the number of women serving
on active duty is about 15 percent, and that female personnel serving
in Guard and Reserve capacities is 17.6 percent and growing. VA reports
that 44 percent of the transitioning female veterans are seeking care
at VA. As the number of females in uniform grow, so too will the
percentage of females seeking services at VA. VFW is encouraged by the
improvements this bill, and we remain hopeful this legislation will
ease access to servicers at VA by women veterans.
The VFW recognizes that VA has begun to compile data with the goal
of better understanding the barriers facing women within VA. We
encourage VA to continue studying with an eye toward creating a more
accepting culture at VA for female veterans. The improvements cited in
this bill are an excellent means for progressing toward that goal.
The VFW supports section 101, which would require VA to study
barriers in providing comprehensive health care for women including:
scope of services provided to women, effective outreach, mental health
care and gender sensitivity of its health care providers. For many
years, VA has been a gender-focused institution. All health care,
documents, outreach, and programs were focused on male veterans,
institutionalizing a lack of sensitivity for the needs of female
veterans. Studies such as this will enable VA to move beyond the one-
size-fits-all ideals and tailor its services to the specific needs of
female veterans. It is our understanding that VA has already
successfully executed a sample study of women veterans, the ``Women
Veterans Ambulatory Care Use Project, Phase II,'' in the West LA area
and this study has contributed to VA's health care providers
understanding of female veterans in this area. For example, the study
finds that female VA users are more likely than non-users to receive
mental health services. We believe the results of this study have led
to increased sensitivity and understanding of women veterans and could
have positive and lasting impacts in the way female veterans are
treated if implemented across the system.
The VFW also supports section 102, which would require a
comprehensive assessment of current health care programs and services
provided to women by the VA. The study would examine services including
specialized programs to treat PTSD, substance abuse and mental illness,
as well as the availability of obstetric and gynecologic care
throughout the VA system. Further, it collects data on waiting times,
health care services offered, demographics, geographic distance, and
other factors faced by female veterans. In time, we believe this data
will aid to close the existing gender gap and provide care sensitive to
the needs of female 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 applaud the recommendation of section 201 to extend health care
coverage, for up to 14 days, to female veterans' newborns. The period
of 14 days is essential to the health of the child and the veteran,
allowing continuity in obstetrics and gynecologic care. The VFW would
encourage research on birth defects of children born to female
veterans; we are highly sensitive to unknown exposures and
environmental factors related to OEF/OIF service. Further
recommendations on this issue are found in the FY 2010 edition of the
Independent Budget (IB).
The VFW is extremely supportive of section 202, which would
authorize VA to provide graduate level training, certification, and
continuing medical education for counseling with specific focus on
evidence-based treatment and care for Military Sexual Trauma (MST) and
PTSD. This is all too common among combat theatre female veterans. In
these cases, VA should strive to be hypersensitive to the environment,
approach, and treatment options when providing care or evaluating
veterans for their physical and mental health needs related to MST.
We also strongly support section 203, which would create a pilot
program to provide childcare for veterans receiving health care through
VA. This is a valuable proposal, which has the potential to eliminate a
tremendous barrier for care, especially for single parents.
In addition, we applaud section 204, which adds two recently
separated female veterans to the VA Advisory Committees on women
veterans and minority veterans. The veteran population is increasing
greatly with the return of OEF/OIF veterans. Veterans of the current
conflict era have specific needs.
A Draft bill to close existing loopholes in law, allowing VA to cover
unmet emergency room treatment for veterans in certain cases
The VFW is pleased to offer our support for the draft legislation
that deals with an issue important to a number of our members. This
bill would allow VA to pay for of emergency care for veterans enrolled
in VHA under certain cases. It closes a loophole that sticks many
veterans unfairly with a large hospital bill.
Section 1725 of Title 38 authorizes VA to reimburse veterans for
medical expenses related to emergency care at non-VA facilities if the
veteran is enrolled and using the VA health care system. This is an
important safety net for many veterans who have no other means to pay
for potentially life-saving care. However, veterans who receive a
portion of their care cost from another source, such as an insurance
settlement or judgment are not eligible for any reimbursement, even if
that amount is a fraction of the cost of their care. This bill allows
VA to be a secondary payer in those situations, so the vet will not
have to pay out of pocket. Additionally, it removes care accidents
where insurance pays out for medical coverage from the list of things
that would bar VA from paying for emergency care.
This legislation lifts these restrictions, treating VA as a
secondary payer to cover the remaining amount due for a veteran's
emergency room care. We fully support this legislation. VFW believes
that all essential emergency room care should be covered for all
veterans.
Mr. Chairman, this concludes my testimony. I would be happy to
answer any questions that you or the Members of the Subcommittee may
have. Thank you.
Prepared Statement of Todd Bowers, Director of Government Affairs, Iraq
and Afghanistan Veterans of America
Madam Chair, and Members of the Subcommittee, thank you for
inviting Iraq and Afghanistan Veterans of America (IAVA) to testify
today, and for giving us the opportunity to present our views on H.R.
784, H.R. 785, H.R. 1211 and drafted legislation pertaining to
emergency care. On behalf of IAVA and our more than 125,000 members and
supporters, I would also like to thank you for your unwavering
commitment to our Nation's veterans.
H.R. 784
IAVA is very concerned with the national shortage of mental health
professionals, and in particular, how this shortage affects access to
adequate mental health care for troops and veterans. The VA has already
been flooded by new veterans seeking care for psychological injuries.
More than 178,000 Iraq and Afghanistan veterans seen at the VA have
been given a preliminary diagnosis of a mental health problem, about 45
percent of new veterans who visited the VA for any reason.
Although the VA was initially caught unprepared with a serious
shortage of staff and an exceedingly inadequate budget, the Department
has made significant progress in responding to the needs of new
veterans. Thanks to a mental health budget that has doubled since 2001,
the VA has been able to devote $37.7 million to placing psychiatrists,
psychologists, and social workers within primary care clinics. While
psychologist staff levels were below 1995 levels until 2006, the VA has
recruited more than 3,900 new mental health employees, including 800
new psychologists, bringing the VA's total mental health staff to about
17,000 people. The VA is now the single largest employer of
psychologists in the country.
That being said, access to mental health care, particularly for
rural and female veterans, is still an issue, in part because of the
continued shortage of mental health professionals. As an example,
Montana ranks fourth in sending troops to war, but the state's VA
facilities provide the lowest frequency of mental health visits.
H.R. 784 will establish congressional oversight over vacancies in
the VA's mental health professional positions, and the increased
transparency will help improve staffing at VA hospitals and clinics.
IAVA fully supports this legislation and looks forward to seeing its
rapid implementation.
H.R. 785
With the passage of the historic ``Post-9/11'' GI Bill last year,
there will be a flood of Iraq and Afghanistan veterans taking advantage
of their new education benefits and attending universities across the
Nation. It is to be expected that many of these veterans will turn to
their student health centers while attending school for medical care.
This is an opportune time to advertise and extend VA mental health care
services to new veterans.
H.R. 785 helps facilitate this by ensuring that student health
centers and counseling services at universities have the appropriate
support from the VA to provide the best services to our Nation's
student-veterans.
