[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 1293, H.R. 1197,
H.R. 1302, H.R. 1335, H.R. 1546, H.R. 2734,
H.R. 2738, H.R. 2770, H.R. 2898 AND
DRAFT DISCUSSION LEGISLATION
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
JUNE 18, 2009
__________
Serial No. 111-29
__________
Printed for the use of the Committee on Veterans' Affairs
----------
U.S. GOVERNMENT PRINTING OFFICE
51-868 PDF WASHINGTON : 2009
For sale by the Superintendent of Documents, U.S. Government Printing
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Washington, DC 20402-0001
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
__________
June 18, 2009
Page
Legislative Hearing on H.R. 1293, H.R. 1197, H.R. 1302, H.R.
1335, H.R. 1546, H.R. 2734, H.R. 2738, H.R. 2770, H.R. 2898 and
Draft Discussion Legislation................................... 1
OPENING STATEMENTS
Hon. Deborah L. Halvorson........................................ 1
Chairman Michael Michaud, prepared statement of.................. 15
Hon. Gus M. Bilirakis............................................ 2
Hon. John Boozman................................................ 13
WITNESSES
Halvorson, Hon. Deborah L., a Representative in Congress from the
State of Illinois.............................................. 9
Hare, Hon. Phil, a Representative in Congress from the State of
Illinois....................................................... 3
McNerney, Hon. Jerry, a Representative in Congress from the State
of California.................................................. 5
Mitchell, Hon. Harry E., a Representative in Congress from the
State of Arizona............................................... 4
Paralyzed Veterans of America, Fred Cowell, Senior Health Policy
Analyst........................................................ 10
Prepared statement of Mr. Cowell............................. 16
Perriello, Hon. Thomas S.P., a Representative in Congress from
the State of Virginia.......................................... 12
Teague, Hon. Harry, a Representative in Congress from the State
of New Mexico.................................................. 8
Prepared statement of Congressman Teague..................... 15
SUBMISSIONS FOR THE RECORD
U.S. Department of Veterans Affairs, Robert A. Petzel, M.D.,
Acting Principal Deputy Under Secretary for Health, Veterans
Health Administration.......................................... 20
American Academy of Physician Assistants, statement.............. 24
American Legion, Joseph L. Wilson, Deputy Director, Veterans
Affairs and Rehabilitation Commission, statement............... 26
Buyer, Hon. Steve, Ranking Republican Member, Committee on
Veterans' Affairs, and a Representative in Congress from the
State of Indiana, statement.................................... 27
Disabled American Veterans, Joy J. Ilem, Deputy National
Legislative Director, statement................................ 28
Moran, Hon. Jerry, a Representative in Congress from the State of
Kansas, statement.............................................. 37
National Association of Veterans' Research and Education
Foundations, statement......................................... 37
National Military Family Association, Barbara Cohoon, Government
Relations Deputy Director, statement........................... 41
Veterans of Foreign Wars of the United States, Christopher
Needham, Senior Legislative Associate, National Legislative
Service, statement............................................. 44
Vietnam Veterans of America, Bernard Edelman, Deputy Director for
Policy and Government Affairs, statement....................... 47
Wounded Warrior Project, statement............................... 49
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 June 22, 2009, and VA responses...................... 52
Hon. Henry E. Brown, Jr., Ranking Republican Member,
Subcommittee on Health, Committee on Veterans' Affairs, to
Hon. Eric K. Shinseki, Secretary, U.S. Department of
Veterans Affairs, letter dated June 24, 2009, and VA
responses.................................................. 61
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Joseph L. Wilson, Deputy
Director, Veterans Affairs and Rehabilitation Commission,
American Legion, letter dated June 22, 2009, and the
American Legion responses.................................. 70
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Joy J. Ilem, Deputy
National Legislative Director, Disabled American Veterans,
letter dated June 22, 2009, and Ms. Ilem's responses....... 71
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Fred Cowell, Senior
Health Policy Analyst, Paralyzed Veterans of America,
letter dated June 22, 2009, and Mr. Cowell's responses,
letter dated July 28, 2009................................. 73
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Christopher Needham,
Senior Legislative Associate, National Legislative Service,
Veterans of Foreign Wars of the United States, letter dated
June 22, 2009, and VFW's responses......................... 75
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Bernard Edelman, Deputy
Director for Policy and Government Affairs, Vietnam
Veterans of America, letter dated June 22, 2009, and Mr.
Edelman's responses, letter dated July 23, 2009............ 77
LEGISLATIVE HEARING ON H.R. 1293, H.R. 1197,
H.R. 1302, H.R. 1335, H.R. 1546, H.R. 2734,
H.R. 2738, H.R. 2770, H.R. 2898 AND
DRAFT DISCUSSION LEGISLATION
----------
THURSDAY, JUNE 18, 2009
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:03 a.m., in
Room 334, Cannon House Office Building, Hon. Deborah Halvorson
presiding.
Present:
Representatives Teague, McNerney, Halvorson, Perriello,
Boozman, and Bilirakis.
OPENING STATEMENT OF CHAIRMAN MICHAUD, AS PRESENTED BY HON.
DEBORAH L. HALVORSON
Mrs. Halvorson [presiding]. This hearing will now come to or
der.
Before I go into my opening statement, I would like to
welcome to the hearing today a distinguished group of law
students who are spending the summer with the Board of
Veterans' Appeals. Many fine law schools are represented and
there are veterans, members of the National Guard, and a Marine
spouse among the group.
So, again, welcome to the hearing today. If you would like
to stand up, I would like to welcome you, if anybody is here in
the audience today. Thank you.
[Applause.]
Mrs. Halvorson. Thank you for being with us today. I would
like to thank everyone for coming.
Actually, before I start on my opening remark, I want to
tell the audience that we are scheduled for votes somewhere
between 10:15 and 10:30. And it is not like there will be one
or two votes. There will be about 27 of them. What we do not
get done, I am going to ask all the panelists to submit their
testimony for the record. And anybody else, any questions that
they have will be answered by staff.
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 draft legislation as well as
recently introduced legislation within this Subcommittee's
jurisdiction in a clear and orderly process.
So I do not necessarily agree or disagree with the bills
here today, but I do believe that this is an important part of
the legislative process.
So I welcome frank, open discussions from all parties that
this legislation would affect.
We have 11 bills before us today. And obviously we will
probably be submitting most of them for the record. And each of
the bills addresses important issues affecting our veterans and
their families.
These bills address a wide range of issues including help
for family caregivers of wounded veterans, improving the
nonprofit research and education corporations, establishing a
position of Director of Physician Assistant, and creating a
Committee on Care of Veterans with Traumatic Brain Injury.
[The prepared statement of Chairman Michaud appears on p. 15
.]
Mrs. Halvorson. We will also consider a lot of other
important bills. But at this time, I would like to allow Mr.
Hare a chance--oh, I am sorry. Mr. Bilirakis, would you like to
give an opening remark, please?
OPENING STATEMENT OF HON. GUS M. BILIRAKIS
Mr. Bilirakis. Just very brief. Thank you very much, I
appreciate it, Madam Chair.
I appreciate you holding this legislative hearing and
welcome the opportunity to discuss the 11 legislative proposals
before us today.
Knowing we have a full schedule, and of course votes coming
up this morning, I will keep my remarks very brief.
Our Ranking Member, Steve Buyer, is a sponsor of one of the
bills on the agenda, H.R. 1293, the ``Disabled Veterans Home
Improvement and Structural Alteration Grant Increase Act of
2009.''
Unfortunately, Steve is unable to be here this morning, and
I ask unanimous consent, Madam Chair, that his statement be
included in the record.
Mrs. Halvorson. So ordered.
[The prepared statement of Congressman Buyer appears on
p. 27.]
Mr. Bilirakis. Thank you.
In his absence, I would like to take a few moments to
explain this bill.
H.R. 1293 would increase the amount available for grants
under the Home Improvement and Structural Alteration (HISA)
Program. The HISA program provides grants as part of the U.S.
Department of Veterans Affairs' (VA's) Home Health Services to
make home improvements that are necessary to continue care in
the veteran's home.
Both veterans with service-connected and nonservice-
connected disabilities are eligible to receive this benefit.
H.R. 1293 would raise the authorized grant amount from
$4,100 to $6,800 for service-connected veterans and from $1,200
to $2,000 for nonservice-connected veterans.
It is a good, bipartisan bill and I urge my colleagues to
support it.
In closing, I want to thank all the Members who have
introduced the bills we will consider today and all of our
witnesses for taking time to provide their views. I look
forward to a productive discussion and I yield back.
Thank you, Madam Chair.
Mrs. Halvorson. Thank you, Mr. Bilirakis, for being here
and for being a part of this.
So we will start with Mr. Hare and then we will go to Mr.
Mitchell.
STATEMENTS OF HON. PHIL HARE, A REPRESENTATIVE IN CONGRESS FROM
THE STATE OF ILLINOIS, AND HON. HARRY E. MITCHELL, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF ARIZONA
STATEMENT OF HON. PHIL HARE
Mr. Hare. Thank you, Madam Chair. Good morning.
And let me just say before I give the testimony how very
much I appreciate having the opportunity to be here today. I
miss this Subcommittee and I miss the full Committee. It is an
incredible Committee and it works in a very wonderful,
bipartisan way.
So thank you for having me.
Ranking Member Bilirakis, thank you, too, for allowing me
to be here today.
I am very pleased to provide testimony in support of H.R.
1302, a bill that I introduced to elevate the current physician
assistant (PA) Advisor, also known as the PA Advisor, to a
full-time Director of PA services in the VA's Central Office.
I would like to thank my colleagues, Representative Jerry
Moran for his leadership with me on this bill as well as
Chairman Filner, Chairman Michaud, Ranking Member Buyer and
Brown and many other VA Committee colleagues joining us as co-
sponsors.
PAs have long been a key component in the Veterans Health
Administration, with over 1,800 PAs currently employed there,
roughly 30 percent of whom are veterans.
While the PA Advisor position established by Congress in
the year 2000 has been valuable, many problems still exist.
For example, as the AAPA explained in their written
testimony of October 18, 2007, ``In one case, a local facility
decided that a PA could not write out patient prescriptions
despite licensure in the State allowing prescriptive authority.
In other facilities, PAs are told that the VA facility cannot
use PAs and will not hire PAs.''
These inconsistencies and restrictions not only hinder PAs
currently employed by the VA, but also discourage PAs from even
entering the VA system. Quite simply, this is a position that
needs to be made permanent and based at the VA Central Office.
The lack of a Director of PA services at the VA prevents
necessary recruitment and retention of the PA workforce in the
VA, all at a time when the Veterans Administration needs more
health care professionals to provide medical care for our
veterans.
Considering the fact that nearly 40 percent of all VA PAs
are projected to retire in the next 5 years, the VA is in
danger of losing its PA workforce unless some attention is
directed toward recruiting and retention of this critical group
of people.
PAs are the fourth fastest-growing profession in the
country, yet the VA is simply not competitive with the private
sector for new PA graduates and is missing an opportunity to
improve the quality of veterans' health care.
One of the biggest challenges facing current and future PAs
in the VA system is their exclusion from recruitment and
retention efforts and benefits.
The VA designates physicians and nurses as critical
occupations and so priority, scholarships and loan repayment
programs to those critical occupations.
However, the PA profession has not been determined to be a
critical occupation at the VA despite the fact that the VA has
determined that PAs and Nurse Practitioners (NPs) are
functionally interchangeable and that they perform equal work.
A permanent Director at the Veterans Affairs Central Office
(VACO) would serve as an advocate on behalf of the physician
assistants and work to ensure their fair treatment.
Additionally, VA medical facilities at times post vacant
positions for NPs only, excluding physician assistants. There
is also a hiring trend in the VA of NPs outpacing PAs nearly
three to one, again despite the interchangeability between the
NPs and the physician assistants.
Finally, PAs are not included in any of the VA's special
locality pay bands, so PAs' salaries are not regularly tracked
and reported by the VA. There is evidence that this has
resulted in lower pay for physician assistants employed by the
VA compared to other health care professionals. This only
serves as yet another deterrent to PAs to enter the VA system.
The physician assistant profession is invaluable to the VA
and it is time for the VA to devote some serious attention to
the profession's recruitment and retention.
Enactment of my bill, H.R. 1302, is a very good start.
There is no significant cost to elevating and relocating the
position. This change is common sense and it promotes quality
medical care for our veterans.
H.R. 1302 is nearly identical to a bill that was reported
by your Committee in the 110th Congress, which passed the House
by a unanimous voice vote.
This bill, which also has been endorsed in the Senate by
Senator Susan Collins of Maine and Daniel Inouye of Hawaii, is
supported by the Veterans Affairs Physician Assistant
Association, the American Academy of Physician Assistants, and
the Blinded Veterans Association.
Madam Chairman and Ranking Member, thank you again for
allowing me to testify on the importance of physician
assistants in the VA health care system. I appreciate your
giving me the time and would be happy to answer any questions
you may have.
Thank you again very much for having me this morning.
Mrs. Halvorson. Do the Members have any questions?
[No response.]
At this time, we will go to Mr. Mitchell for his 5 minutes.
STATEMENT OF HON. HARRY E. MITCHELL
Mr. Mitchell. Thank you, Madam Chair. And I want to thank
you for inviting me to speak this morning in support of H.R.
1197, the ``Medal of Honor Health Care Equity Act of 2009.''
The Congressional Medal of Honor is awarded for conspicuous
gallantry and intrepidity at the risk of life above and beyond
the call of duty. It is the military's highest honor. Today
there are only 98 living recipients.
Last year, a medal recipient was injured in Chandler,
Arizona. This veteran, Fred Ferguson, was awarded the Medal of
Honor for flying his helicopter into enemy fire over Hue'
Vietnam. Despite his valor, which saved the lives of five
fellow soldiers, he was ineligible for health care through the
VA when he was injured.
The VA uses a priority scale to determine eligibility for
health care services. Top priority is given to veterans with
service-connected disabilities, former prisoners of war, and
Purple Heart recipients. Priority is also given to those who
have rendered special service or who demonstrate financial
need.
Each of these categories of veterans should be ensured
priority access to health care. Unfortunately, Medal of Honor
recipients do not automatically fall into any of these priority
categories and some of them fall through the cracks.
Now Fred Ferguson may not need medical care from the VA. In
fact, he received excellent care at Scottsdale Healthcare
Osborn's Hospital.
But in order to ensure that the 98 living Medal recipients
and all future Medal of Honor recipients have guaranteed access
to high-quality health care, Dr. Roe, my Republican counterpart
on the Oversight and Investigation Subcommittee, joined me in
introducing the ``Medal of Honor Health Care Equity Act.''
We are not talking about a large population of veterans,
but they deserve access to medical care from the VA no matter
what.
