[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
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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

                              ----------                              


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

                                  
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