IAVA is pleased to support H.R. 785 and looks forward to working
with Representative Tsongas to ensure that this legislation is enacted
in a timely manner and does not contain any technical deficiencies. It
is our hope that language within the bill will be modified to clearly
define what is termed as ``large enrollment'' in section 1(b)(1). It is
critical that mental health services be available to all veterans no
matter what school they attend. Any university with Iraq and
Afghanistan veterans should have the appropriate amount of counselors
ready to assist veterans. If only schools with a very high veteran
population are allocated these resources, veterans attending
institutions with a smaller veteran population will continue to fall
through the cracks. In addition, section 1(b)(1)(A) contains the
following language: ``training for clinicians on treatment for mental
illness commonly experienced by such veterans.'' IAVA would like to see
this language more clearly defined to reduce the risk of certain
illnesses going undiagnosed and untreated.
H.R. 1211
IAVA is pleased to see that the Subcommittee is focusing on the
unique needs of women veterans. Improvement of VA health care for women
veterans is one of IAVA's 2009 Legislative Priorities. More than 11
percent of Iraq and Afghanistan veterans are women, and they deserve
the same access to health care as any other American veteran.
The ``Women Veterans Health Care Improvement Act'' will help gather
critical information on the quality of VA care provided to women
veterans. By identifying barriers to care or gaps in services that
women veterans are experiencing, the VA and Congress can better address
these shortfalls.
With respect to Title II, section 202 of the discussion draft, IAVA
would like to see funding devoted to the study of the best evidence-
based treatment and care for veterans suffering from post-traumatic
stress disorder as a result of both sexual trauma and combat trauma, so
that mental health care providers within the VA can be trained on these
particular treatments. This combination of traumas has rarely been
studied, but with more females serving in Iraq and Afghanistan, the
possibility of both these traumas occurring in new veterans is
significant. The VA's mental health providers must be prepared.
In addition to this recommendation, as part of IAVA's 2009
Legislative Agenda, we have made multiple recommendations to adequately
address the needs of women veterans. In particular, IAVA supports
prioritized hiring of female practitioners and outreach specialists,
increased funding for specialized in-patient women-only PTSD clinics,
and significant expansion of the resources available to women coping
with Military Sexual Trauma.
While not all of these issues are addressed in the Herseth Sandlin
bill, it is our hope that these provisions will be incorporated into
future legislation. IAVA thanks the Chairwoman for her work on women
veterans' issues, and looks forward to seeing the final language of the
bill.
Thank you for your time. Semper Fi.
Prepared Statement of Gerald M. Cross, M.D., FAAFP, Principal Deputy
Under Secretary for Health, Veterans Health Administration,
U.S. Department of Veterans Affairs
Good Morning Mr. Chairman and Members of the Subcommittee. Thank
you for inviting me here today to present the Administration's views on
four bills (one of which is in draft form) that would affect Department
of Veterans Affairs (VA) programs that provide veterans benefits and
services. With me today is Walter A. Hall, Assistant General Counsel.
We appreciate the opportunity to discuss the bills on today's agenda.
H.R. 784 Quarterly Report on Vacancies
H.R. 784 would require the Secretary to submit quarterly reports to
Congress on any vacancies in mental health professional positions
(i.e., psychiatrists, psychologists, social workers, marriage and
family therapists, and licensed professional mental health counselors)
at any VA medical facility. These reports would have to identify the
Veterans Integrated Services Network (VISN) in which the medical
facility is located and would be submitted to Congress not later than
30 days after the last day of a fiscal quarter. This reporting
requirement would terminate after December 31, 2014.
VA does not support H.R.784 because it is unnecessary. VA has been
working diligently to enhance mental health services throughout our
system. We have done this, in part, by increasing our core staff to
date by 4,000 positions, and we plan again this year to continue
increasing the number of mental health professionals in the field to
ensure sustained operations of this vital service line at our medical
centers and clinics. Our commitment to ensuring that veterans receive
needed mental health services necessarily demands that we do our utmost
to ensure that staffing levels at VA points of access are sufficient.
This data is best collected and controlled, however, at the local
level. This is because staffing and workloads are inescapably dependent
on local factors related to the local veteran population, usage rates,
veterans' particular health care needs, and local employment factors.
We achieve oversight by holding the VISN managers accountable to senior
leadership. Given that the current model is effective, we think the
value in creating a quarterly reporting requirement at the national
level is limited, particularly given it would necessitate the creation
of a new complex data infrastructure to meet the bill's requirements
and have no accurate or helpful context once removed from local
factors. We would be pleased to brief the Committee at any time on our
efforts.
We estimate the cost of H.R. 784 to be $188,000 in Fiscal Year
2010; $1 million over a 5-year period; and just over $1 million over a
10-year period.
H.R. 785 Pilot Program to Provide Outreach and Training to College and
University Mental Health Centers
The key provisions of H.R. 785 would require VA to conduct a 4-year
pilot to provide outreach and training services related to the mental
health needs of veterans who served in Operation Enduring Freedom (OEF)
and Operation Iraqi Freedom (OIF) to certain college or university
counseling centers, student health centers, and student service
centers. Educational institutions covered by the bill would be those
that have a large population of enrolled OEF and OIF veterans.
Specifically, VA would be required to:
train clinicians at those sites on mental illnesses
commonly experienced by these veterans;
train those clinicians on how to assist veterans seeking
VA mental health services;
train administrative staff who interact with these
veterans on crisis management and other relevant skills;
train peer counselors who conduct support groups for
these veterans; and
provide any other service VA deems necessary or
appropriate.
VA supports the intent of the bill's drafters. While costs are not
prohibitive for such a pilot project, we believe more effort needs to
go into identifying the precise scope and intended objectives of the
pilot program before we can analyze whether H.R. 785 constitutes an
effective means of achieving those ends. We are also concerned that the
pilot program not dilute or duplicate our ongoing outreach efforts
targeted at this veteran population and, more importantly, not detract
from our ability to provide direct patient care to these and other
veterans.
That said, however, we are committed to doing more in this area. We
have already developed a comprehensive training course for suicide
awareness that focuses particularly on this cohort of veterans. (This
training is mandatory for certain VHA staff.) We have already shared
the training module with the Department of Defense, and we will next
direct each VA medical facility to offer it to the clinical and
administrative staff at local community colleges, 4-year colleges, and
universities. The advantage to this training module is that it is
targeted at veteran-patients, is self-taught, and is accessible
electronically online or in hard copy.
Additionally, we have developed some excellent Public Service
Announcements relevant to the bill's concerns. We will ensure these are
also made available to colleges and universities for broadcast on
campus stations. Included in such materials will be our advertisements
and outreach materials on the Department's suicide prevention hotline
and safe-driving initiative. We will also take immediate steps to
establish liaisons with colleges and universities at the local level as
well as enhance our existing associations with affiliated educational
institutions by, for instance, inviting their staff to attend
conferences at the local VA medical facilities relating to the health
needs of OEF/OIF veterans.
We welcome the opportunity to meet with the Subcommittee to discuss
these initiatives further.