H.R. 1197 has been endorsed by the Disabled American
Veterans (DAV) and I appreciate your support for this bill.
Madam Chair, thank you again for permitting me to appear
before the Subcommittee today and I will be very glad to answer
any questions. Thank you.
Mrs. Halvorson. Are there any questions?
[No response.]
At this time, I would like to bring up panel two, which
includes myself, Mr. McNerney, Mr. Perriello, and Mr. Teague.
Thank you for not waiting for me to dismiss you. You would
have been sitting there for a while.
Gentlemen, since I am here, I will go last.
Mr. McNerney, if you would like to proceed with your 5
minutes.
STATEMENTS OF HON. JERRY MCNERNEY, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF CALIFORNIA; HON. HARRY TEAGUE, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW MEXICO; AND
HON. DEBORAH L. HALVORSON, A REPRESENTATIVE IN CONGRESS FROM
THE STATE OF ILLINOIS
STATEMENT OF JERRY MCNERNEY
Mr. McNerney. Thank you, Chairwoman Halvorson.
I would like to thank the Chairman of the Committee, Mr.
Filner, the Ranking Member, Mr. Buyer, leadership from Mr.
Boozman, and Mr. Michaud for their hard work on behalf of our
veterans and all Members of the Committee for being on the
Committee and working hard and looking out for our veterans'
best interests.
I am going to be speaking on behalf of traumatic brain
injury (TBI), a bill which I introduced last year and passed by
unanimous consent.
More than 1.6 million troops have served in Iraq and
Afghanistan and about half of those brave men and women are now
veterans. Traumatic brain injury or TBI has become the
signature wound of the wars in Iraq and Afghanistan.
A RAND Corporation study estimates that up to 320,000
troops who served in these conflicts suffer from brain trauma.
Milder forms of TBI can result, this is milder forms, can
result in cognitive problems such as headaches, difficulty in
thinking, memory problems, abnormal speech or language, and
limited functioning of arms and legs.
TBI's effects on veterans and their families can be
devastating.
I have met personally with several veterans in my district
who suffer from severe brain injury in Iraq. One is doing well
in my hometown with a 4-year scholarship from the Sentinels of
Freedom. I just had lunch with him a couple of weeks ago and I
am very pleased to see how well he has adjusted.
Unfortunately, many wounded veterans face an even more
arduous path to recovery.
The brain is probably the most adaptable organ of the body,
but any time there is a traumatic injury or section of the
brain that is damaged, it takes time to adjust and compensate.
When a soldier is wounded, he or she is first transported
to a trauma center to treat brain swelling. Brain swelling is
the biggest and most immediate risk from a brain injury.
After being stabilized, soldiers may face invasive surgical
procedures and painful cooling treatments to combat
inflammation, followed by extensive physical and psychological
therapy.
I have seen firsthand how difficult this treatment is and
we owe our veterans the very best.
Blasts from improvised explosive devices have become one of
the most common causes of injury for troops currently serving
in combat zones. And recent studies show that 59 percent of
blast exposed patients at Walter Reed have been found to have
some form of TBI.
In April of 2007, the Veterans Administration began
screening veterans who served in Iraq and Afghanistan since the
beginning of October 2001 for symptoms that may be associated
with TBI. Of the 61,285 veterans that the VA screened for TBI,
11,804 or 19 percent of those veterans screened positive for
TBI symptoms.
U.S. Department of Defense (DoD) and Veterans
Administration experts note that TBI can occur even if a victim
does not suffer from an obvious physical injury which sometimes
takes place when a person is within the vicinity of powerful
detonation.
In these instances, signs and symptoms of TBI, such as the
ones I mentioned earlier, are not often readily recognized.
According to the Department of Defense and the Veterans
Administration mental health experts, mild TBI can also produce
behavioral symptoms similar to post-traumatic stress disorder
or other mental health conditions. And TBI almost always causes
post-traumatic stress.
The relationship between TBI and post-traumatic stress can
further complicate diagnosis and treatment. As a result,
further research must be conducted to examine the long-term
effects of these injuries, which are not yet fully understood,
and the best treatment models to address TBI and improve
coordination of care for injured veterans.
Traumatic brain injuries have often affected a large number
of female servicemembers. And as the number of women enlisted
in the Armed Forces continues to grow, we must ensure that our
focus on health care continues to encompass all veterans.
I hope we can continue to collect data to ensure that the
women veterans receive the same quality of care as their male
counterparts, and I am committed to working on this Committee
to assist in that endeavor.
When a soldier is transitioning to civilian life, it is
imperative that we have a system in place that is able to
properly evaluate and assess the risks and challenges, if any,
these veterans and their families might face.
Given that evidence suggests that combat-related TBI is an
increasingly frequent occurrence and that the effects of TBI
are still poorly understood, prioritizing research and
oversight will help plan for addressing treatment and long-term
care.
Research into TBI is also particularly important for
understanding post-traumatic stress because the amnesia that
often occurs as a result of TBI increases the challenges of
post-traumatic stress treatment.
Studies have shown that in the absence of factual recall,
individuals may have delusional or reconstruct memories of
trauma. These individuals may retain false memories rather than
factual results.
Closely related to cognitive impairment are mental health
issues such as depression and anxiety disorders. These
psychological issues often interact with physical injury to
decrease patients' overall health status and adherence to
medical regimes.
Those who experience TBI may behave impulsively because of
damage that removes many of the brain checks on the regulation
of behavior. Without the limits provided by these higher brain
functions, these individuals may overreact to seemingly
innocent or neutral stimuli.
For these reasons, I was compelled to introduce legislation
to address these critical issues. H.R. 1546, the ``Caring for
Veterans with Traumatic Brain Injury Act,'' directs the
Secretary of Veterans Affairs to establish within the Veterans
Health Administration a Committee on Care of Veterans with
Traumatic Brain Injury to continually assess the Veterans
Health Administration's capability to meet the treatment and
rehabilitation needs of veterans suffering with TBI.
In addition, this legislation will help TBI specific
education and training programs for VA health professionals in
order to better serve our Nation's veterans.
Though money has been allocated by Congress to help study
and combat the effects of TBI, there is still room for
improvement, something I hope H.R. 1546 will be able to help
address.
The bipartisan ``Caring for Veterans with Traumatic Brain
Injury Act'' passed the House unanimously in the 110th Congress
as a part of Chairman Michaud's H.R. 2199, the ``Traumatic
Brain Injury Health Enhancement and Long-Term Support Act of
2007.''
TBI has become one of the signature injuries of the wars in
Afghanistan and Iraq. As the Department of Veterans Affairs
transitions to a 21st century institution that better meets its
mission of serving veterans, it is imperative that it addresses
the 21st century injuries such as TBI.
I appreciate the testimony and comments expressed by all
groups on the panel today and I am grateful for their service
to this great country.
I thank you for the opportunity to testify here today.
Mrs. Halvorson. Mr. Teague?
STATEMENT OF HON. HARRY TEAGUE
Mr. Teague. Yes. Madam Chairwoman Halvorson, thank you.
Ranking Member and fellow Subcommittee Members, thank you
all for allowing me the opportunity to speak on behalf of H.R.
2738.
It was my honor and pleasure to introduce this bill and I
believe that this legislation will provide some needed relief
for the families who care for our Nation's veterans.
H.R. 2738 would allow family caregivers to get some of
their travel expenses paid for when they are accompanying
veterans to medical treatment facilities.
This bill would provide lodging payments, a common cost
that a veteran's family incurs when they are trying to ensure
that their loved ones are receiving the care that they need.
The bill also provides for some flexibility on the
definition of caregivers, realizing that in this day and age, a
veteran may not have immediate family members caring for them.
This bill also recognizes not only the immediate family
caregivers that reside with the veteran but also extended
family members and stepchildren that may not reside with the
veteran.
Ms. Chairwoman, I do not need to tell anyone in this room
or in this Congress that access to health care is not as easy
as it should be or in my district and in many other districts
that are rural, it is even harder.
While my district is roughly the same geographic size as
the State of Pennsylvania, there is no VA hospital located
within its boundaries.
Veterans who live in Silver City, New Mexico, are often
forced to meet at the local VA clinic's parking lot at 1
o'clock in the morning so that a DAV van can take them to the
State's only VA hospital in Albuquerque.
While this legislation does not create new hospitals, it
helps to make travel easier for all of our veterans living in
rural areas. They can make a trip to the VA facility and have
their family assist them with that journey and not have the
added worry of wondering how they will pay for such a trip
during these difficult financial times.
If an examination at the hospital takes a bit longer than
usual, they do not have to rush back home late at night. We can
now give them some peace of mind with this bill.
Madam Chairwoman, I believe that this measure is the least
we can do for our Nation's veterans after they have given so
much in defense of our country.
I do not think that forcing a veteran to take money out of
his pocket or her pocket while they are accessing benefits that
they have earned makes sense. And I do not think it is the
right thing to do. We should not make it more difficult for our
veterans to get to VA facilities. We should take steps to make
it easier on them.
I think that all of my colleagues would agree with me on
that statement and I hope that I can have their support on this
bill.
Madam Chairwoman and Ranking Member, I thank you for the
time that you have given me to speak on behalf of this bill
today.
I would also like to thank the staff of the Health
Subcommittee for their assistance, expertise, and insight on
this matter.
This concludes my testimony and I am ready to answer any
questions you may have regarding H.R. 2738. Thank you.
[The prepared statement of Congressman Teague appears on
p. 15.]
Mrs. Halvorson. Thank you, Mr. Teague.
Last on panel two are my two bills. But before I do that,
we have some testimony on H.R. 1302 from Congressman Jerry
Moran. I would like unanimous consent to include that in the
record.
[The prepared statement of Congressman Moran appears on
p. 37.]
STATEMENT OF HON. DEBORAH L. HALVORSON
Mrs. Halvorson. My first bill is H.R. 1335, which would
prohibit the collection of co-payments and other fees from
catastrophically disabled veterans who receive medical or
nursing home care from the Department of Veterans Affairs.
Right now some catastrophically disabled veterans are
thrown into financial hardship because of the health care co-
payment that they must pay to the VA.
Catastrophically disabled veterans have severely disabling
conditions that compromise their ability to carry out
activities of daily living, including such basics as self-care
tasks, such as eating, bathing, and dressing.
Disabled veterans in situations like this have enough
challenges to face on a daily basis and scraping together
enough money to make their co-payment should not be another
challenge that they have to deal with.
I will allow the rest of my testimony to be included in the
record.
The other bill is H.R. 2898, which authorizes the VA to
make available supportive services to family caregivers who
provide critical health care services to our wounded warriors.
My bill would provide counseling, better training, and
respite care for family caregivers and it would make sure that
the VA conducts community outreach through PSAs, brochures and
information pamphlets.
Finally, it would assist caregivers with locating support
services from the public, private, and nonprofit agencies.
Last year, my stepson was severely injured while serving in
Afghanistan. At first, we were just relieved that he was simply
alive. That, of course, was our number one priority. After
that, it was clear that he would make it through all of his
surgeries at Walter Reed. Our immediate concern then became how
are we going to take care of him.
He was not in a good state and needed constant care. We
were blessed to have the resources and the time available to
drive him to his rehabilitation every day and take care of him
at home as he recuperated.
Thankfully, after time and rehabilitation, he is back on
his feet and going to be fine. But it was that experience,
however, that has given me the insight to understand the
sacrifice that family caregivers, and gladly so, give and make
for our America's wounded warriors 24 hours a day and 7 days a
week.
H.R. 2898 is a strong step in the right direction. And I am
so pleased that this was a bill that we were able to bring
forward.
So at this time, if anybody has questions for any of the
bills that are before us.
[No response.]
If not, we will bring up panel three, Fred Cowell, Senior
Health Policy Analyst, Paralyzed Veterans of America (PVA); Joy
Ilem, Deputy National Legislative Director of the Disabled
American Veterans; Mr. Joseph Wilson, Deputy Director of
Veterans Affairs and Rehabilitation Commission of the American
Legion; Mr. Christopher Needham, Senior Legislative Associate,
National Legislative Service, Veterans of Foreign Wars; and
Bernard Edelman, Deputy Director for Policy and Government
Affairs, Vietnam Veterans of America.
We will start with Mr. Cowell. I apologize if they start
votes. What we will have you do is then submit all of your
testimony for the record.
So, please, Mr. Cowell, you will be recognized for 5
minutes.
STATEMENT OF FRED COWELL, SENIOR HEALTH POLICY ANALYST,
PARALYZED VETERANS OF AMERICA
Mr. Cowell. Thank you, Madam Chairperson, Ranking Member,
Members of the Subcommittee.
Paralyzed Veterans of America would like to thank you for
the opportunity to provide testimony today on legislation
pending before the Subcommittee and other draft legislation
concerning the needs of caregivers who assist veterans on a
daily basis.
H.R. 1335, PVA would like to thank Member Halvorson for
introducing this important bill. As you know, PVA members are
some of the most frequent users of VA health care. In fact, PVA
members receive 85 to 90 percent of their medical care through
the VA health care system.
With this in mind, PVA supports H.R. 1335 to prohibit the
Secretary of VA from collecting co-payments from
catastrophically disabled, Priority Group 4 veterans. However,
we would like to recommend that the Subcommittee make a change
to the legislative language prior to the markup of this bill.
In examining this bill, we realized that the current
language that refers to hospital and nursing home care does not
meet the intent of the legislation. This language is very
narrow in scope and would seemingly only benefit veterans in
inpatient settings.
However, the intent has always been to relieve these
severely disabled veterans of all burdensome co-payments. To
that end, we have recommended that Subcommittee staff change
the language to hospital and medical care services so as to
properly meet Congressional intent.
This change would ensure that catastrophically disabled
veterans who often require extensive VA outpatient
rehabilitative care, VA inpatient and outpatient preventive
services, and who often experience prolonged inpatient hospital
stays will be protected.
Catastrophically disabled veterans were pleased when the
House Committee on Veterans' Affairs approved, and the House of
Representatives passed H.R. 6445 during the 110th Congress to
eliminate VA co-pays for catastrophically disabled veterans.
In fact, the House bill received unanimous support from
both sides of the aisle. Unfortunately, the Senate never took
action on the measure.
This year, however, the Senate Committee on Veterans'
Affairs has approved S. 801, which includes the elimination of
co-pays for Priority Group 4 veterans. The Senate version also
includes the recommended language change.
Together with H.R. 1335, PVA members and other
catastrophically disabled veterans now have real hope that
financial relief will soon be forthcoming.
H.R. 1293, the HISA grant increase. First, Mr. Chairman,
PVA would like to thank Congressman Buyer for introducing this
important piece of legislation. PVA strongly supports H.R.
1293, the ``Disabled Veterans Home Improvement and Structural
Alteration Grant of 2009.''
These increases will help defray the constantly rising cost
for accessibility modifications to veterans' homes. This VA
benefit enables veterans to maximize their functional abilities
and return to a home following medical treatment that meets
their needs.
PVA certainly hopes that Congress will give this
legislation favorable consideration as it will benefit
America's most severely disabled veterans.
PVA applauds the draft legislation to expand caregiver
assistance opportunities. PVA actually believes that each of
the four draft bills that take into consideration the needs of
family caregivers should be combined into a single
comprehensive bill as we believe that each of these bills has
important aspects to assist veterans and their caregivers.
Particularly we believe training assistance is a critical
aspect in supporting caregivers who care for veterans.
A particular focus on respite care mentioned in one of the
draft bills is also an important part of any comprehensive
caregiver assistance legislation.
Respite care allows time for caregivers to ease their
emotional and physical burdens for a period of time and it
helps ensure that the caregiver will maintain their commitment
to the disabled veteran and his or her needs.
Additionally, PVA has no objection to the legislation that
would provide health care services to caregivers through
opening of CHAMPVA. In some cases, caregivers do not have other
care options available to meet their own needs, particularly if
the provision of caregiver services is essentially their job.
This draft legislation will remedy this significant concern
that many caregivers have.
Regarding travel expenses for family caregivers
accompanying veterans to medical treatment facilities, PVA
strongly supports this draft legislation.
As the Committee knows, many of our veterans returning from
Operation Enduring Freedom and Operation Iraqi Freedom have
significant disabling injuries, including TBI. Many of these
individuals require constant care.
PVA appreciates the efforts of the Committee to ensure that
travel expenses for these needed assistants are provided.
One disappointment that PVA would like to point out is the
exclusion of any type of caregiver allowance from the draft
bills being considered. Providing a financial benefit has been
one of the important issues that we have advocated for in
addressing caregiver issues.
We hope that the Subcommittee will examine ways to
incorporate this important idea into final legislation.
And, finally, Mr. Chairman, PVA supports H.R. 2770's
language to make improvements that will streamline the
operations, increase the effectiveness, and maintain
accountability of nonprofit research and education
corporations.
These entities provide extremely valuable services to VA,
to VA researchers, and ultimately to the veterans who benefit
from research breakthroughs.
Madam Chairman and Members of the Subcommittee, PVA would
like once again 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.
I will be happy to answer any questions that you might
have.
[The prepared statement of Mr. Cowell appears on p. 16.]
Mrs. Halvorson. And before we go on to Mr. Edelman, Mr.
Perriello would like to make a statement. He has a bill. He was
somewhere else. He just made it. Before we head out.
STATEMENT OF HON. TOM PERRIELLO, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF VIRGINIA
Mr. Perriello. Thank you very much, Chairlady.
Good morning, everyone. Let me begin by thanking Chairman
Michaud and Ranking Member Brown for holding this hearing on
bills aimed at addressing some of the health care concerns
faced by veterans and those who care for them.
I appreciate the opportunity to offer testimony in support
of
H.R. 2734, the ``Health Care for Family Caregivers Act of
2009.''
In the words of former First Lady Rosalyn Carter, quote,
``There are only four kinds of people in the world, those who
have been caregivers, those who are currently caregivers, those
who will be caregivers, and those who will need caregivers.''
Mrs. Carter's observations are particularly telling when
considering our brave men and women in uniform.
Today more than ever revolutionary advances in military
medicine have significantly increased a servicemember's chances
of surviving a catastrophic injury sustained in combat. But in
many cases, surviving such injuries is only half the battle.
Recovering requires a long-term commitment not only from
the veteran but also from those who love and care for the
veteran.
Simply stated, taking care of our veterans means taking
care of those who care for them when they are unable to care
for themselves.
Once an injured veteran returns home from treatment at a
DoD or VA hospital, it is often a spouse, mother, father, or
other loving family member who steps up to the challenge of
providing ongoing care. And while this care is provided out of
a sense of love, compassion, and duty, it oftentimes shifts
into a full-time commitment requiring the caregiver to make
significant personal decisions regarding professional goals,
commitments, and obligations.
H.R. 2734, the ``Health Care for Family Caregivers Act,''
would help provide some relief to those family caregivers faced
with the difficult decisions related to caring for a veteran
confronting a catastrophic injury.
The bill would extend CHAMPVA benefits to eligible family
caregivers of a select group of veterans defined as those who
receive special monthly compensation for aid and attendant care
and homebound care under Title 38. The expanded CHAMPVA benefit
is limited to the primary family caregiver who lacks health
care coverage.
Family members are defined to include nuclear and extended
family members as well as step family members. And there is no
residency requirement whereby the family member must live with
the veteran.
Because many family caregivers leave their positions of
employment to undertake the full-time task of caring for the
veteran, the bill also exempts eligible family caregivers from
deductibles and co-payments required of other CHAMPVA
beneficiaries.
As a Nation, we have an obligation to care for those who
have stood in the defense of freedom. H.R. 2734 is a
commonsense bill which continues our commitment to American
veterans.
I would like to thank all of the veterans services
organizations for their continued support. I would also like to
thank the Department of Veterans Affairs for their testimony
and willingness to work cooperatively to advance responsible
legislation which effectively addresses the needs of veterans
and those who care for them.
I look forward to meeting with leaders and subject matter
experts from the Veterans Health Administration this month to
discuss this important matter in a comprehensive manner.
I thank the Subcommittee for holding this hearing and look
forward to answering any questions you may have. Many thanks.
Mrs. Halvorson. At this time, I would like to acknowledge
Mr. Boozman for comments.
OPENING STATEMENT OF HON. JOHN BOOZMAN
Mr. Boozman. Thank you.
We appreciate you all being here, and I apologize that we
have to interrupt. Yet, we do not want to have you have to wait
around forever.
The only thing that we have to do here, there are lots of
things that we can get out of, but we do have to go vote when
we are supposed to.
I do want to congratulate you, Ms. Ilem, on your promotion
to Deputy National Legislative Director. We all appreciate your
hard work for the DAV. I know that you have been invaluable in
many cases in providing some very, very good information. So we
do want to congratulate you on behalf of, I think, all of us
very much so, and especially our staffs. We appreciate your
help and appreciate your hard work on behalf of veterans.
I yield back.
Mrs. Halvorson. Thank you, Mr. Boozman.
Since there are 7 minutes left for us to vote, instead of
making panels 3 and 4 wait until we are done with our 27 votes
or somewhere around there, we are going to have you all submit
your testimony for the record.
And anybody who has questions, we will submit them and we
will make sure everybody has a record of that.
With that, I would like to adjourn the Subcommittee.
[Whereupon, at 10:43 a.m., the Subcommittee 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 11 bills before us today. Each of the bills address
important issues affecting our veterans and their families. These bills
address a wide range of issues including help for family caregivers of
wounded veterans; improving the nonprofit research and education
corporations; establishing a position of Director of Physician
Assistant; and creating a Committee on Care of Veterans with Traumatic
Brain Injury. We will also consider important bills to enhance health
care and other benefits to veterans. This includes updating the benefit
amount for the Home Improvement and Structural Alteration grant;
eliminating the co-payments from veterans who are catastrophically
disabled; extending health care benefits to Vietnam era herbicide
exposed veterans and Gulf-War era veterans; and assigning Medal of
Honor recipients to the Priority Group 3 category.
I look forward to hearing the views of our witnesses on these bills
before us.
Prepared Statement of Hon. Harry Teague,
a Representative in Congress From the State of New Mexico
Mr. Chairman and Ranking Member Brown and fellow Subcommittee
Members, thank you for allowing me the opportunity to speak on behalf
of H.R. 2738. It was my honor and pleasure to introduce this bill, and
I believe that this legislation will provide some much needed relief
for the families who care for our Nation's veterans.
H.R. 2738 would allow family caregivers to have some of their
travel expenses paid for when they are accompanying veteran to medical
treatment facilities. This bill would provide lodging payments, a
common cost that a veteran's family incurs when they are trying to
ensure that their loved ones are receiving the care that they need. The
bill also provides for some flexibility on the definition of
``caregivers,'' realizing that in this day and age, a veteran may not
have immediate family members caring for them. This bill also
recognizes not only the immediate family caregivers that reside with
the veteran, but also extended family members and step-children that
may not reside with the veteran.
Mr. Chairman, I don't need to tell anyone in this room or in this
Congress that access to health care is not as easy as it should be. In
my district, and in many other districts that are rural, it's even
harder. While my district is roughly the same geographic size as the
State of Pennsylvania, there is no VA hospital located within its
boundaries. Veterans who live in Silver City, New Mexico are often
forced to meet in the local VA clinic's parking lot at one in the
morning so that a DAV van can take them to the State's only VA hospital
in Albuquerque.
While this legislation does not create new hospitals, it helps to
make travel easier for all of our veterans living in rural areas. They
can make a trip to the VA facility and have their family assist them
with that journey, and not have the added worry of wondering how they
will pay for such a trip during these difficult financial times. If an
examination at the hospital takes a bit longer than usual, they don't
have to rush back home late at night. We can now give them some peace
of mind with this bill.
Mr. Chairman, I believe that this measure is the least we can do
for our Nation's veterans, after they have given so much in defense of
our country. I don't think that forcing a veteran to take money out of
his or her pocket while they are accessing benefits that they've earned
makes sense, and I don't think it's the right thing to do.
We shouldn't make it more difficult for veterans to get to VA
facilities. We should take steps to make it easier on them.
I think that all of my colleagues would agree with me on that
statement, and I hope that I could have their support on this bill.
Mr. Chairman and Ranking Member Brown, I thank you for the time
that you've given me to speak on behalf of this bill today. I would
also like to thank the staff of the Health Subcommittee for their
assistance, expertise and insight on this matter.
This concludes my testimony and I am ready to answer any questions
you may have regarding H.R. 2738.
Prepared Statement of Fred Cowell,
Senior Health Policy Analyst, Paralyzed Veterans of America
Chairman Michaud, Ranking Member Brown, and Members of the
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for the opportunity to provide testimony today on legislation
pending before the Subcommittee and other draft legislation concerning
veterans health care needs. We hope that the Subcommittee will take our
concerns under consideration as it moves its legislation forward in the
111th Congress. Mr. Chairman, we appreciate the legislative successes
that veterans have realized under your leadership and we look forward
to continued success in the future. PVA is particularly pleased with
the emphasis on meeting the needs of veterans' caregivers.
H.R. 1335, Co-Payments for Catastrophically Disabled Priority Group 4
Veterans
As you know, PVA members are some of the highest users of VA health
care. In fact, catastrophically disabled veterans, like PVA members,
receive 85 to 90 percent of their care from the VA.
With this is mind, PVA supports H.R. 1335, to prohibit the
Secretary of VA from collecting co-payments from catastrophically
disabled Priority Group 4 veterans. However, we would like to recommend
that the Subcommittee make a change to the legislative language prior
to the markup for this bill. In examining this bill, we realized that
the current language that refers to ``Hospital and Nursing Home Care''
does not really meet the intent of the legislation. This language is
very narrow in scope and would seemingly only benefit veterans in
inpatient settings. However, the intent has always been to relieve this
important segment of the veteran population of all burdensome co-
payments. To that end, we have recommended that the Subcommittee staff
change the language to ``Hospital and Medical Care Services'' so as to
properly meet congressional intent. This would ensure that
catastrophically disabled veterans who often take advantage of
outpatient rehabilitative, preventive, and other health services will
be protected.
In 1985, Congress approved legislation which opened the VA health
system to all veterans. In 1996, Congress again revised that
legislation with a system of rankings establishing priority ratings for
enrollment. Within that context, PVA worked hard to ensure that those
veterans with catastrophic disabilities would be placed in a higher
enrollment category. To protect their enrollment status, veterans with
catastrophic disabilities were allowed to enroll in Priority Group 4
even though their disabilities were nonservice-connected and regardless
of their incomes. However, unlike other Priority Group 4 veterans, if
they would otherwise have been in Priority Group 7 or 8, due to their
incomes, they would still be required to pay all fees and co-payments,
just as others in those categories do now for every service they
receive from VA.
PVA believes this is unjust. VA recognizes these veterans' unique
specialized status on the one hand by providing specialized service for
them in accordance with its mission to provide for special needs. The
system then makes them pay for those services. Unfortunately, these
veterans are not casual users of VA health care services. Because of
the nature of their disabilities they require a lot of care and a
lifetime of services. In most instances, VA is the only and the best
resource for a veteran with a spinal cord injury, and yet, these
veterans, supposedly placed in a higher priority enrollment category,
have to pay fees and co-payments for every service they receive as
though they had no priority at all.
We were pleased when the House Committee on Veterans' Affairs
approved and the House of Representatives eventually passed
legislation--H.R. 6445--during the 110th Congress to eliminate this
financial burden placed on catastrophically disabled veterans. In fact,
the House bill received unanimous support from Republicans and
Democrats as well as the VA. Unfortunately, the Senate never took
action on the measure and the legislation was never enacted. This year,
the Senate Committee on Veterans' Affairs has approved S. 801 which
includes the elimination of co-payments for Priority Group 4 veterans.
The Senate version also includes the recommended language change.
Together with H.R. 1335, PVA members have real hope that we will
finally be able to resolve this issue during the 111th Congress.
H.R. 1293, the ``Disabled Veterans Home Improvement and Structural
Alteration Grant Increase Act of 2009''
PVA strongly supports H.R. 1293, the ``Disabled Veterans Home
Improvement and Structural Alteration Grant Increase Act of 2009.'' The
costs for improvements and modifications for homes have continued to go
up dramatically, in spite of the recent downturn in housing
construction. There have been anecdotes of great deals now available
for home improvements. But it can be expected that as we come out of
the current recession, home improvement costs will continue to go up.
The Home Improvement and Structural Alterations (HISA) grant is
provided through local VA medical facilities and is often critical to
allowing an injured veteran to leave the hospital setting and return
home. The HISA grant allows these veterans to make basic modifications
without having to tap into the benefit available through the Specially
Adapted Housing grant. We certainly hope that Congress will give this
quick and favorable consideration as it will particularly benefit the
most severely disabled veterans.
H.R. 1546, the ``Caring for Veterans With Traumatic Brain Injury Act of
2009''
PVA fully supports the provisions of H.R. 1546, the ``Caring for
Veterans With Traumatic Brain Injury Act of 2009.''
The RAND Corporation Center for Military Health Policy Research
recently completed a comprehensive study titled Invisible Wounds of
War: Psychological and Cognitive Injuries, Their Consequences, and
Services To Assist Recovery. RAND found that the effects of TBI are
still poorly understood, leaving a gap in knowledge related to how
extensive the problem is or how to handle it. The study evaluated the
prevalence of mental health and cognitive problems of Operation
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) servicemembers;
the existing programs and services available to meet the health care
needs of this population; the gaps that exist in these programs and
what steps need to be taken to improve these services; and the costs of
treating or not treating these conditions.