We estimate the cost of the pilot project to be $828,000 in Fiscal
Year 2010 and just over $3 million over the 4-year duration of the
pilot program.
Draft Bill to Expand Eligibility for Reimbursement for non-VA Emergency
Care
This draft bill would expand the benefit available under 38 U.S.C.
Sec. 1725 related to the payment or reimbursement of expenses incurred
by a veteran who received unauthorized emergency treatment from a non-
VA provider for a non-service connected disability. Currently, to be
eligible for reimbursement of such expenses, a veteran must meet a
number of criteria, including that he or she not have ``other
contractual or legal recourse against a third party that would, in
whole or in part, extinguish such liability to the provider.'' 38
U.S.C. Sec. 1725(b)(3)(C). The draft bill would amend that particular
eligibility criterion to require that the veteran have no other
contractual or legal recourse against a third party that would in whole
extinguish the veteran's liability to the private provider.
The draft bill would further provide for the coordination of
benefits when a veteran has other legal or contractual recourse against
a third party responsible for only partial payment of the veteran's
financial liability for the non-VA emergency treatment. In such cases,
the draft bill would require VA to be a secondary payer, but it would
limit VA's financial liability to the difference between the amount
already paid by the third party (excluding copayment or deductible
amounts owed by the veteran) up to the amount VA would be authorized to
pay under the program, i.e. 70 percent of the Medicare rate. That is,
the VA-allowable amount would be offset by the amount already paid by
the responsible third party. For example, if a non-VA provider billed a
veteran $100 for the emergency treatment covered under section 1725,
the third party paid $50 on the claim, and the VA-allowable amount for
such treatment is $80, then VA would be responsible for paying $30 to
the non-VA provider under the draft bill. Payment by the Secretary
would then extinguish the veteran's liability to the non-VA provider
for the expenses of the emergency treatment at issue. VA's payment
could not include co-payments or similar payments owed by the veteran.
All of these amendments would apply to non-VA emergency treatment
furnished on or after October 8, 2007.
VA supports the draft bill. Under current law, VA is a payer of
last resort. Consequently, a veteran who would otherwise be eligible
for reimbursement or payment of private emergency medical expenses is
ineligible for the benefit because a third party makes partial payment
toward the veteran's emergency treatment expenses pursuant to other
contractual or legal recourse available to the veteran. In these cases,
veterans are often left with sizeable medical debts for which they are
personally liable. We understand the purpose for the legislation is to
remedy this limited situation. Payment by the Secretary as secondary
payer would fully extinguish the veteran's liability to the private
provider who furnished the emergency treatment.
It is not feasible to cost this proposal without extensive data on
veterans' personal liability for non-VA emergency care expenses
following partial payments made by third parties under various personal
injury protection policies. Those data are not available. We have
therefore estimated the cost of the draft bill based on the average
payment made by the Secretary for unauthorized non-VA emergency
treatment of veterans' non-service connected disabilities. We estimate
the cost of implementing this draft bill to be $500,000 for Fiscal Year
2010, $3 million over a 5-year period, and $7.8 million over a 10-year
period.
H.R. 1211 ``Women Veterans Health Care Improvement Act''
The last bill on today's agenda is the ``Women Veterans Health Care
Improvement Act,'' which contains a number of provisions that I will
address individually.
Section 101 would require VA to contract with a qualified
independent entity or organization to carry out a comprehensive
assessment of the barriers encountered by women veterans seeking
comprehensive health care from VA, building on the VA's own ``National
Survey of Women Veterans in Fiscal Year 2007-2008'' (National Survey).
Many requirements related to sample size and the scope of the survey
would apply to the conduct of the assessment. Section 101 would also
require the contractor-entity to conduct research on the effects of the
following concerns on the study participants:
The perceived stigma associated with seeking mental
health care services.
The effect of driving distance or availability of other
forms of transportation to the nearest appropriate VA facility on
access to care.
The availability of child care.
The acceptability of integrated primary care, or with
women's health clinics, or both.
The comprehension of eligibility requirements for, and
the scope of services available under, such health care.
The perception of personal safety and comfort of women
veterans in inpatient, outpatient, and behavioral health facilities of
the Department.
The gender sensitivity of health care providers and staff
to issues that particularly affect women.
The effectiveness of outreach for health care services
available to women veterans.
The location and operating hours of health care
facilities that provide services to women veterans.
Such other significant barriers identified by the
Secretary.
Additionally, section 101 would require the Secretary to ensure
that the heads of the Center for Women Veterans and the Advisory
Committee on Women Veterans review the results of the comprehensive
assessment and submit their own findings with respect to it to the
Under Secretary for Health and other VA offices administering women-
veterans health care benefits.
VA supports section 101 but notes that the results of our National
Survey will not be available until later in the fiscal year.
Consequently, we do not think it feasible to enter into a contract for
the mandated assessment and research until we have first had a chance
to complete and fully analyze the results of the National Survey. Only
in this way can the assessment and research adequately build on the
National Survey and reliably augment, rather than duplicate, VA's
efforts in this area. We estimate the cost of section 101 to be $3\1/2\
million.
Section 102 of H.R. 1211 would require VA to enter into a contract
with an entity or organization to conduct a very detailed and
comprehensive assessment of all VA health care services and programs
provided to women veterans at each VA facility. The assessment would
have to include VA's specialized programs for women with PTSD, homeless
women, women requiring care for substance abuse or mental illnesses,
and those requiring obstetric and gynecologic care. It would also need
to address whether effective health care programs (including health
promotion and disease prevention programs) are readily available to,
and easily accessed by, women veterans based on a number of specified
factors.
After the assessment is performed, the bill would require VA to
develop an extremely detailed plan to improve the provision of health
care services to women veterans, taking into account, among other
things, projected health care needs of women veterans in the future and
the types of services available for women veterans at each VA medical
center. VA would then be required to report to Congress on the
assessment and plan, including any administrative or legislative
recommendations VA deems appropriate.
What is unclear in the bill is whether the contractor-entity
conducting the assessment would also be required to develop the follow-
up ``plan,'' as the terms of section 102 refer to the contractor's
conduct of ``studies and research'' required by that section.
VA supports section 102 only if the development of the mandated
plan would be conducted by a contractor-entity. We estimate the total
costs of this section to be $4,354,000 during the period of Fiscal Year
2010 through Fiscal Year 2012.
Section 201 of H.R. 1211 would authorize VA to provide hospital
care and medical services to newborns of women-veterans who receive
their maternity care through the Department. This treatment authority
would be limited to 14 days, beginning on the date of the child's
birth.
We appreciate and understand the Committee's interest in this
issue. Before we can take a position on section 201, however, we first
need to determine whether the time-frame of 14 days is appropriate.
Additionally, we must complete the cost estimate for this provision.
Once we complete these analyses, we will submit our views and cost
estimate for the record.
Section 202 would require VA to carry out a program to provide
graduate medical education, training, certification, and continuing
medical education for mental health professionals who provide sexual
trauma care and counseling services and care and counseling for Post-
Traumatic Stress Disorder (PTSD). We do not support section 202 because
it is unnecessary. Further, the training and continued medical
education and training that VA currently requires of these mental
health professionals far surpasses that which would be required by this
provision.