According to RAND, 57 percent of those reporting a probable TBI had
not been evaluated by a physician for brain injury. Military service
personnel who sustain catastrophic physical injuries and suffer severe
TBI are easily recognized, and the treatment regimen is well
established. However, DoD and VA experts note that TBI can also be
caused without any apparent physical injuries if a person is in the
vicinity of powerful detonations and that signs and symptoms are often
not readily recognized but can include chronic headache, irritability,
behavioral disinhibition, sleep disorders, confusion, memory problems,
and depression.
Emerging literature (including the RAND study) strongly suggests
that even mildly injured TBI patients may have long-term mental and
physical health consequences. According to DoD and VA mental health
experts, mild TBI can also produce behavioral manifestations that mimic
PTSD or other mental health conditions. Additionally, TBI and PTSD can
be coexisting conditions in one individual. Much is still unknown about
the long-term impact of these injuries and the best treatment models to
address mild-to-moderate TBI.
On July 12, 2006, the VA Office of the Inspector General (OIG)
issued Health Status of and Services for Operation Enduring Freedom/
Operation Iraqi Freedom Veterans after Traumatic Brain Injury
Rehabilitation. The report found that better coordination of care
between DoD and VA health care services was needed to enable veterans
to make a smooth transition. The OIG Office of Health Care Inspections
conducted follow on interviews to determine changes since the initial
interviews were conducted in 2006. The OIG concluded that 3 years after
completion of initial inpatient rehabilitation, many veterans with TBI
continue to have significant disabilities and, although case management
has improved, it is not uniformly provided to these patients.
The creation of a Committee on Care of Veterans with Traumatic
Brain Injury may help to improve this coordination and identify best
practices for care for these injured warriors. However, Congress must
be aggressive with its oversight to ensure that the Committee does not
simply identify the issues, but works to implement them throughout the
VA system.
H.R. 1302, Director of Physician Assistant Services
PVA supports H.R. 1302, a bill that would establish a position of
Director of Physician Assistant Services. This legislation is
consistent with a recommendation included in the FY 2010 edition of The
Independent Budget.
The Department of Veterans Affairs is the largest single Federal
employer of physician assistants (PA), with approximately 1,800 full-
time PA positions, and has utilized PAs since 1969 when the profession
started. However, once Congress enacted P.L. 106-419, the ``Veterans
Benefits and Health Care Improvement Act of 2000,'' which directed that
the Under Secretary for Health appoint a PA Advisor, the Veterans
Health Administration (VHA) only assigned the PA position as a part-
time, field-based employee. Finally, in April 2008, VHA made the
position a full-time employee, but the position is still field-based
and often does not receive travel funding until late in the second
quarter each year, resulting in missed opportunities to attend VHA
meetings. It is time to establish a real, permanent staff PA at the VA
to oversee these critical care providers.
H.R. 1197, the ``Medal of Honor Health Care Equity Act of 2009''
PVA strongly supports the provisions of H.R. 1197, the ``Medal of
Honor Health Care Equity Act of 2009.'' It is clear that veterans who
have been awarded our Nation's highest military award for valor should
be afforded any and all benefits possible in recognition of their
service.
H.R. 2722, the ``Veterans Nonprofit Research and Education Corporations
Enhancement Act of 2009''
PVA strongly supports the provisions of draft legislation regarding
Nonprofit Research and Education Corporations. This bill should allow
these corporations (also known as NPCs) to fulfill their full potential
in supporting VA research and education, which ultimately results in
improved treatments and high quality care for veterans, while ensuring
VA and congressional confidence in NPC management.
Since passage of P.L. 100-322 in 1988 (codified at 38 U.S.C.
Sec. 7361-7368), the NPCs have served as an effective ``flexible
funding mechanism for the conduct of approved research and education''
performed at VA medical centers across the nation. NPCs provide VA
medical centers with the advantages of on-site administration of
research by nonprofit organizations entirely dedicated to serving VA
researchers and educators, but with the reassurance of VA oversight and
regulation. During 2007, 85 NPCs received nearly $230 million and
expended funds on behalf of approximately 5,000 research and education
programs, all of which are subject to VA approval and are conducted in
accordance with VA requirements.
NPCs provide a full range of on-site research support services to
VA investigators, including assistance preparing and submitting their
research proposals; hiring lab technicians and study coordinators to
work on projects; procuring supplies and equipment; monitoring the VA
approvals; and a host of other services so the principal investigators
can focus on their research and their veteran patients.
Beyond administering research projects and education activities,
when funds permit, these nonprofits also support a variety of VA
research infrastructure expenses. For example, NPCs have renovated
labs, purchased major pieces of equipment, staffed animal care
facilities, funded recruitment of clinician-researchers, provided seed
and bridge funding for investigators, and paid for training for
compliance personnel.
Although the authors of the original statute were remarkably
successful in crafting a unique authority for VA medical centers,
differing interpretations of the wording and the intent of Congress,
gaps in NPC authorities that curtail their ability to fully support VA
research and education, and evolution of VA health care delivery
systems have made revision of the statute increasingly necessary in
recent years. This draft legislation should allow the NPCs to better
serve VA research and education programs while maintaining the high
degree of oversight applied to these nonprofits.
This legislation reinforces the idea of ``multi-medical center
research corporations'' which provides for voluntary sharing of one NPC
among two or more VA medical centers, while still preserving their
fundamental nature as medical center-based organizations. Moreover,
accountability will be ensured by requiring that at a minimum, the
medical center director from each facility must serve on the NPC board.
This authority will allow smaller NPCs to pool their administrative
resources and to improve their ability to achieve the level of internal
controls now required of nonprofit organizations.
The legislation also clarifies the legal status of the NPCs as
private sector, tax exempt organizations, subject to VA oversight and
regulation. It also modernizes NPC funds acceptance and retention
authorities as well as the ethics requirements applicable to officers,
directors and employees and the qualifications for board membership.
Moreover, it clarifies and broadens the VA's authority to guide
expenditures.
PVA has been a strong supporter of the NPCs since their inception,
recognizing that they benefit veterans by increasing the resources
available to support the VA research program and to educate VA health
care professionals.
Draft Legislation to Direct the Secretary of Veterans Affairs to
Provide Care for Certain Vietnam-era and Persian Gulf Veterans
PVA fully supports the draft legislation that would require the VA
to provide hospital care, medical services, and nursing home care for
certain Vietnam-era veterans exposed to herbicide and veterans of the
Persian Gulf War without expiration. These veterans have certainly
earned this benefit through their dedicated service to this nation and
due to the nature of the injuries and illness which they suffer.
Draft Legislation to Address the Needs of Family Caregivers
(H.R 2734, H.R. 2738, and Proposed Bills)
PVA applauds the draft legislation to expand caregiver assistance
opportunities. PVA actually believes that each of the four draft bills
that take into consideration the needs of family caregivers should be
combined into a single comprehensive bill as we believe that each of
these bills have important aspects to address this issue. Particularly,
we believe training and assistance is a critical aspect of supporting
caregivers who care for veterans. We also applaud the fact that the
legislation requires the Secretary to provide training through the use
of the word ``shall'' instead of ``may.'' While seemingly a trivial
concern, such language will ensure that the Secretary does not have the
option of reducing these services if VA is faced with the budget
challenges that inevitably will occur.
As the veteran community is aware, family caregivers also provide
mental health support for veterans dealing with the emotional,
psychological, and physical effects of combat. Many PVA members with
spinal cord injury also have a range of co-morbid mental illnesses;
therefore, we know that family counseling and condition specific
education is fundamental to the successful reintegration of the veteran
into society. Providing education and training to family caregivers
will pay dividends in care well beyond any costs associated with the
program.
The aspects of personal independence and quality care are of
particular importance to veterans with spinal cord injury/dysfunction.
Paralyzed Veterans has over 60 years of experience understanding the
complex needs of spouses, family members, friends, and personal care
attendants that love and care for veterans with lifelong medical
conditions. These veterans need the health care expertise and care from
a health team comprised of medical professionals, mental health
professionals, and caregivers. As a part of the health care team,
caregivers must receive ongoing support to provide quality care to the
veteran. Legislation to provide these services is critically needed.
But while the current draft text emphasizes ``interactive training
session'' and ``Internet-based'' services, we want to ensure that this
does not preclude VA from providing more effective ``in person
training'' for those who may need it to provide the quality of care
needed by veterans. The VA must also work to enforce and maintain an
efficient case management system that assists veterans and family
caregivers with medical benefits and family support services.
A particular focus on respite care, mentioned in one of the draft
bills, is also an important part of any comprehensive caregiver
assistance legislation. Providing for the needs of catastrophically
disabled veterans in particular can exact a heavy toll on the
caregiver. Respite care allows that caregiver to ease the emotional,
psychological, and physical burden for a period of time, and it ensures
that the caregiver will maintain a real commitment to the disabled
veteran and his or her needs.
PVA has no objection to the legislation that would provide health
care services to caregivers through the opening of CHAMPVA. In some
cases, caregivers do not have other health care options available to
meet their own needs, particularly if the provision of caregiver
services is essentially their job. The draft legislation will remedy
this significant concern that many caregivers have.
There are approximately 44 million individuals across the United
States that serve as caregivers on a daily basis. The contributions of
caregivers in today's society are invaluable economically as they
obviate the rising costs of traditional institutional care. The
services rendered by caregivers are also priceless socially and
emotionally, as they allow ailing and disabled veterans to live more
independently and often in the comfort of their own homes with their
friends and family. Unfortunately, VA can only estimate how many of
these caregivers serve veterans. By conducting a survey of these
valuable caregivers and the services they provide, VA can better
estimate their impact and any associated costs to increase support to
these individuals. Without this information, it will be difficult for
VA to honestly provide recommendations on funding caregiver programs to
the White House and Congress.
Regarding travel expenses for family caregivers accompanying
veterans to medical treatment facilities, PVA supports the draft
legislation. As the Committee knows, many of our veterans returning
from Operation Enduring Freedom and Operation Iraqi Freedom have
significant disabling injuries including TBI. Many of these individuals
require constant care. PVA appreciates the efforts of the Committee to
ensure the travel expenses for these needed assistants are provided. We
also understand and accept the VA's need to limit the number of
attendants and use certain travel services, but we ask the Committee to
use its oversight to ensure that regulations prescribed by VA are not
so restrictive as to preclude family support activities.
Our experience has shown that when the veteran's family unit is
left out of the treatment plan, the veteran suffers with long
reoccurring medical and social problems. However, when family is
included in the health plan through services such as VA counseling and
education services, veterans are more apt to become healthy,
independent, and productive members of society.
One disappointment that PVA would like to point out is the
exclusion of any type of caregiver allowance from the draft bills being
considered. Providing a financial benefit has been one of the important
issues that we have advocated for in addressing caregiver issues. We
hope that the Subcommittee will examine ways to incorporate this
important idea in final 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. I would be
happy to answer any questions that you might have.
Prepared Statement of Robert A. Petzel, M.D.,
Acting 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 11 bills and drafts 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, and are also pleased to support most of the proposed
legislation. We believe that we could carry out the new authorities we
are supporting within the funding levels proposed in the 2010 and 2011
budget requests.
H.R. 1197--``Medal of Honor Health Care Equity Act of 2009''
Mr. Chairman, the first bill on the agenda is H.R. 1197. This bill
would amend 38 U.S.C. 1705 to give Medal of Honor recipients
eligibility to receive VA medical care at the Priority 3 level. VA
supports H.R. 1197. We estimate the increased cost to be insignificant
and can be funded within existing funding levels.
H.R. 1293--``Disabled Veterans Home Improvement and Structural
Alteration Grant Increase Act of 2009''
VA also supports H.R. 1293 which would increase the amount
available to disabled veterans for home improvements and structural
alterations (HISA) furnished as part of home health services. This bill
represents the first increase in the HISA grant rate in 17 years. VA
also recommends to the Chairman that the Subcommittee increase the rate
periodically so that the grant amount keeps pace with the rate of
inflation and the rising cost of materials and installation. We
estimate the cost for H.R. 1293 to be $5.8 million in FY 2010, $5.9
million in FY 2011, $29.8 million over 5 years, and $61.4 million over
10 years. VA will provide a cost estimate to the Subcommittee for the
record that assumes the additional cost of increasing the payments with
inflation.
The Veterans Benefits Administration offers the Specially Adapted
Housing (SAH) and Special Housing Adaptations (SHA) grants, which are
distinct from HISA grants administered through the Veterans Health
Administration. With a cap of $60,000, the SAH grant is the largest and
is for the most severely, service-connected, disabled veterans and
servicemembers entitled to compensation for permanent and total
disability due to:
The loss or loss of use of both lower extremities, such
as to preclude locomotion without the aid of braces, crutches, canes,
or a wheelchair;
Blindness in both eyes, having only light perception,
plus loss or loss of use of one lower extremity;
The loss or loss of use of one lower extremity together
with (1) residuals of organic disease or injury, or (2) the loss or
loss of use of one upper extremity, which so affect the functions of
balance or propulsion as to preclude locomotion without the aid of
braces, crutches, canes, or a wheelchair;
The loss or loss of use of both upper extremities such as
to preclude use of the arms at or above the elbows; or
A severe burn injury.
SHA grant is the next largest at $12,000 and is for veterans and
servicemembers who are entitled to disability compensation for
permanent and total service-connected disability that:
Includes loss or loss of use of both hands;
Is due to Blindness in both eyes with 5/200 visual acuity
or less; or
Is due to a severe burn injury.
HISA grants are the only grants available for nonservice-connected
veterans and conditions (currently limited to $1,200). An increased
amount is available for service-connected veterans (currently $4,100).
Although not required, the HISA grant can be used in conjunction with
the SAH or SHA grant to help cover some of the additional costs a
veteran may be facing when building or adapting a home to meet his/her
unique needs. The HISA grant may be a stand alone project for veterans
who are also receiving the SAH/SHA grant, or in most cases, used by
veterans who are not eligible for the SAH or SHA grants.
In October, the SAH and SHA grant amounts will be linked to a new
cost-of-construction index that will adjust annually for inflation.
Conversely, the HISA amounts have not been increased in several years
and have not kept up with inflation. The proposed legislation serves to
increase the amount available to veterans who are not covered by the
SAH and SHA grants to make some modifications to their homes to
accommodate their various disabilities. Those who are eligible for the
SAH and SHA grant are our most severely injured, service-connected
veterans, and these additional funds supporting modification or
construction of their home is justified.
H.R. 1302--``To Establish a Director of Physician Assistant Services''
H.R. 1302 would eliminate the Physician Assistant (PA) Advisor
position established by Public Law 106-419, the Veterans Benefits and
Health Care Improvement Act of 2000, and establish a Director of
Physician Assistant (PA) Services within the Office of the Under
Secretary for Health. VA does not support this bill.
The functions of the proposed Director of PA Services are already
being performed by the PA Advisor. Moreover, the PA Advisor position
was converted to full-time on April 14, 2008, and it will be based in
VA Central Office at the expiration of the current incumbent's term in
April 2010.
In addition, VA does not support the proposed organizational
realignment of the Director of PA Services to the Office of the Under
Secretary for Health. The position's current alignment within the
Office of Patient Care Services is consistent with all other clinical
program leadership positions and provides the PA Advisor access to the
Under Secretary for Health for any issues that cannot be resolved
within the current structure. Moreover, such a realignment would create
a disparity and an artificial distinction between physician assistants
and nurse practitioners. This situation could result in unnecessary
friction or tension between these two categories of employees. The cost
of implementing this bill is insignificant.
H.R. 1335--``Prohibition on Collection of Certain Co-payments''
H.R. 1335 would amend 38 U.S.C. 1710 to prohibit a veteran who is
catastrophically disabled from making any payment for the receipt of
hospital care or nursing home care provided pursuant to that section.
VA supports this proposal; however, we note it is unclear if this
proposal is intended to eliminate nursing home care co-payments since
the legislation refers only to section 1710 of title 38 and authority
for nursing home care falls under 38 U.S.C. 1710A. We believe any co-
payment requirements under this section would remain in place. We
further note that the bill does not address pharmacy co-payments. The
projected cost would be about $2.6 million for FY 2010 and 2011, $13.3
million over 5 years, and $28 million over 10 years. VA will provide a
cost estimate to the Subcommittee for the record that assumes the
legislation eliminates all co-payments for this population.
H.R. 1546--``Caring for Veterans with Traumatic Brain Injury''
VA also supports H.R. 1546, which would establish a committee on
the Care of Veterans with Traumatic Brain Injury to evaluate the care
provided to veterans, identify problems in caring for such veterans,
identify successful models of treatment, and advise the Secretary
accordingly. The committee would be comprised of VA employees. The cost
of this bill would be insignificant and can be absorbed within existing
funding levels.
H.R. 2722--``Veterans Nonprofit Research and Education Corporation
Enhancement Act of 2009''
H.R. 2722 would update the law applicable to VA's nonprofit
research and education corporations (corporations). VA-affiliated
nonprofit research corporations are critical to VA's overall research
program because they provide flexible funding mechanisms for the
administration of non-VA funds for the conduct of VA-approved research.
A key provision of this bill would authorize a single corporation
to facilitate the conduct of research and education at more than one VA
medical center. H.R. 2722 would also make it clear that corporations
may reimburse a VA laboratory for the preliminary costs it incurs
before a research project has been officially approved by the
Secretary. VA would also be authorized to reimburse corporations for
costs incurred for the assignment of corporation employees to VA under
the Intergovernmental Personnel Act of 1970 (IPA). This would ensure
that, in this respect, corporations are treated like any other
qualified nonprofit corporations under the IPA.
Additionally, this bill would clarify that corporations may set
fees for certain education and training programs they administer and
retain those funds to offset program expenses. The legal prohibition on
a corporation accepting fees derived from VA appropriations would
remain.
VA fully supports H.R. 2722. The authority to establish multi-
medical center research corporations would significantly advance VA
research activities. Currently a corporation is established in only one
medical center and can provide support as a flexible-funding mechanism
for that facility. Small VA research programs that are currently unable
to support the existence of a corporation at their facility would be
able to obtain needed support from a multi-medical center research
corporation. While providing the authority for this expanded utility of
the nonprofit corporations, the bill would, nonetheless, ensure that
all medical centers involved in a multi-medical center arrangement
maintain a voice on the board of directors of the research corporation.
The utility of the corporations to VA would also be increased by
permitting them to reimburse the Department for research planning costs
that are necessarily incurred prior to approval of a research project
by VA. Currently corporations are prohibited from funding research
projects that are not officially approved by VA. As a result, VA
laboratories are responsible for the preliminary costs of any research
project before it is officially approved, and they bear those costs
entirely for projects that are ultimately disapproved. This paradigm
creates a financial disincentive for VA laboratories to initiate
research and a chilling effect on the conduct of innovative VA
research. The bill would appropriately solve this problem.
VA does have one technical concern with H.R. 2722. Section 7 of the
bill attempts to rectify an impracticable extension of the criminal
conflicts of interest laws to non-Government employees working for a
non-Government employer. The proposed revisions to 38 U.S.C. 7366
remove the words ``laws and,'' effectively subjecting covered persons
to only the Federal ethics regulations. However, the Federal ethics
regulations are also unenforceable in the NPC context. VA recommends
replacing the current language in section 7366 with a new provision
requiring all NPCs to adopt an enforceable code of conduct, reviewable
by the VA, which prohibits conflicts of interest.
There would be no costs associated with enactment of the H.R. 2722.
H.R. 2734--``Health Care for Family Caregivers Act of 2009''
H.R. 2734 would amend 38 U.S.C. 1781 to medical care under Civilian
Health and Medical Program of the Department of Veterans Affairs
(CHAMPVA) to family caregivers who serve as the ``primary family
caregiver'' for veterans receiving compensation under 38 U.S.C. 1114(r)
or (s) and who have no entitlement to care or services under certain
health-plan contracts. In addition, these family caregivers would not
be subject to deductibles, premiums, co-payments, cost-sharing, or
other fees for medical care. The bill would also amend 38 U.S.C. 1701
to define the term caregiver services and the term family caregiver.
The term family caregiver is defined as members of the disabled
veteran's family (including parents, spouses, children, siblings, step-
family members, and extended family members) who provide caregiver
services to the veteran for their disability.
VA would like to address the Subcommittee's specific questions
regarding CHAMPVA. Currently, VA has the authority to provide medical
care for the survivors and dependents of certain veterans through
CHAMPVA. In Fiscal Year (FY) 2008, approximately 317,000 beneficiaries
were enrolled in CHAMPVA, and VA projects this number will increase to
329,000 in FY 2009. Approximately 17 percent of CHAMPVA beneficiaries
are under 23 years of age (approximately 54,000 children) and 83
percent are over 23 years of age (approximately 263,000 spouses or
surviving spouses). In FY 2009, these numbers are expected to increase
to 56,000 children and 273,000 spouses or surviving spouses. In FY
2008, just over 219,000 enrollees used CHAMPVA. Approximately 63,000 of
these users were survivors of veterans, and about 156,000 receive
benefits with a living veteran. In FY 2009, VA anticipates 230,000
total users, 68,500 of whom will be survivors of a veteran and 161,500
who will receive benefits with a living veteran.
VA shares the Committee's desire to enhance the level of VA support
provided to caregivers. To that end, the Department is currently
undertaking a comprehensive review of existing benefits to determine
potential gaps. We would like to ask that the Committee defer action on
this bill until our work is complete. In addition, we would like to
note a few immediate concerns with this bill. First, the legislation
would authorize the primary family caregivers to receive care as
CHAMPVA beneficiaries. CHAMPVA is a cost-sharing program. VA is
concerned the bill specifies family caregivers would not be subject to
the same deductibles, premiums, co-payments, cost-sharing, or other
fees for medical care that are applicable to the existing population.
Second, there is no scope or limitation to this benefit. If a veteran
died or no longer needed caregiver services, the legislation as written
would allow this individual to continue receiving benefits for the
course of his or her lifetime. Third, the legislation provides
eligibility to those veterans who receive special monthly compensation
(SMC) under subsection (r) or (s) of section 1114 of title 38, some of
who may not need caregiver support. The legislation as written would
extend benefits to some veterans without clinical need. We anticipate
the costs of this provision would be $261 million in FY 2010, $1.59
billion over 5 years and a 10 year total of $3.8 billion.
H.R. 2738--``Travel Expenses for Family Caregivers Accompanying
Veterans to Medical Treatment Facilities''
H.R. 2738 would amend 38 U.S.C. 111, which authorizes payments for
certain beneficiaries' travel, to clarify that an attendant includes a
family caregiver. Furthermore, it would make clear that the expenses of
attendant travel include lodging and subsistence for the period of time
a qualified person is traveling to and from a treatment facility as
well as during the treatment episode for such person. In addition, the
bill would amend 38 U.S.C. 1701 to define the term caregiver services
and the term family caregiver. The term family caregiver in this draft
is limited to members of the disabled veteran's family (including
parents, spouses, children, siblings, step-family members, and extended
family members) who provide caregiver services to the veteran for their
disability. However, VA notes only those attendants who would otherwise
be eligible under VA's beneficiary travel authority would qualify. If a
veteran is not eligible for attendant benefits under VA's existing
authority, his or her caregiver would not be eligible to receive the
benefits available under this legislation.
VA shares the Committee's desire to enhance the level of VA support
provided to caregivers. As stated above, the Department is currently
undertaking a comprehensive review of existing benefits to determine
potential gaps. We would like to ask that the Committee defer action on
this bill until our work is complete. The projected cost of this
provision would be $314 million in FY 2010, $1.8 billion over 5 years,
and $4.3 billion over 10 years.
Discussion Draft 1: Provision of Care and Services for Certain Veterans
Exposed to Herbicide and Veterans of the Persian Gulf War
VA supports the draft bill to provide, without expiration, hospital
care, medical services, and nursing home care for certain Vietnam-era
veterans exposed to herbicide and for veterans of the Persian Gulf War,
notwithstanding that there is insufficient medical evidence to conclude
their disability is associated with their service. This legislation
would restore statutory eligibility for care that existed from 1981 to
2002. Since VA has continued to provide care under this authority,
there are no additional costs associated with this bill.
The Department cannot comment on the remaining discussion draft
bills at this time. We will submit our views and cost estimates at a
later date.
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.
Prepared Statement of American Academy of Physician Assistants
On behalf of the more than 75,000 clinically practicing physician
assistants (PAs) in the United States, the American Academy of
Physician Assistants (AAPA) is pleased to submit comments in support of
H.R. 1302, a bill to amend title 38, United States Code, to establish
the position of Director of Physician Assistant Services within the
office of the Under Secretary of Veterans Affairs for Health. The AAPA
is very appreciative of Representatives Phil Hare and Jerry Moran for
their leadership in introducing this important legislation. The Academy
also wishes to thank Chairman Michaud, Chairman Filner, Ranking Member
Buyer, and other Members of the Subcommittee and Committee for co-
sponsoring H.R. 1302.
AAPA believes that enactment of H.R. 1302 is essential to improving
patient care for our Nation's veterans, ensuring that the more than
1,800 PAs employed by the VA are fully utilized and removing
unnecessary restrictions on the ability of PAs to provide medical care
in VA facilities. Additionally, the Academy believes that enactment of
H.R. 1302 is necessary to advance recruitment and retention of PAs
within the Department of Veterans Affairs.
Physician assistants are licensed health professionals, or in the
case of those employed by the Federal Government, credentialed health
professionals, who----
practice medicine as a team with their supervising
physicians
exercise autonomy in medical decisionmaking
provide a comprehensive range of diagnostic and
therapeutic services, including performing physical exams, taking
patient histories, ordering and interpreting laboratory tests,
diagnosing and treating illnesses, suturing lacerations, assisting in
surgery, writing prescriptions, and providing patient education and
counseling
may also work in educational, research, and
administrative settings.
Physician assistants' educational preparation is based on the
medical model. PAs practice medicine as delegated by and with the
supervision of a physician. Physicians may delegate to PAs those
medical duties that are within the physician's scope of practice and
the PA's training and experience, and are allowed by law. A physician
assistant provides health care services that were traditionally only
performed by a physician. All States, the District of Columbia, and
Guam authorize physicians to delegate prescriptive privileges to the
PAs they supervise. AAPA estimates that in 2008, over 257 million
patient visits were made to PAs and approximately 332 million
medications were prescribed or recommended by PAs.
The PA profession has a unique relationship with veterans. The
first physician assistants to graduate from PA educational programs
were veterans, former medical corpsmen who had served in Vietnam and
wanted to use their medical knowledge and experience in civilian life.
Dr. Eugene Stead of the Duke University Medical Center in North
Carolina put together the first class of PAs in 1965, selecting Navy
corpsmen who had considerable medical training during their military
experience as his students. Dr. Stead based the curriculum of the PA
program in part on his knowledge of the fast-track training of doctors
during World War II. Today, there are 142 accredited PA educational
programs across the United States. More than 1,800 PAs are employed by
the Department of Veterans Affairs, making the VA the largest single
employer of physician assistants. These PAs work in a wide variety of
medical centers and outpatient clinics, providing medical care to
thousands of veterans each year. Many are veterans themselves.
Physician assistants (PAs) are fully integrated into the health
care systems of the Armed Services and virtually all other public and
private health care systems. PAs are on the front line in Iraq and
Afghanistan, providing immediate medical care for wounded men and women
of the Armed Forces. PAs are covered providers in TRICARE. In the
civilian world, PAs work in virtually every area of medicine and
surgery and are covered providers within the overwhelming majority of
public and private health insurance plans. PAs play a key role in
providing medical care in medically underserved communities. In some
rural communities, a PA is the only health care professional available.
Why are PAs so fully integrated into most public and private health
care systems? We believe it's because they foster the use and inclusion
of their PA workforce. Each branch of the Armed Services designates a
PA Consultant to the Surgeon General. And, many major medical
institutions credit their integration of PAs in the workforce to a
Director of PA Services. To name just a few, the Cleveland Clinic, the
Mayo Clinic, the University of Texas MD Anderson Cancer Center, and New
Orleans' Ochsner Clinic Foundation all have Directors of PA Services.
We believe that what works for the Armed Services and the private
sector will also work for the VA.
How does the lack of a Director of PA Services at the VA relate to
recruitment and retention of the VA workforce? As far as the AAPA can
tell, there are no recruitment and retention efforts aimed toward
employment of physician assistants in the VA. The VA designates
physicians and nurses as critical occupations, and so priority in
scholarships and loan repayment programs goes to nurses, nurse
practitioners, physicians, and other professions designated as critical
occupations. The PA profession has not been determined to be a critical
occupation at the VA, so moneys are not targeted for their recruitment
and retention. PAs are not included in any of the VA special locality
pay bands, so PA salaries are not regularly tracked and reported by the
VA. We've been told that this has resulted in lower pay for PAs
employed by the VA than for health care professionals who perform
similar medical care. Why are PAs not considered a critical occupation
at the VA? Is it possible they were overlooked, because there was no
one to raise the issue?