We believe it is essential that our medical professionals across
the system be able to effectively recognize and treat the
manifestations of sexual trauma and PTSD. To that end, we train our
mental health professions on evidence-based practices (EBPs) for PTSD
and associated conditions that can result from sexual trauma, such as
depression and anxiety. VA is also conducting two national training
initiatives to educate therapists in two particular EBPs for PTSD. The
first of these is Cognitive Processing Therapy (CPT), which began in
2006. Following didactic training, clinicians participate in clinical
consultations to attain full competency in CPT. VA is also using new
CPT treatment manuals, originally developed and tested in civilian
settings for victims of rape and child sexual abuse, which had been
adapted specifically for VA and the Department of Defense by inclusion
of material on the treatment of issues arising from the experience of
sexual trauma during military service. To date, VA has trained 1,484 VA
clinicians in the use of CPT.
The second national initiative is an education and training module
on Prolonged Exposure (PE) for treatment of PTSD, which began in 2008.
As you are likely aware, there have been a number of studies supporting
the use of exposure treatment for PTSD. Originally PE was developed to
treat sexual-assault survivors, but it has been successfully adapted
for the treatment of combat-related PTSD. To date, OMHS has trained 233
clinicians in the use of PE.
VA has also begun training its mental health professionals in
Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral
Therapy (CBT), which are evidence-based psychotherapies for anxiety and
depression, two mental health conditions that can result from the
experience of sexual trauma. Similar to the two PTSD-related training
initiatives, this training program includes the use of didactic
training materials adapted for the treatment of sexual trauma
experienced during military service and clinical case studies involving
women veterans. This training program began in 2008, and VA has already
trained 151 clinicians.
As our mental health professionals receive training under these two
initiatives and other targeted training programs, we carefully monitor
their clinical practice to ensure they are delivering state-of-the-art
care to their patients.
Finally, I would like to mention that VA has established the
Military Sexual Trauma (MST) Support Team at the national level to
monitor MST screening and treatment, oversee MST-related education and
training, and promote best practices for screening and treatment of the
mental and physical health consequences of MST. This MST Support Team
hosts monthly MST teleconference training calls. Typically, more than
100 phone-lines are used with multiple listeners on each line. Sample
topics include: evidence-based psychotherapies, MST in Primary Care
settings, health issues associated with men who have experienced MST,
and cultural issues affecting patients suffering from MST and/or MST-
related treatments. Credits for professional continuing education are
available for those who participate in these training calls. The MST
Support Team operates an intranet Web site homepage with links to MST-
related resources and materials (including training materials), reports
on MST screening and treatment of MST-related health problems, and MST-
related discussion forums. The Team also hosts an annual clinical
training program for MST Coordinators, which is a 5-day training
session on both the treatment of MST and program development strategies
for VA facilities. Lastly, the MST Support Team is currently revising
the Veterans Health Initiative Independent Study course on MST for
which Continuing Education credit is available.
In short, the training described above is designed to complement
the professional training of VA's highly qualified mental health staff
by providing them with additional training in emerging, cutting-edge
therapies and practices. Note that this is in addition to the
continuing medical education required by the providers' State licensing
boards and/or professional specialty boards and organizations.
VA estimates the cost of implementing section 202 to be $9\1/2\ in
Fiscal Year 2010, $46 million over a 5-year period, and $99 million
over a 10-year period.
Section 203 would require VA, not later than 6 months after the
date of the bill's enactment, to carry out a 2-year pilot program at no
fewer than three VISNs to furnish child-care services (directly or
indirectly) to eligible veterans as a means of improving their access
to mental and health care services. Eligible veterans would include
veterans who are the primary caretaker of a child and who are receiving
regular or intensive mental health care services or any other intensive
health care services for which the Secretary determines the provision
of child care would improve the veterans' access to care. Child care
would be limited to the time during which the veteran actually receives
the covered services and the time required to travel to and from the VA
facility for the covered services. VA would be permitted to provide
child care services through a variety of means, i.e., stipends offered
by licensed child care centers (directly or through a voucher system),
the development of partnerships with private agencies, collaboration
with other Federal facilities or programs, or the arrangement of after-
school care.
We share the Committee's interest in ensuring appropriate access to
care. Once we have completed our analysis, we will submit our views and
cost estimate for the record.
Section 204 would require the Department's Advisory Committee on
Women Veterans to include recently-separated women veterans. It would
also require the Department's Advisory Committee on Minority Veterans
to include recently separated minority-group veterans. These
requirements would apply to Committee appointments made on or after the
date of this bill's enactment.
We fully support section 204. These amendments would help both
Committees to better identify and address the needs of their respective
veteran-populations.
Mr. Chairman, this concludes my prepared statement. I would be
pleased to answer any questions you or any of the Members of the
Subcommittee may have.
Statement of Hon. Bob Filner, Chairman,
Committee on Veterans' Affairs
Chairman Michaud, thank you for the opportunity to testify before
the Sub Committee on Health on this legislation which will assist
veterans who get hurt while they are off-duty and require emergency
care in non-VA medical facilities.
Under current law, the VA does not pay for emergency treatment for
non-service connected conditions in non-VA facilities if a veteran has
third party insurance that pays either full or a portion of the
emergency care. This includes veterans who carry an auto insurance
policy providing minimal health care coverage.
I first became aware of this issue through Stephen Brady, a sixty
percent service connected veteran who was in a serious motorcycle
accident in October of 2007 and received emergency care in a non-VA
facility. Mr. Brady carried an auto insurance policy which covered
$10,000 in medical costs, even though his total medical bill far
exceeded $10,000. As you can imagine, this has caused undue stress and
financial hardship on veterans such as Stephen Brady.
In the last Congress, I introduced H.R. 5888 to address this
problem. Since then, I've worked to make some improvements to the
legislation by including new provisions clarifying the reimbursement
responsibilities of the VA.
Specifically, the new provision defines the VA as a secondary payor
where a third party insurer covers a part of the veteran's medical
liability.
It also explains that the VA is only responsible for the difference
between the amount paid by the third party insurer and the VA allowable
amount. Veterans would continue to be responsible for copayments owed
to the third party insurer.
And finally, it protects our veterans by clarifying that they are
not liable for any remaining balance due to the provider after the
third party insurer and the VA have made their payments.
In the new Congress, I hope that the Committee supports and passes
this importance piece of legislation.
In closing, I look forward to the day when veterans like Stephen
Brady can focus on their recovery, instead of being overburdened with
financial concerns.
Thank you again for the opportunity to share my thoughts with you.
Statement of Paralyzed Veterans of America
Mr. Chairman and Members of the Subcommittee, Paralyzed Veterans of
America (PVA) would like to thank you for the opportunity to submit a
statement for the record on H.R. 784; H.R. 785; the ``Women Veterans
Health Care Improvement Act;'' and draft legislation concerning
emergency treatment furnished in a non-Department of Veterans Affairs
(VA) facility. PVA appreciates the emphasis this Subcommittee continues
to place on addressing mental health needs of veterans. We are also
pleased to see that the Subcommittee intends to address the needs of a
rapidly growing population--women veterans.
H.R. 784
PVA fully supports H.R. 784, a bill that requires the VA to provide
quarterly reports on vacancies in mental health professional positions.
As explained in the FY 2010 edition of The Independent Budget, there is
a national shortage of behavioral health professionals. Despite this
fact, the VA still must improved its succession planning in mental
health services in order to address the professional field shortages,
recruitment, and retention challenges.
Ultimately, the key to ensuring that the VA is able to provide
adequate mental health services to the current generation of veterans
and veterans of previous eras is strong oversight. As such, this
legislation establishes an additional tool that can be used for that
oversight. As explained in The Independent Budget:
The development of the MHSP [Mental Health Strategic Plan]
and the new Uniform Mental Health Services package provide an
excellent road map for the VHA's transformation of its mental
health services to veterans. However . . . the IBVSOs have
expressed continued concern about the pace of implementation of
the mental health clinical, education, and research programs.
There are also significant gaps that need to be closed,
especially in oversight of mental health programs and in the
case management programs for OEF/OIF combat veterans.
Given the incredible amount of resources that have been invested in
VA mental health programs in recent years this oversight will be
critical. For additional recommendations and discussion about VA mental
health programs, please refer to the FY 2010 edition of The Independent
Budget.
H.R. 785
PVA supports H.R. 785, a bill that requires the VA to conduct a
pilot program to provide outreach and training to certain college and
university mental health centers. Much like the issues addressed with
regards to H.R. 784, the VA is at a critical period in its provision of
mental health services. This pilot program will allow the VA to expand
its efforts to meet the needs of Operation Enduring Freedom and
Operation Iraqi Freedom (OEF/OIF) veterans. This legislation is
particularly timely in light of the possibility for substantial new
enrollments of this generation of veterans into colleges and
universities as a result of the benefits provided under the Post-9/11
GI Bill. As with the broader mental health programs administered by the
VA, the success of this program will also depend on serious oversight.
However, if successful, this pilot program could provide an effective
blueprint for the expansion of VA mental health services in the future.
The ``Women Veterans Health Care Improvement Act''
PVA supports the draft legislation--the ``Women Veterans Health
Care Improvement Act.'' Women have played a vital part in the military
service throughout our history. In the last 50 years their roles,
responsibilities, and numbers have significantly increased. Current
estimates indicate that there are 1.8 million women veterans comprising
nearly 8 percent of the United States veteran population. According to
Department of Defense (DoD) statistics, women servicemembers represent
15 percent of active duty forces, 10 percent of deployed forces, 20
percent of new recruits, and are a rapidly expanding segment of the
veteran population.
Historically, women have represented a small numerical minority of
veterans who receive health care at Department of Veterans Affairs (VA)
facilities. However, if women veterans from Operation Enduring Freedom
and Operation Iraqi Freedom (OEF/OIF) continue to enroll at the current
enrollment rate of 42\1/2\ percent, it is estimated that the women
using VA health care services will double in two to 4 years.
As the population of women veterans undergoes exponential growth in
the next decade, VA must act now to prepare to meet the specialized
needs of the women who served. Overall the culture of VA needs to be
transformed to be more inclusive of women veterans and must adapt to
the changing demographics of its women veteran users--taking into
account their unique characteristics as young working women with
childcare and eldercare responsibilities. VA needs to ensure that women
veterans' health programs are enhanced so that access, quality, safety,
and satisfaction with care are equal for women and men.
This legislation is meant to expand and improve health care
services available in the 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 veterans population.
Title I of the bill would authorize a number of studies and
assessments that would evaluate the health care needs of women
veterans. Furthermore, these studies would also identify barriers and
challenges that women veterans face when seeking health care from the
VA. Finally, the VA would be required to assess the programs that
currently exist for women veterans and report this status to Congress.
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 disseminate information on effective treatment,
including evidence-based treatment, for women veterans dealing with
Post-Traumatic Stress Disorder (PTSD). 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. Finally, we would encourage the
Subcommittee to review the extensive policy section in the FY 2010
edition of The Independent Budget--``Women Veterans' Health and Health
Care Programs.''
Emergency Treatment in a Non-VA Facility
The draft legislation will expand eligibility for emergency medical
care at the VA for some veterans. Currently, veterans who have a third-
party insurance provider that pays a portion of medical expenses in the
event of an emergency do not have the balance of their medical expenses
covered by the VA. This proposed legislation should eliminate that
situation. It will prevent the VA from denying payment for emergency
service at non-VA hospitals when a veteran is partially covered by
their third-party insurance.
We do have one question about the legislation. PVA is unclear about
why a seemingly arbitrary date--October 8, 2007--was chosen as the
effective date? Otherwise, PVA supports this legislation.
Mr. Chairman and Members of the Subcommittee, PVA would once again
like to thank you for the opportunity to provide our views on this
important legislation. We look forward to working with you to continue
to improve the health care services available to veterans.
Thank you again. We would be happy to answer any questions that you
might have.
Statement of Thomas J. Berger, Ph.D., Senior Analyst for
Veterans' Benefits and Mental Health Issues, and Marsha Four, Chair,
National Women Veterans Committee, Vietnam Veterans of America
Mr. Chairman, Ranking Member Brown, Distinguished Members of the
House Veterans' Affairs Subcommittee on Health and honored guests,
Vietnam Veterans of America (VVA) thanks you for the opportunity to
present our statement for the record views on this important veterans
legislation being presented before this Subcommittee today.
It is indisputable that the number of women in the military has
risen consistently since the 2 percent cap on their enlistment in the
Armed Forces was removed in the early 1970s. This has resulted in an
increased number of women we can now call ``veterans'', and most
assuredly, will have a direct bearing on the number of women who will
be knocking on the door of the VA in the very near future. A focus on
the capacity and capability of the VA to equitably and effectively
provide care and services must be a priority today. Planning and
readiness is essential for the future. These responsibilities also
require oversight and accountability in order to meet both VA and
veteran goals, objectives, requirements, standards, and satisfaction,
along with agency advancement.
While much has been done over the past few years to advance and
ensure greater equity, safety, and provision of services for the
growing number of women veterans in the VA system, these changes and
improvements have not been completed implemented throughout the entire
VA system. In some locations, women veterans still experience
significant barriers to adequate health care and oversight with
accountability. Thus VVA asks the new Secretary to ensure senior
leadership at all VA facilities and in each VISN to be held accountable
for ensuring that women veterans receive appropriate care in an
appropriate environment.
Additionally, there is much to learn about women veterans as a
separate patient cohort within the VA. Women's Health is now studied as
a specialty in every medical school in the country. It has moved far
beyond that of obstetrics and gynecology. Gender has an impact on
nearly every system of the body and mind. This has great significance
in the ability of any health care system to provide the most
appropriate, comprehensive, and evidence-based scientific treatment and
care. This also has a direct effect on the delivery system along with
staff requirements to meet the needs of women now utilizing the VA
health care system, as well as for those new women veterans who will be
coming into the system in the future.
The VA has already identified that our country's new women veterans
are younger and that they expect to use the system more consistently.