The outlook for PA employment at the VA does not differ from that
for nurse practitioners and physicians. Approximately 40 percent of PAs
currently employed by the VA are eligible for retirement in the next 5
years, and the VA is simply not competitive with the private sector for
new PA graduates. The U.S. Bureau of Labor Statistics, U.S. News and
World Report, and Money magazine all speak to the growth, demand, and
value of the PA profession. The challenge for the VA is that the growth
and demand for PAs is in the private sector, not the VA.
According to the AAPA's 2008 Census Report, PA employment in the
Federal Government, including the VA, continues to decline. AAPA's
Annual Census Reports of the PA Profession from 1991 to 2008 document
an overall decline in the number of PAs who report Federal Government
employment. In 1991, nearly 22 percent of the total profession was
employed by the Federal Government. This percentage dropped to
approximately 9 percent in 2008. New graduate census respondents were
even less likely to be employed by the government (17 percent in 1991
down to 5 percent in 2008).
Unless some attention is directed toward recruitment and retention
for PAs, the AAPA believes that the VA is in danger of losing its PA
workforce. This is particularly critical because it is happening at a
time when the U.S. and the VA are facing a primary care workforce
shortage. The elevation of the PA Advisor to a full-time Director of PA
Services in the VA Central Office is the first step in focusing the
VA's efforts on recruitment and retention of PAs.
The current position of Physician Assistant (PA) Advisor to the
Under Secretary for Health was authorized through section 206 of P.L.
106-419 and has been filled as a part-time, field position. Prior to
that time, the VA had never had a representative within the Veterans
Health Administration with sufficient knowledge of the PA profession to
advise the Administration on the optimal utilization of PAs. This lack
of knowledge resulted in an inconsistent approach toward PA practice,
unnecessary restrictions on the ability of VA physicians to effectively
utilize PAs, and an underutilization of PA skills and abilities. The PA
profession's scope of practice was not uniformly understood in all VA
medical facilities and clinics, and unnecessary confusion existed
regarding such issues as privileging, supervision, and physician
countersignature.
Although the PAs who have served as the VA's part-time, field-based
PA Advisor have made progress on the utilization of PAs within the
agency, there continues to be inconsistency in the way that local
medical facilities use PAs. In one case, a local facility decided that
a PA could not write outpatient prescriptions, despite licensure in the
State allowing prescriptive authority. In other facilities, PAs are
told that the VA facility can not use PAs and will not hire PAs. These
restrictions hinder PA employment within the VA, as well as deprive
veterans of the skills and medical care PAs have to offer.
The Academy also believes that the elevation of the PA Advisor to a
full-time Director of Physician Assistant Services, located in the VA
central office, is necessary to increase veterans' access to quality
medical care by ensuring efficient utilization of the VA's PA workforce
in the Veterans Health Administration's patient care programs and
initiatives. PAs are key members of the Armed Services' medical teams
but are an underutilized resource in the transition from active duty to
veterans' health care. As health care professionals with a longstanding
history of providing care in medically underserved communities, PAs may
also provide an invaluable link in enabling veterans who live in
underserved communities to receive timely access to quality medical
care.
Thank you for the opportunity to submit a statement for the hearing
record in support of H.R. 1302. AAPA is eager to work with the House
Committee on Veterans Affairs Subcommittee on Health to improve the
availability and quality of medical care to our Nation's veteran
population.
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 this opportunity to submit The American Legion's
views on these various pieces of legislation: H.R. 2722; H.R. 1197;
H.R. 1293; H.R. 1302; H.R. 1335; H.R. 1546; H.R. 2734; H.R. 2738; and
Draft Discussions on Extending Health Care to Vietnam-era Veterans
Exposed to Herbicides and Gulf War Era Veterans; Providing Supportive
Services for Family Caregivers Accompanying the Veteran on Visits to
VA; and Requiring the Department of Veterans Affairs (VA) to Collect
Survey Data on Family Caregivers.
H.R. 2722
This bill seeks to amend title 38, United States Code (U.S.C.), to
modify and update provisions of law relating to nonprofit research and
education corporations, and for other purposes.
The American Legion has no official position on this piece of
legislation.
H.R. 1197
This bill seeks to assign priority status for hospital care and
medical services provided through the Department of Veterans Affairs
(VA) to certain veterans who are recipients of the Medal of Honor.
The Medal of Honor is the highest military decoration awarded to a
member of the United States Armed Forces. The recipients have earned
this award by displaying heroism and bravery while risking their lives
during service to this great Nation.
In addition to supporting H.R. 1197, The American Legion would
support legislation to place Medal of Honor recipients in Priority
Group 1 for VA health care.
H.R. 1293
This bill seeks to amend title 38, U.S.C., to improve the quality
of care provided to veterans in VA medical facilities, to encourage
highly qualified doctors to serve in hard-to-fill positions in such
medical facilities, and for other purposes.
The American Legion supports legislation that seeks to improve the
quality of care for veterans, to include medical and structural
accommodations that also improve quality of life. The American Legion
feels section 2c of H.R. 1293 is unclear and thereby requests
clarification.
H.R. 1302
This bill seeks to amend title 38, U.S.C., to establish the
position of Director of Physician Assistant Services within the office
of the Under Secretary of Veterans Affairs for Health.
The American Legion supports legislation to establish Director of
Physician Assistant (PA) services in the Department of Veterans Affairs
(VA). It is The American Legion's contention that the elevation of the
current position of PA Advisor to Director is a necessity to increase
veterans' access to quality medical care by ensuring efficient
utilization of the programs and initiatives.
The American Legion urges Congress to act on the matter immediately
to ensure the approximately 2,000 PAs within VA have sufficient and
full-time representation at the policy level.
H.R. 1335
This bill seeks to amend title 38, U.S.C., to prohibit the
Secretary of Veterans Affairs from collecting certain co-payments from
veterans who are catastrophically disabled.
The American Legion supports this piece of legislation.
H.R. 1546
This bill seeks to amend title 38, U.S.C., to direct the Secretary
of Veterans Affairs to establish the Committee on Care of Veterans with
Traumatic Brain Injury (TBI).
It is The American Legion's position that TBI is usually
accompanied by various injuries to include Post Traumatic Stress
Disorder (PTSD). We also contend that policies supporting care for this
``Signature Wound'' must be implemented and communicated from the
policy level to the field. The American Legion supports this piece of
legislation.
H.R. 2734
This bill seeks to amend section 1781 of title 38, U.S.C., to
provide medical care to family members of disabled veterans who serve
as caregivers to such veterans.
The American Legion supports any legislation that accommodates
those who care for this Nation's veterans.
H.R. 2738
This bill seeks to amend title 38, U.S.C., to provide travel
expenses for family caregivers accompanying veterans to medical
treatment facilities.
The American Legion supports any legislation that accommodates
those who care for this Nation's veterans. Veterans who injure
themselves while serving this great Nation are entitled to all that
places them in the best of care. We also contend that expenses and
support should be provided by VA to all who participate in care for the
veteran.
Draft Discussion on Extending Health Care to Vietnam Era Herbicide
Exposed Veterans and Gulf-War Era Veterans
The American Legion believes adequate and quality care should be
provided for those who sustained illnesses and injuries while serving
honorably. We also believe such discussion should be implemented
expeditiously as there is no pause button for this Nation's veterans.
As time progresses, so does the extent of pain of our Nation's
veterans.
The American Legion reaffirms its support for Vietnam veterans with
Agent Orange exposure in VA Priority Group 6 for VA health care. The
American Legion also supports legislation to give VA the authority to
include ill Gulf War veterans in Priority Group 6 for VA health care.
The American Legion supports the measures outlined in this bill
which would provide health care, medical services and nursing home care
for certain Vietnam era veterans exposed to herbicide and veterans of
the Persian Gulf War.
Draft Discussion on Providing Supportive Services for Family Caregivers
The American Legion supports legislation that adequately provides
for those who are unselfishly caring for our Nation's veterans and
believes such legislation should be implemented immediately.
Draft Discussion on Requiring VA to Collect Data on Family Caregivers
of Veterans Through Surveys
It is The American Legion's position that the Department of
Veterans Affairs maintains a database of those who are caring for this
Nation's veterans. Collecting such data is only part of the
accountability process. It's also imperative that VA, upon collecting
this data, accurately assess services rendered and compensate
caregivers adequately.
Conclusion
Mr. Chairman and Members of the Subcommittee, The American Legion
sincerely appreciates the opportunity to submit testimony on the above
mentioned pieces of legislation and looks forward to working with you
and your colleagues on these very important issues. Thank you.
Prepared Statement of Hon. Steve Buyer,
Ranking Republican Member, Committee on Veterans' Affairs,
and a Representative in Congress from the State of Indiana
On March 4, 2009, I introduced H.R. 1293, the Disabled Veterans
Home Improvement and Structural Alteration Grant Increase Act of 2009.
This bill would provide an increase in the amount payable to veterans
under the Department of Veterans Affairs (VA) Home Improvement and
Structural Alteration Program.
Known as the HISA program, this important VA benefit provides
grants to veterans who require home adaptations to provide access to
in-home medical care.
Typically, HISA grants are used for such things as widening doors;
putting in handrails or special lighting; making kitchens, bathrooms,
windows, or electrical outlets and switches more accessible; building
ramps or improving entrance paths and driveways.
The benefit is paid from the medical care appropriation and is
available to both veterans with service-connected and non-service
connected disabilities. A service-connected veteran can receive a HISA
grant in addition to other home adaptations grants available through
the Veterans Benefits Administration.
Congress first authorized VA to establish the HISA program as part
of outpatient care for home health services in 1973. We have been
engaged in the Global War on Terror for nearly 8 years and are seeing
an increasing number of servicemembers returning from Iraq and
Afghanistan utilizing VA health care. It is especially important that
this program remains relevant and can meet the needs of our newest
generation of veterans.
The current maximum amount of a HISA grant is $4,100 for service-
connected veterans and $1,200 for non-service connected veterans. This
amount was established by Congress in 1992 and has not been raised in
17 years.
My bill would increase the maximum amount of a grant to $6,800 for
service-connected veterans and $2,000 for non-service connected
veterans. This is a 66 percent increase. It would reflect a 3 percent
increase for each year since 1992 to account for inflation and the
increased cost of home modifications.
This increase is long overdue, and I urge my colleagues to support
this legislation. It would have a direct and immediate impact on
improving health care and the quality of life for our disabled
veterans.
Prepared Statement of Joy J. Ilem
Deputy 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. We
appreciate the Subcommittee's leadership in enhancing Department of
Veterans Affairs (VA) health care programs on which many service-
connected disabled veterans must rely, and we also appreciate the
opportunity to offer our views on the eight bills and three draft
measures under consideration by the Subcommittee today.
H.R. 1197--Medal of Honor Health Care Equity Act of 2009
This bill would assign a higher priority status to Medal of Honor
recipients for VA medical services and hospital care, by virtue of
their extraordinary service to our country.
Mr. Chairman, our Nation owes a tremendous debt to the individuals
awarded the Medal of Honor. As of June 2009, only 96 recipients of this
medal are still living. The Medal of Honor is the highest military
award for valor in action against an enemy of the United States. This
bill would uphold our Nation's commitment to these select few by
conveying to them a higher enrollment priority status for access to VA
hospital care and medical services. While the DAV has no national
resolution from our membership that endorses this particular
legislation, we would offer no objection to its enactment and we
appreciate the effort being made on behalf of these extraordinary
heroes.
H.R. 1293--Disabled Veterans Home Improvement and Structural Alteration
Grant Increase Act of 2009
This bill is intended to increase VA payments for improvements and
structural alterations furnished as part of home health services to
severely disabled veterans enrolled in VA health care. This bill would
increase the amount payable to service-connected veterans from $4,100
to $6,800, and for nonservice-connected veterans from $1,200 to $2,000.
Structural alterations to homes enable the chronically sick and
disabled to remain in their homes rather than be institutionalized at
much higher overall cost to the government. The existing payment
limitations have not been increased for many years, and unless the
amounts of these grants are periodically adjusted, inflation erodes
these benefits. The Independent Budget (IB) for fiscal year (FY) 2010
recommends doubling the existing grant rate of payment in the case of
service-connected veterans residing temporarily in homes owned by
others and this similar proposed rate increase is fully consistent with
our concerns as expressed therein. This measure would be beneficial to
severely disabled veterans; therefore, we support the purposes of this
bill and urge its enactment. Additionally, given that the rate has
remained stagnant for so many years, we also ask the Subcommittee to
consider amending the bill to include a periodic index to enable this
rate to be adjusted from time to by the administration to reflect
inflation in construction costs.
H.R. 1302--To establish the position of Director of Physician Assistant
Services Within the Office of the Under Secretary of Veterans Affairs
for Health
This measure would amend title 38, United States Code, section
7306(a) to require the current position of Director of Physician
Assistant Services within the office of the Under Secretary of Veterans
Affairs for Health to serve in a full-time capacity at the Central
Office of the Department. The bill would require the individual who
serves in this position to encumber the full-time position in VA
Central Office not later than 120 days after the date of enactment.
The VA is the largest Federal employer of physician assistants
(PAs), with approximately 1,800 full-time PA positions. In the VA
health care system, PAs are essential primary care providers literally
in millions of outpatient and inpatient encounters working in
ambulatory care clinics, emergency medicine and 22 other VA medical and
surgical subspecialties.
When the position of PA Advisor was created in 2000, as authorized
by the Veterans Benefits and Health Care Improvement Act of 2000, the
position consisted of collateral administrative duties added to a
field-based PA Advisor's direct patient care responsibilities. In April
2008, the PA Advisor function was finally converted to a full-time
position, but the incumbent continues to be field-based at a VA health
care facility, rather than located at the VA Central Office.
DAV and the other veteran service organizations that produce the IB
have urged that this position be made full-time within Veterans Health
Administration (VHA) headquarters. This would allow for:
an increase in scope of PA-specific clinical and human
resources policy issues;
the opportunity to participate in major health care VA
strategic planning Committees and functions; and
inclusion in aspects of planning on seamless transition,
polytrauma centers, traumatic brain injury staffing and the work of the
newly established Office of Rural Health Care.
Additionally, PAs could assist in emergency disaster planning since
34 percent of all VA-employed PAs are veterans or currently serve in
the military reserves.
In addition to supporting this bill, we urge that this occupation
be included in any recruitment and retention legislation the
Subcommittee reports because, by 2012, it is projected that 28 percent
of the VA PA workforce will be eligible for retirement. In our opinion,
passage of this bill to require the PA Advisor to be located in VA
Central Office on a full-time basis, would be a good start in
addressing some of these challenges. Although we do not have a specific
resolution in support of this measure, the bill is consistent with
recommendations outlined in the FY 2010 IB and would help to ensure
access to high quality health care services for veterans using the VA
health care system. Therefore, DAV supports this bill and urges its
enactment.