For example, in December 2008, the VA reported that of the total
102,126 female OEF/OIF veterans, 42.2 percent of them have already
enrolled in the VA system, with 43.8 percent using the system for 2-10
visits. Among these returning veterans, 85.9 percent are below the age
of 40 and 58.9 percent are between 20 and 29. In fact, the average age
of female veterans using the VA system is 48 compared with 61 for men.
Therefore it is clear that the needs of women veterans are growing and
already taxing the VA system, which historically has focused on an
older population.
The 110th Congress put forward two bills related to women veterans
S.2799 and H.R. 4107 that unfortunately were not finalized with
passage. So VVA is pleased to see the reintroduction of such
legislation with H.R.1211 and applauds the efforts of this Committee to
bring women veterans' health care to the forefront of attention in the
111th Congress. However, VVA does wish to make comments on a number of
specific provisions included in this proposed legislation.
Title I: Studies and Assessments of Department of Veterans Affairs
Health Services for Women Veterans:
Section 101: Study of Barriers for Women Veterans to Health Care from
the Department of Veterans Affairs--Section 101(a)(4)
VVA believes that this study is vital to understanding today's
women veterans and that building on the ``National Survey of Women
Veterans in Fiscal Year 2007-2008'' is a referenced starting point.
However, VVA also believes that there is a need to expand several
elements in this section. For example, section 101(a)(4) should include
a survey of sufficient size and diversity to be statistically
significant for women of all ethnic groups and service periods.
Section 101(b)--VVA believes that this study should identify the
``best practices'' that facilities utilize to overcome identified
barriers.
Section 101(b)(2)--VVA believes that with the fragmentation of
women's health care services there needs to be consideration for
driving time/transportation to medical facilities that offer specialty
care as well as primary care.
Section 101(d)(1)--While VVA holds great respect for and recognizes
the important work of both the Office of the Center for Women Veterans
and that of the Advisory Committee on Women Veterans, this section as
written would limit the initial review, creating unnecessary delays.
Rather, VVA believes that this study should also go immediately to
these two entities, plus the VA Undersecretary for Health, the Deputy
Undersecretary for Quality and Performance, the Deputy Undersecretary
for Operations, the Office of Patient Care Services, and the Chief
Consultant for the Women Veterans Health Program for review and
recommendations, which in turn are then forwarded to the Deputy
Undersecretary for action to remove or ameliorate the identified
barriers.
Section 101(e)(2)--VVA recognizes that this section requires that
30 months after the VA publishes the 2007-08 National Survey of Women
Veterans that the VA Secretary in turn is required to report to
Congress on the barriers study and what actions the VA is planning.
However, in reality, this means that the information/directions
contained in the '07-08 report is/are put ``on hold'' for 2\1/2\ years.
Therefore VVA believes that the Secretary's report to Congress should
also include what actions--if any--have transpired both during the
survey and the 30 month hiatus.
Section 102(1)--VVA believes this section should include
appropriate language directing the study format to include the use of
evidence-based ``best practices in care delivery''.
Title II: Improvement and Expansion of Health Care Programs of the
Department of Veterans Affairs for Women Veterans
Section 201--VVA asks that particular reflective consideration be
given to the following--VVA seeks a change in this section of the
proposed legislation that would increase the time for the provision of
neonatal care from 14 to 30 days, as needed for the newborn children of
women veterans receiving maternity/delivery care through the VA.
Certainly, only newborns with extreme medical conditions would require
this time extension. VVA believes that there may be extraordinary
circumstances wherein it would be detrimental to the proper care and
treatment of the newborn if this provision of service was limited to
solely 14 days. If the infant must have extended hospitalization, it
would allow time for the case manager to make the necessary
arrangements to arrange necessary medical and social services
assistance for the woman veteran and her child. This has important
implications for our rural women veterans in particular. And this is
not to mention cases where there needs to be consideration of a woman
veteran's service-connected disabilities, including toxic exposures and
mental health issues, especially during the pre-natal period.
Section 202--VVA has concerns about the VA establishing a
``certification'' program. In order to be valid, VVA believes that such
a certification program be based upon and modeled after those already
utilized by many professional organizations. Such a certification
program would lend itself well to oversight and accountability. Too
many VA certification programs now consist of only a 1-hour training
class or reading materials.
Section 202(e)(2)--Although this section calls for reporting the
number of women veterans who have received counseling, care and
services under subsection (a) from ``professionals and providers who
received training under subsection (4)'', VVA asks ``Who in the VA is
already trained and holds professional qualifications under these
subsections? ''
A Concern of Non-inclusion--During the 110th Congress, VVA was
heartened to see that the S.2799 legislation included a ``Long Term
Study of Health of Women Veterans of the Armed Forces Serving Operation
Iraq Freedom and Operation Enduring Freedom''. However, VVA is
extremely disappointed to see that any mention of this proposed study
is missing from H.R. 1211 which is currently under consideration by the
111th Congress. As you know, the second round of the National Vietnam
Veterans Readjustment Study was never completed by the VA, even though
it was mandated by Congress to do so. VVA urges you not to let this
opportunity be lost again on a statistically significant and diverse
population of veterans. With regard to women veterans and the NVVRS, if
and when the VA is ever held accountable and again directed to complete
this important study, VVA is extremely interested in the issue of auto-
immune diseases found in the study.
As time, social environments, and veterans' population demographics
change, there are also cultural expectations based on scientific
advancements in health care that elicit a re-definition of women
veterans' needs in the VA system. Knowing the needs is vital to
understanding and meeting them. The VA has recognized many of the needs
of women veterans by actually creating interest groups comprised of not
only VA staff, but veterans as well. For example, there is recognition
that younger women veterans are also working women who need flexible
clinic and appointment hours in order to also meet their employment and
child-care obligations. They also need to have sexual health and family
planning issues addressed, along with the needs of infertility and pre-
natal maternity. And there are unanswered questions and concerns about
the role of exposures to toxic substances and women's reproductive
health.
The new women veterans also need increased mental health services
related to re-adjustment, depression, and re-integration, along with
recognition of differences among active duty, Guard, and reserve women.
The VA already acknowledges the issue of fragmented primary care,
noting that in 67 percent of VA sites, primary care is delivered
separately from gender specific health care--in other words, two
different services at two different times, and in some cases, two
different services, two different times, and two different delivery
sites. The VA also notes that there are too few primary care physicians
trained in women's health, and at a time when medicine recognizes the
link between mental and medical health, most mental health is separate
from primary care. VVA seeks to ensure that every woman veteran has
access to a primary care provider who meets all her primary care needs,
including gender specific and mental health care in the context of an
on-going patient-clinician relationship; and that general mental health
providers are located within the women's and primary care clinics in
order to facilitate the delivery of mental health services.
Vietnam Veterans of America applauds the VA for elevating its
Office of Women's Health to the Strategic Health Care Group level. With
this action, the VA has ``pumped up'' the volume on the attention and
direction of the VA regarding women veterans. But there remains much to
be learned about women veterans as a health care cohort. Data
collection and analytical studies will provide increased opportunities
for research and health care advancement in the field of women's
health, as well as offer evidence-based ``best practices'' models and
innovative treatments.