H.R. 1335--To Prohibit the Secretary of Veterans Affairs From
Collecting Certain Co-payments From Veterans Who Are Catastrophically
Disabled
This bill would prohibit the Secretary of Veterans Affairs from
collecting co-payments from catastrophically disabled veterans in
receipt of VA hospital or nursing home care.
Mr. Chairman, thousands of veterans survive catastrophic traumas in
civilian life. Some of them have been able to overcome the tremendous
challenges imposed on them by accidents or disease and have been able
to rejoin the workforce and be productive, taxpaying citizens. We
believe that catastrophically injured veterans should not face the
double jeopardy of disability and an additional financial penalty of
paying VA co-payments in order to access VA health care and services
for which they are fully eligible. These veterans, many wheelchair-
bound and spinal-cord injured, already spend thousands of dollars
annually on health-related supports and services (such as personal
attendants, adapted housing and automobiles, special equipment, etc.)
that able-bodied veterans do not need to bear, or even consider. If a
catastrophically ill or spinal-cord injured veteran succeeds in the
daunting personal quest to remain in, or re-join, the labor force, we
believe where possible the government should provide that veteran
proper incentives to remain employed. Setting aside co-payments would
be one such appropriate incentive.
In reviewing H.R. 1335, we note the language in the bill
specifically refers to hospital and nursing home care. However, we
would hope the bill is intended to exempt these designated veterans
from co-payments for hospital care and medical services under title 38,
United States Code, Sec. 1710. We are concerned that if left as
currently crafted, the intent of the bill would be construed to include
an exemption only from co-payments for inpatient services, forcing
these targeted beneficiaries to continue paying co-payments for
outpatient care and prescription medications. We recommend
clarification in the bill to reflect Congressional intent.
In conjunction with DAV's national resolution from our membership,
resolution number 172, calling for legislation to repeal all co-
payments for military retirees and veterans' medical services and
prescriptions, and as a partner organization constituting the FY 2010
IB, the DAV fully supports this provision. This bill also corresponds
to the IB's recommendation that veterans designated by VA as being
catastrophically disabled for the purpose of enrollment in health care
eligibility Priority Group 4 should be made exempt from health care co-
payments and other fees.
H.R. 1546--Caring for Veterans with Traumatic Brain Injury Act of 2009
This measure would direct the Secretary of Veterans Affairs to
establish the Committee on Care of Veterans with Traumatic Brain Injury
(TBI) in the VHA. The bill would require the Under Secretary for Health
to appoint to the Committee employees of the Department with expertise
in the care of veterans with TBI.
The bill would task the Committee with initially and continually
assessing the capability of the VA to treat and rehabilitate veterans
with TBI by evaluating the care provided and identifying systemwide
problems and specific VA facilities where program enrichment would be
needed to improve TBI treatment and rehabilitation. The bill would
require the Committee to identify successful model programs in the
treatment and rehabilitation of veterans with TBI that should be
implemented more widely in or through VA facilities.
The Committee would be required to advise the Under Secretary for
Health regarding the development of policies for TBI care and
rehabilitation, make recommendations for improving programs of care at
specific facilities throughout the VA, and for establishing special
programs of education and training for VHA employees relevant to caring
for veterans with TBI. The Committee would also concern itself with the
research needs and priorities related to caring for veterans with TBI
as well as the appropriate allocation of resources to underwrite such
activities.
Beginning June 1, 2010 and for each subsequent year thereafter, the
bill would require the Secretary to submit a report on the activities
of the TBI committee to the Committees on Veterans' Affairs of the
Senate and House of Representatives. Under the bill, the Secretary's
report would be required to include a list of the members of the
committee; the assessment of the Under Secretary for Health after
reviewing the initial findings of the committee regarding the
capability of the VA to effectively meet the treatment and
rehabilitation needs of veterans with TBI on a systemwide and facility
by facility basis; the plans of the Committee for further assessments,
the findings and recommendations made by the Committee to the Under
Secretary and the view of the Under Secretary on such findings and
recommendations; a description of the steps taken, plans made including
a timetable for the execution of such plans; and resources to be
applied toward improving the capability of the VA to effectively meet
the treatment and rehabilitation needs of veterans with TBI.
Mr. Chairman, DAV has no resolution that specifically identifies
the need for this committee, but we do have a resolution, number 164,
which calls for the VA and the Department of Defense (DoD) to
coordinate efforts to address mild and moderate TBI and concussive
injuries and establish a comprehensive rehabilitation program and
standardized protocol utilizing appropriately formed clinical
assessment techniques to recognize and treat neurological and
behavioral consequences of all levels of TBI. It also calls for any TBI
studies or research undertaken by VA and DoD to include older veterans
of past military conflicts who may have suffered similar injuries that
went undetected, undiagnosed, and untreated. We believe the intent to
effectively care for and treat those with TBI is commendable, and that
an advisory committee with this charter would be consistent with that
important and timely goal. Therefore, DAV offers no objection to the
purposes of this bill and we look forward to its enactment.
H.R. 2722--Veterans Nonprofit Research and Education Corporations
Enhancement Act of 2009
This bill would modernize and enhance oversight and reporting
requirements of nonprofit research and education corporations that
support VA biomedical research by managing extramural grant funds made
available to VA principal investigators. It would also provide new
guidance and policy requirements for the operation of these
corporations within the VA research program, and would be responsive to
recent recommendations made by the VA Inspector General for improved
accountability within some of these corporations.
The basic statutory authority for these corporations was enacted in
1988, so this bill would be the first significant amendment to that
statute. If enacted, this bill would authorize the corporations to
fulfill their full potential in supporting VA biomedical research and
education, the results of which would improve treatments and promote
high quality care for veterans, while underwriting VA and Congressional
confidence in these corporations' management of public and private
funds.
Mr. Chairman, VA's research and education corporations, operating
in almost 90 VA locations, provide an important element in VA's overall
Medical and Prosthetic Research programs, and provide major support for
its myriad health professions educational programs. Absent these
corporations, VA principal investigators, the majority of whom are
clinicians, would not be able to accept or use grant funds from
numerous Federal granting agencies (e.g., National Institutes of
Health, National Science Foundation, etc.) and VA would not be able to
participate in numerous clinical trials, education and specialized
clinical training programs sponsored by the pharmaceutical industry,
medical equipment manufacturers, and other sponsors. Funded research
from outside VA's annual discretionary appropriation makes up almost
one-third of VA's global research budget. This legislation is endorsed
by Friends of VA Medical Care and Health Research (FOVA), as well as
the National Association of VA Research and Education Foundations
(NAVREF).
While DAV has no adopted resolution on this particular matter, DAV
is a strong supporter of a robust VA biomedical research and
development program, and we believe enactment of this bill would be in
that program's best interest. Therefore, DAV would have no objection to
enactment of this bill.
Draft Bill--To Direct the Secretary of Veterans Affairs to Provide,
Without Expiration, Hospital Care, Medical Services, and Nursing Home
Care for Certain Vietnam-era Veterans Exposed to Herbicide and Veterans
of the Persian Gulf War
This bill would permanently authorize hospital care, medical
services and nursing home care to Vietnam veterans exposed to
herbicides while deployed, and for all veterans of the Persian Gulf
War. Title 38, United States Code, Sec. 1710(e)(3)(A) and (B) provided
VA the authority to enroll in VA health care Vietnam War veterans who
may have been exposed to herbicides while serving in Vietnam and for
Persian Gulf War veterans who served in the Southwest Asia theater of
operations. Both authorities expired on December 31, 2002.
Mr. Chairman, Congress saw fit to provide ``special treatment
authority'' in 1981 (P.L. 97-72) to provide care to Vietnam veterans
who may have been exposed to herbicides, notwithstanding that there was
insufficient medical evidence to conclude that their disabilities were
associated with exposure to herbicides while serving in Vietnam.
Congress repeatedly extended the authority through 1996 (P.L. 104-262)
with certain limitations.
Similarly, veterans who served in the Persian Gulf War in the
Southwest Asia theater of operations were provided special treatment
authority in 1993 \1\ to provide care to Persian Gulf veterans exposed
to toxic substances or environmental hazards. In 1997, P.L. 105-114
removed the requirement that the veteran had been exposed to toxic
substances or environmental hazards, only requiring service in the
Southwest Asia theatre of operations during the Persian Gulf War. In
1998,\2\ Congress extended the authority through 2001, and subsequently
through 2002.\3\
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\1\ Pub. L. 103-210 (1993).
\2\ Pub. L. 105-368 (1998).
\3\ Pub. L. 107-135 (2002).
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The DAV applauds VA for continuing to enroll veterans in these
circumstances. Based on wartime service and the often unknown hazards
of military duty, these veterans deserve access to VA health care, a
system dedicated to the unique needs of veterans. The DAV believes this
is an important bill and looks forward to the Subcommittee's approval
and its eventual passage into law.
FAMILY CAREGIVER SUPPORT SERVICES
Mr. Chairman, we note in the remaining four bills on which we offer
testimony, that each legislative measure directed at family caregivers
of disabled veterans would propose a standard definition for ``family
caregiver.'' While we recognize the importance of defining a program's
target population, we ask the Subcommittee to consider VA's position,
with which the DAV agrees, that ``[f]amily structures are changing in
all facets of society, and VA is sensitive to the fact that a specific
list or a strict definition of family members may not be appropriate
for many veterans. Discretion is needed to ensure that veterans retain
autonomy in designating caregivers who are competent and in whom they
are confident. . . . We believe the definition of caregiver should be
broadly defined to encompass a variety of potential caregivers, thus
eliminating the need for a discrete list that may inadvertently exclude
a candidate (such as a friend, neighbor, or significant other) that
meets the veteran's needs and preferences. Leaving discretion to the
Secretary to approve any potential caregiver would ensure this
adaptability.'' \4\
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\4\ Madhulika Agarwal (Chief Officer, Patient Care Services,
Veterans Health Admin., U.S. Dept of Veterans Affairs). Testimony on
Meeting the Needs of Family Caregivers before the House Veterans
Affairs Committee, Subcommittee on Health. (June 4, 2009). http://
veterans.house.gov/hearings/hearing.aspx?NewsID=412.
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Family caregiving is a complex role that bridges both quality of
care and quality of life of disabled veterans. Caregivers play a
critical role in facilitating recovery and maintaining the veteran's
independence and quality of life while residing in their community, and
are an important component in the delivery of health care by the VA.
Research has found that all too often the role of informal caregiver
exacts a tremendous toll on that caregiver's health and well-being.
Family caregiving has been associated with increased levels of
isolation, depression and anxiety, higher use of prescription
medications, compromised immune function, poorer self-reported physical
health, and increased mortality. Research also suggests that caregiver
support services can help to reduce adverse health outcomes arising
from caregiving responsibilities, can improve overall health status of
the caregiver and care recipient, and delay placement into a more
costly nursing home care setting.\5\
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\5\ Mittelman, M.S., et al. A Family Intervention to Deplay Nursing
Home Placement of Patients with Alzheimers Disease--A Randomized
Controlled Trial. JAMA 276(21), 1725-1731. (April 2, 1997).
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The DAV believes caregivers of severely disabled veterans should be
seen as a resource and supported in their role. Accordingly, the
delegates to our most recent National Convention, held in Las Vegas,
Nevada, August 9-12, 2008, approved resolution number 165, calling for
legislation that would provide comprehensive supportive services,
including but not limited to financial support, health and homemaker
services, respite, education and training and other necessary relief,
to family caregivers of veterans severely injured, wounded or ill from
military service.
Draft Bill--To Amend Title 38, United States Code, To Provide Support
Services for Family Caregivers of Disabled Veterans, and for Other
Purposes
This bill would establish a new section 1786 of title 38, United
States Code, to authorize a series of new and enhanced benefits for
caregivers of disabled veterans, and would establish a broadened
definition of the term ``family caregiver'' to include persons such as
parents who would become eligible under its terms. The new section
would require the Secretary to make interactive training sessions
available on an Internet Web site for family caregivers of disabled
veterans. Under the bill, the training would teach family caregivers
techniques, strategies, and skills for recording details regarding the
health of a veteran and in general for caring for a disabled veteran,
to include those with post-traumatic stress disorder (PTSD) or TBI,
including those who have returned from deployments in Operations
Enduring or Iraqi Freedom (OEF/OIF).
The bill would also require the Secretary to provide family
caregivers with information regarding public, private and nonprofit
agencies that might offer support, and to work with the Assistant
Secretary for Aging in the Department of Health and Human Services
(HHS) to provide family caregivers of disabled veterans with access to
the HHS Aging and Disability Resource Centers. Also the bill would
require the establishment of an Internet-based service to include a
directory of available services, an electronic message board, other
tools for family caregivers to interact with each other to create areas
of peer support, and comprehensive health-related information on issues
relevant to the needs of disabled veterans and their family caregivers.
The bill would require outreach to inform disabled veterans and
their families of the services that would be provided under this bill,
to include public service announcements, brochures, pamphlets,
participation in social networking sites; methods for reaching rural
families; and a dedicated Web page on VA's existing Web site that
focuses on caregiver support. The bill would require VA's Web site to
launch new interactive elements for caregivers, including furnishing
information based on the location of the person using the Web site.
This measure also would make technical and conforming changes to
section 1782 of title 38, United States Code, pertaining to counseling
and mental health services for family caregivers, by authorizing these
services for family caregivers as defined in the new section 1786
otherwise crafted in this bill. Also, this expanded definition of
family caregiver would be technically extended by the bill to section
1720B of title 38, United States Code, in order that respite care could
be available for newly defined family caregivers. The final provision
of the bill would require the Secretary to ensure that the needs of the
veterans receiving family caregiver services are being met, and that
respite facilities providing such care are appropriate, including age-
appropriate, for the veterans concerned.
We believe the intent of this bill is laudable and as this
Subcommittee is aware, VA has eight caregiver support pilot programs
that the DAV believes should be evaluated for effectiveness and
feasibility and if implemented, would be affected by this measure. For
example, the pilot program being conducted in Long Beach, CA, works
with a community coalition to provide interventions that support
caregivers for veterans with TBI, PTSD and dementia across the State of
California using telehealth, Web, telephone and video tele-
conferencing. Interventions are provided by the VA Cares Caregiver
Center; California Caregiver Resource Centers; the ``Powerful Tools''
Caregiver Training program; and Stanford University's Internet-based
Caregiver Self Management Program. The program will assess the
effectiveness of a 6-week-long online workshop, called ``Building
Better Caregivers,'' that provides training to at-home caregivers of
veterans who suffer from TBI, PTSD, Alzheimer's disease or other forms
of dementia. The interactive online workshop will also provide a forum
in which small groups of caregivers can share personal experiences and
insights on solving problems, handling difficult emotions and
celebrating milestones. Each week, participants will be asked to log on
at least three times and spend 2 hours on lessons and homework.