The VA is a massive health care system that possesses challenges
for the new Secretary, VA leadership, and all those VA employees who
provide and deliver care treatment, and services to our Nation's
veterans. VVA is hopeful that any shortfalls can be turned into
positive action with resolve through a progressive implementation plan
which turns hopeful plans into reality.
H.R. 784, VVA has no objections to the proposed emendation of Title
38, U.S. Code which directs the Secretary of Veterans Affairs to submit
quarterly reports to Congress on vacancies in mental health
professional positions in Department of Veterans Affairs medical
facilities.
H.R. 785, VVA generally supports the bill as written; however, we
suggest that there be an evaluation report after 1 year of operations.
The legislation should be passed as the pilot program to provide
outreach, training and evaluation to certain college and university
mental health centers relating to the mental health of veterans of
Operation Iraq Freedom and Operation Enduring Freedom.
Emergency Treatment in Non-VA Facilities, VVA is pleased to support
the proposed emendation to Title 38, United States Code, to expand
veteran eligibility for reimbursement by the Department of Veterans
Affairs for emergency treatment in a non-Department facility.
As you may well remember from several previous appearances before
this Committee, VVA has addressed the problems associated with the VA's
paradigm for delivery of health care. Until very recently this paradigm
has been predicated on placing resources where there is a large
concentration of veterans eligible for services. In other words, the
chief mechanism for service delivery of veterans' health care has been
in or near large urban centers. However, those service men and women
fighting our current wars in Iraq and Afghanistan (and elsewhere)
comprise the most rural fighting force since before World War I.
The Department of Defense reports that over 40 percent of our
current military force originates from towns and communities of 25,000
or less. What this means is that we collectively must re-think the
paradigm of how we deliver medical services, including emergency
medical services, to veterans in need.
The proposed emergency care legislation is a good start in toward
testing what is going to work in regard to delivering quality health
care services to veterans (including demobilized National Guard and
Reserves) who live in less populous areas of our country, and deserves
to be enacted and implemented as quickly as possible.
VVA thanks this Committee for the opportunity to submit testimony
for the record.
MATERIAL SUBMITTED FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
March 12, 2009
Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, D.C. 20240
Dear Secretary Shinseki:
Thank you for the testimony of Dr. Gerald Cross, Principal Deputy
Under Secretary for Health, Veterans Health Administration, at the U.S.
House of Representatives Committee on Veterans' Affairs Subcommittee on
Health Legislative Hearing on H.R. 784, H.R. 785, H.R. 1211, and a
Draft Discussion on Reimbursement for Emergency Care that took place on
March 3, 2009.
Please provide answers to the following questions by April 23,
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on
Health.
1. In your testimony on H.R. 1211, you state that VA needs to
first determine if the 14 day timeframe is appropriate for newborn
care. The Subcommittee would appreciate it if VA could get back to us
within the next four to 6 weeks regarding section 201 of H.R. 1211.
2. As with section 201 of H.R. 1211, the Subcommittee would
appreciate it if VA could get back to us within the next four to 6
weeks with their analysis, views and cost on carrying out a pilot
program to furnish child-care services (directly or indirectly) to
eligible veterans.
3. Please provide the Committee with information on the location
and status of current mental health staff vacancies, including VA's
progress in filling those vacancies.
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by April 23, 2008.
Sincerely,
MICHAEL H. MICHAUD
Chairman
CW/jb
__________
Questions for the Record
Hon. Michael Michaud
Chairman
Subcommittee on Health
House Committee on Veterans' Affairs
March 3, 2009
Legislative Hearing on H.R. 784, H.R. 785, H.R. 1211 and Discussion
Draft on Emergency Care Reimbursement
Question 1: In your testimony on H.R. 1211, you state that VA needs
to first determine if the 14 day timeframe is appropriate for newborn
care. The Subcommittee would appreciate it if VA could get back to us
within the next four to 6 weeks regarding section 201 of H.R. 1211.
Response: Section 201 of H.R. 1211 would authorize the Department
of Veterans Affairs (VA) to provide hospital care and medical services
to newborns of women Veterans who receive their maternity care through
VA. The proposal authorizes care for the first 14 days following the
child's birth.
VA has evaluated the circumstances related to care for newborns and
concluded the optimal period for VA coverage is 7 days, beginning with
the date of the child's birth. VA has analyzed data and found that 94
percent of mothers and their infants are released from medical
facilities within the first 7 days. This limit would still afford the
remainder of women Veterans sufficient opportunity to make alternate
financial arrangements, such as Medicaid or the State Children's Health
Insurance Program for their infants. In addition, we note that this
level of coverage is significantly beyond the standard provided under
group health insurance policies which typically cover only routine care
for the newborn child for up to 48-96 hours of the mother's maternity
stay at the hospital.
Services covered under this analysis include up to 7 days of health
care services for newborns. Health care services include room and board
and ancillaries, daily physician services, and post-discharge physician
care delivered within the mandated period of coverage. VA estimates the
cost of this program to be $55.3 million in the first year, $293.6
million over 5 years, and $589.3 million over 10 years.
Question 2: As with section 201 of H.R. 1211, the Subcommittee
would appreciate it if VA could get back to us within the next four to
6 weeks with their analysis, views and cost on carrying out a pilot
program to furnish child-care services (directly or indirectly) to
eligible veterans.
Response: H.R. 1211, section 203, requires the Secretary of VA to
carry out a 2-year pilot program under which the Secretary provides
child care assistance to qualified Veterans in at least three Veterans
Integrated Services Networks (VISN). Child care assistance under this
section may include:
1. Stipends for the payment of child care offered by licensed
child care centers (either directly or through a voucher program);
2. The development of partnerships with private agencies;
3. Collaboration with facilities or programs of other Federal
departments or agencies; and
4. The arrangement of after school care.
Under this section, child care assistance may only be provided for
the period of time that the qualified Veteran (1) receives a health
care service at a VA facility, and (2) travel time to and from such
facility for health care service. A qualified Veteran, under this
section, means a Veteran who is the primary caretaker of a child and
who is receiving one or more of the following health care services from
VA:
1. Regular mental health care services
2. Intensive mental health care services
3. Any other intensive health care services for which the
Secretary determines that providing child care would improve access by
qualified Veterans.
We support the Committee's intent in removing barriers that could
limit a veteran's access to health care. However, we do not support
this bill because the benefits are not tailored to those Veterans who
would otherwise forgo health care in the absence of Government-
subsidized child care assistance. Moreover, this pilot would shift
resources that could be used to support the direct delivery of health
care to Veterans to those who may have existing child care options
available. Since VA has no experience in predicting the use of child
care services by ``qualified Veterans,'' we estimate that costs for
this pilot could be up to the $1\1/2\ million authorized by the bill.
Question 3: Please provide the Committee with information on the
location and status of current mental health staff vacancies, including
VA's progress in filling those vacancies.
Response: VA has developed a number of initiatives that have had a
significant positive impact on the recruitment and retention of mental
health professionals. With the aid of these recruitment initiatives, VA
mental health staffing levels have increased by over 5,000 full time
employee (FTE) since fiscal year (FY) 2005, when VA began implementing
its Mental Health Strategic Plan. Currently, there are almost 19,000
mental health professionals employed by VA, and 95 percent of all
Veterans seeking new mental health services are seen within 14 days for
evaluation and initiation of treatment. Although vacancies exist, most
are quickly filled. There is no systemic problem with ``unfilled''
positions that impact the delivery of timely care to Veterans. VA has
recruitment goals, and those goals increase annually.
Staffing goals can not be viewed in a vacuum, and VA considers
several factors in determining appropriate staffing levels for mental
health professionals. This process includes sufficiently training
professionals to ensure required services are delivered at facilities
(or to ensure these services are available through tele-mental health)
and scheduled at times convenient for Veterans. VA also is establishing
productivity standards, which will be performance-based and sensitive
to the multiple settings in which mental health care is provided. These
standards will recognize the roles and intensity of care needed in
various settings. Once established, those productivity standards will
support determinations of optimal mental health staffing levels.
Although specific data on staff vacancies are not available in VA's
databases, it can provide a staffing level assessment of the number of
vacancies for positions funded by the Mental Health Enhancement
Initiative. These positions, however, only represent about 4,500 of the
approximately 19,000 total mental health professionals.
Table 1. Vacancies in mental health positions at Veterans Health Administration (VHA) medical facilities and
outpatient clinics, for the core mental health professions
----------------------------------------------------------------------------------------------------------------
Vacant FTE Vacant FTE Vacant FTE
in active in pre- not in Vacancies as
FTE total recruitment recruitment recruitment a percent of
for vacant (% of vacant (% of vacant (% of vacant overall
positions FTE for each FTE for each FTE for each positions*
profession) profession) profession)
----------------------------------------------------------------------------------------------------------------
Nurses 688.00 554.05 54.00 79.95 7.3%
----------------------------------------------------------------------------------------------------------------
(80.5%) (7.9%) (11.6%)
----------------------------------------------------------------------------------------------------------------
Psychiatrists 538.16 464.43 38.35 35.38 19.4%
----------------------------------------------------------------------------------------------------------------
(86.3%) (6.6%) (7.1%)
----------------------------------------------------------------------------------------------------------------
Social Work 835.80 646.30 110.50 79.00 19.2%
----------------------------------------------------------------------------------------------------------------
(77.3%) (13.2%) (9.5%)
----------------------------------------------------------------------------------------------------------------
Psychology 680.40 553.80 66.80 59.80 21.9%
----------------------------------------------------------------------------------------------------------------
(81.4%) (9.8%) (8.8%)
----------------------------------------------------------------------------------------------------------------
Totals 2,742.36 2,218.58 269.65 254.13 13.9%
----------------------------------------------------------------------------------------------------------------
(80.9%) (9.8%) (9.3%)
----------------------------------------------------------------------------------------------------------------
* Reported vacancies divided by current known staff positions plus reported vacancies)
Table 2 shows the location of vacancies by VISN for each of the
core mental health professions, as requested. While there is some
variability across VISNs, it is not dramatic and is primarily accounted
for by the size of the VISN, in terms of number of facilities and
number of unique Veterans served. Totals nationally appear in the last
row, to confirm that all vacancies shown in Table 1 also are accounted
for in Table 2.
Table 2. Distribution of vacant FTE across VISNs, by profession
----------------------------------------------------------------------------------------------------------------
Nursing Social Work
Vacancies in Psychiatry Vacancies in Psychology
VISN Mental Health Vacancies (FTE) Mental Health Vacancies (FTE)
Settings (FTE) Settings (FTE)
----------------------------------------------------------------------------------------------------------------
1 30.65 24.55 52.50 34.80
----------------------------------------------------------------------------------------------------------------
2 21.90 8.40 22.20 18.10
----------------------------------------------------------------------------------------------------------------
3 39.10 4.20 28.10 23.50
----------------------------------------------------------------------------------------------------------------
4 21.00 18.75 31.00 32.25
----------------------------------------------------------------------------------------------------------------
5 17.00 12.50 40.00 25.00
----------------------------------------------------------------------------------------------------------------
6 54.00 28.95 52.00 46.00
----------------------------------------------------------------------------------------------------------------
7 46.00 31.60 34.00 46.00
----------------------------------------------------------------------------------------------------------------
8 48.00 47.00 50.20 56.10
----------------------------------------------------------------------------------------------------------------
9 33.50 39.50 43.50 37.50
----------------------------------------------------------------------------------------------------------------
10 32.95 23.93 38.75 38.65
----------------------------------------------------------------------------------------------------------------
11 25.00 25.20 41.00 32.40
----------------------------------------------------------------------------------------------------------------
12 15.70 14.38 30.60 25.50
----------------------------------------------------------------------------------------------------------------
15 29.00 31.10 37.50 27.00
----------------------------------------------------------------------------------------------------------------
16 50.00 38.08 67.50 46.50
----------------------------------------------------------------------------------------------------------------
17 43.00 38.62 18.00 38.30
----------------------------------------------------------------------------------------------------------------
18 38.00 42.00 33.40 28.30
----------------------------------------------------------------------------------------------------------------
19 22.50 14.50 30.25 12.00
----------------------------------------------------------------------------------------------------------------
20 24.50 25.45 67.00 32.80
----------------------------------------------------------------------------------------------------------------
21 50.50 35.30 48.50 32.50
----------------------------------------------------------------------------------------------------------------
22 14.20 22.04 42.00 22.50
----------------------------------------------------------------------------------------------------------------
23 31.50 12.13 27.80 26.50
----------------------------------------------------------------------------------------------------------------
Totals 688.00 538.16 835.80 680.40
----------------------------------------------------------------------------------------------------------------
Of the 232 currently active vet centers, 229 have at least one VHA
qualified mental health professional (psychologist, social worker, or
psychiatric nurse; there are no psychiatry staff in vet centers) on
staff as per the Readjustment Counseling Service Handbook. The
remaining three sites (McKeesport, PA, Moline, IL, and Redwood City,
CA) are recruiting for mental health professionals to fulfill this
requirement. The vet center program currently employs 69 licensed
psychologists, 442 licensed social workers, and 12 psychiatric nurses
for a grand total of 523 mental health professionals. Sixty-four
percent of all current vet center team leaders and 60 percent of all
current vet center counselors are licensed psychologists, licensed
social workers, or psychiatric nurses.
Readjustment Counseling Service has increased the overall number of
mental health professionals on staff by 22 percent in the last 15
months. Overall, the current staffing levels are as follows.
----------------------------------------------------------------------------------------------------------------
DEC 2007 MAR 2009 DIFFERENCE
----------------------------------------------------------------------------------------------------------------
Professional on Staff Vet Centers with Mental Health 217 229 + 12
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Mental Health Professionals on Staff
----------------------------------------------------------------------------------------------------------------
Licensed Psychologists 49 69 + 20
----------------------------------------------------------------------------------------------------------------
Licensed Social Workers 367 442 + 75
----------------------------------------------------------------------------------------------------------------
Psychiatric Nurses 13 12 -1
----------------------------------------------------------------------------------------------------------------
Total Mental Health Professionals 429 523 + 94
----------------------------------------------------------------------------------------------------------------