We are pleased the bill mandates VA to provide training; and, while
we believe training is a critical aspect of supporting family
caregivers of disabled veterans, we ask the Subcommittee to ensure that
online training will not be the only venue offered by VA.
VA respite care is one of the few services available with a primary
focus on supporting family caregivers to provide them temporary relief
from their care responsibilities. Caregiver burden is common and
frequently limits the ability of family and friends to provide that
assistance. In fact, respite care is considered the dominant service
strategy to support and strengthen family caregivers under the HHS
Aged/Disabled Medicaid Home and Community-Based (HCBS) waiver program.
A survey conducted on these programs where respondents were asked to
choose from a list of 20 items which services their program provides
specifically to family caregivers, respite care received a 92 percent
response.\6\
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\6\ Feinberg, L and Newman, S. Medicaid and Family Caregiving:
Services, Supports and Strategies Among Aged/Disabled HCBS Waiver
Programs in the U.S. Rutgers Center for State Health Policy. (May 1,
2005).
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While the VA policy allows respite care services to be provided in
excess of 30 days, it requires unforeseen difficulties. Additionally,
local facilities treat 30 days as a ceiling by requiring the approval
of the medical center Director rather than the treating physician or
treatment team. Moreover, for veterans who are required to make co-
payments, long-term care co-payments apply to respite care regardless
of the setting. The DAV believes VA should improve its national respite
care program to make it age appropriate, more flexible, and more
readily available to all severely injured veterans and their
caregivers. We believe VA should enhance this service to reduce the
variability across a veteran's continuum of care by, at a minimum,
allowing a veteran's primary treating physician to approve respite care
in excess of 30 days; making more flexible the number of hours/days
available for use; providing overnight and weekend respite care to
veterans for relief of their caregivers; and eliminating applicable
long-term-care co-payments. Three of the eight VA caregiver pilot
programs previously noted use respite care as their primary focus. The
DAV appreciates the bill's requirement, rather than a discretionary
authority, to ensure the respite care needs of family caregivers of
young and old severely injured veterans will be met.
In addition, HHS announced in September 2008 it would provide VA
with over $19 million to provide consumer-directed home and community-
based services to veterans regardless of age (designed to reach people
who are not eligible for Medicaid). Under this arrangement, VA is
already working with local, State, and Federal agencies including the
Aging and Disability Resource Center (ADRC) unlike this proposed bill,
which requires VA to only collaborate with HHS for access to ADRC,
which has its own limitations for including in their network nonprofit
and other community agencies.
As noted above, this bill requires the VA to contract with a
private entity to provide family caregivers with an Internet-based
service to provide a directory of caregiver support services at the
county level; online tools to allow family caregivers to interact with
their peers and create support networks; and provide comprehensive
information to meet the needs of disabled veterans and family
caregivers. As part of the IB, the DAV believes caregiver support
services should include family counseling and family peer groups so
they can share solutions to common problems. One recommendation in the
IB \7\ calls for VA to develop support materials for family caregivers,
including a social support and advocacy support for the family
caregivers of severely injured veterans. Such support should include:
peer support groups, facilitated and assisted by committed VA staff
members; appointment of caregivers to local and VA network patient
councils and other advisory bodies within the VHA and Veterans Benefits
Administration (VBA); and a monitored chat room, interactive discussion
groups, or other online tools for the family caregivers of severely
disabled OEF/OIF veterans, through My HealtheVet or other appropriate
Web-based platform.
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\7\ The Independent Budget for the Department of Veterans Affairs
Fiscal Year 2010, Medical Care Section, Family and Caregiver Support
Issues Affecting Severely Injured Veterans Subsection, pp 157-162.
(2009). http://www.independentbudget.org/pdf/IB_10medcare.pdf.
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Mr. Chairman, as noted above, DAV resolution number 165 calls for
legislation that would provide comprehensive supportive services,
including but not limited to financial support, health and homemaker
services, respite, education and training and other necessary relief,
to family caregivers of veterans severely injured, wounded or ill from
military service. Also, the IB for FY 2010 recommends a series of
supportive services and benefits for family caregivers of disabled
veterans. Therefore, DAV strongly supports this bill and urges its
enactment as soon as possible. On a final note, in light of the current
VA caregiver pilot initiatives, we ask the Subcommittee to ensure the
provisions outlined in the bill would not restrict or otherwise limit
ongoing efforts by VA.
H.R. 2734--The Health Care for Family Caregivers Act of 2009
This bill would amend section 1781, title 38, United States Code,
to extend eligibility for benefits under the Civilian Health and
Medical Program of Veterans Affairs (CHAMPVA), to certain family
caregivers of the most severely disabled veterans, as determined under
subsections (r) or (s) of section 1114, title 38, United States Code,
who are not currently eligible dependents of those veterans for that
CHAMPVA benefit. The bill would exempt these family caregivers from the
payment of deductibles, co-payments, cost sharing or other fees
associated with their care under CHAMPVA.
Eligibility for CHAMPVA services would be limited to those
caregivers without other entitlements to care under a health-plan
contract as defined under section 1725(f)(2), title 38, United States
Code. Further, ``caregiver services'' and ``family caregiver'' would be
defined similar to the manner they would be defined in other bills
before the Subcommittee today, specifically including parents, spouses,
children, siblings, step-family members and extended family members.
The DAV applauds this worthwhile bill since family caregivers who
provide 36 or more hours of care per week are more likely than non-
caregivers to experience mental health issues, including symptoms of
depression or anxiety--for spouses the symptom rate is six times as
high.\8\ Studies also demonstrate that family caregivers report having
a chronic health condition at more than twice the rate of non-
caregivers.\9\ In addition, studies indicate that when family
caregivers experience extreme stress, they age prematurely and this
level of stress can take as much as 10 years off a family caregiver's
life.\10\
---------------------------------------------------------------------------
\8\ C.C. Cannuscio, C. Jones, et al., Reverberation of Family
Illness: A Longitudinal Assessment of Informal Caregiver and Mental
Health Status in the Nurses' Health Study, Am Jrnl of Pub. Health 92:
305-11. (2002).
\9\ Dept of Health and Human Services (DHHS), Informal Caregiving:
Compassion in Action, Washington, D.C. (1998). http://aspe.hhs.gov/
daltcp/Reports/carebro2.pdf.
\10\ Peter S. Arno, Economic Value of Informal Caregiving,
presented at the VA Care Coordination and Caregiving Forum, Bethesda,
MD (January 25-27, 2006).
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Family caregivers of severely disabled veterans with long-term care
needs are able to divert those at risk from nursing home placement and
in the absence of family caregivers, an even greater burden of direct
care would fall to VA at significantly higher cost to the government
and reduced quality of life for these veterans who have sacrificed so
much. This bill is fully consistent with DAV resolution number 165
supporting the needs of family caregivers of disabled veterans.
Therefore, DAV fully supports its intent and urges this bill to be
enacted.
However, we believe under this proposal that only a minority of
severely disabled veterans who require a high level of care from their
family caregiver would meet the special monthly disability compensation
rates (r) or (s), potentially leaving a majority of family caregivers
in need of medical care without access to such care. We ask the
Subcommittee to give due consideration to this high threshold for
eligibility, which also lacks the appropriate clinical determination
based on need for medical care due to a family member's role as
caregiver of a severely disabled veteran. We recommend the Subcommittee
consider lowering the threshold by adopting the eligibility standard
that currently exists in section 1781(a)(1) of title 38, United States
Code, for a veteran who has a total disability permanent and total in
nature resulting from a service-connected disability.
H.R. 2738--To Amend Title 38, United States Code, To Provide Travel
Expenses for Family Caregivers Accompanying Veterans to Medical
Treatment Facilities
This bill would amend section 111(e), title 38, United States Code,
to authorize family caregivers of certain sick and disabled veterans to
receive beneficiary travel reimbursement, including lodging and
subsistence, during the periods these caregivers accompany such
veterans to and from VA health care facilities, and during the duration
of treatment episodes, with certain limitations.
The bill would also amend section 1701, title 38, United States
Code, to define ``caregiver services'' as one form of non-institutional
care including homemaker and home health aide services, and it would
define ``family caregiver'' as a member of a disabled veteran's family
including parents, spouses, children, siblings, step-family members and
extended family members of a disabled veteran, who provide caregiver
services to a veteran.
Mr. Chairman, VA currently provides beneficiary travel payments to
a member of a veteran's immediate family, legal guardian, or person in
whose household the veteran certifies an intention to live if such
person is traveling for consultation, professional counseling,
training, or mental health services concerning a veteran who is
receiving care for a service-connected disability or is traveling for
bereavement counseling.
The DAV appreciates the intent of this bill since the availability
of transportation is a key concern and barrier for many family
caregivers of disabled veterans to access VA medical care. In order for
veterans and their family caregivers to receive beneficiary travel
payment, the veteran must meet certain eligibility criteria for VA's
travel beneficiary program.\11\ This measure would define the term
``family caregiver'' and include them in being able to receive mileage
reimbursement, lodging, and subsistence under this program.
---------------------------------------------------------------------------
\11\ 38 CFR Sec. 70.10(7) and (8). See also: Beneficiary Travel
Handbook 1601B.05 (July 29, 2008).
---------------------------------------------------------------------------
DAV resolution number 165, as discussed above, calls for
legislation that would provide comprehensive support services to family
caregivers of severely disabled veterans. Therefore, DAV endorses this
legislation and urges its enactment.
Draft Bill--To Direct the Secretary of Veterans Affairs to Annually
Conduct a Survey of Family Caregivers of Disabled Veterans, and for
Other Purposes
This bill would require the VA Secretary to annually conduct a
survey of family caregivers, to determine the number of family
caregivers in the United States; the range of caregiver services
provided by family caregivers, including the average schedule of such
services and the average amount of time a caregiver has spent providing
such services; the support services needed by family caregivers; and
other information the Secretary considers appropriate. The bill would
also require the Secretary to consider the findings of the survey when
carrying out programs regarding family caregivers, and provide these
reports to the House and Senate Committees on Veterans' Affairs. The
bill would also define ``caregiver services'' and ``family caregiver''
in ways similar to the provisions of the other draft bills before the
Subcommittee today.
Mr. Chairman, we agree with your opening statement for this
Subcommittee's June 4, 2009, hearing on meeting the needs of family
caregivers of disabled veterans, specifically that the VA does not
collect data on this population and therefore, the number of family
members who provide care for veterans is unknown. Moreover, in our
testimony for that hearing we indicated a need for VA to conduct a
longitudinal survey to obtain information and develop a nationally
representative profile on the health and functional status of people
who take care of severely disabled veterans.
At that hearing, we cited in our testimony the National Long Term
Care Survey (NLTCS) and Informal Caregiver Survey (ICS) that can be
used to examine such things as how many hours of help caregivers
provide with activities of daily living (ADLs) and instrumental
activities of daily living (IADLs) for chronically disabled elders, and
what number and percentage of those hours are provided by informal
caregivers. It can also be further broken down by primary and secondary
caregivers and by relationship, (e.g., spouse, son, daughter, friend,
etc.) as compared to paid workers. This enables policy researchers to
measure the time burden on caregivers of providing informal care
(especially primary caregivers) in relation to the severity of
disability and other care recipient characteristics. The relationship
between weekly time burden of informal care and self-reported
indicators of caregiver stress can then be analyzed. Further analyses
could be carried out with respect to relationships among time burden of
informal care, self-reported caregiver stress, use/non-use of formal
services, and funding sources for formal services (public/private).
Finally, the NLTCS/ICS contains numerous questions regarding the
primary informal caregiver's perception of the need or lack of formal
services and the reason why these services are not being used if they
are perceived as needed (e.g., lack of affordability, lack of local
availability, etc.). This enables policymakers to estimate (using
various criteria) the potential size and characteristics of the target
population for public policy interventions to assist caregivers.
As part of the IB, the DAV recommends VA should conduct a baseline
national survey of caregivers of veterans to address the needs of
informal caregivers as a public health concern by looking at
population-based public health outcomes of caregivers. Because health
outcomes and quality of life of family caregivers affect the lives of
disabled veterans, data on family caregivers is needed to capture the
influence of their roles and responsibilities as caregivers on their
lives, including influence on work, social, psychological, and physical
burden. Considering the demographics of the enrolled and user
population of the VA health care system, attention to caregivers has
with reason been drawn to the needs of the aging veteran, but that
group represents only one segment--although a large one--of those who
receive and provide care; however, the survey should include a special
emphasis on caregivers of OEF/OIF veterans. In addition, since
caregiving is a lifespan experience, this survey should be conducted at
regular intervals.
In concert with a longitudinal survey, the DAV believes that
caregiver assessments are equally important. In programs where
caregivers are assessed, they can be acknowledged and valued by
practitioners as part of the health care team. While requiring VA to
perform caregiver assessments is not considered in this draft proposal,
we urge VA to ensure this type of health care tool is utilized
throughout the VA health care system. The DAV believes that unlike a
longitudinal population survey, caregiver assessments can identify
those family members most at risk for health and mental health effects
and determine if they are eligible for additional support.
This bill is fully consistent with DAV resolution number 165 and
the IB recommendation that VA conduct annual surveys of family
caregivers as well as periodic assessments to determine their unmet
needs. Therefore, DAV fully endorses this bill and urges its enactment.
Mr. Chairman, again, DAV appreciates the Subcommittee's interest in
these issues, and we appreciate the opportunity to share our views 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 Hon. Jerry Moran,
a Representative in Congress From the State of Kansas
I want to thank Congressman Hare for his leadership on
reintroducing this bill. I join Congressman Hare as an original co-
sponsor of H.R. 1302. This bill creates a full time Director of PA
Services within the Department of Veterans Affairs. This legislation is
beneficial in improving patient care for our Nation's veterans,
ensuring that the more than 1,800 PAs employed by the VA are fully
utilized to provide veterans medical care.
As a Member of Congress who represents one of the most rural
districts in the country, I know that physician assistants are a key to
providing medical care in underserved areas. Often, they are the only
health care professional available. PAs help ensure those who live in
our communities receive timely access to quality health care.
I want to be certain that PAs are appropriately utilized by the VA
to serve our veterans. Like our armed forces that have full-time
directors of PA services, this legislation will establish a dedicated
expert in the VA Central Office. This PA Director will work to fully
integrate the profession into VA health care, ensuring PAs have a
stronger voice in the VA so they can better serve our veterans and
their patients.
In May of last year, the House approved this bill. I am hopeful
this Committee will continue its support and this year we can enact
H.R. 1302 into law.
Prepared Statement of National Association of Veterans' Research and
Education Foundations
The National Association of Veterans' Research and Education
Foundations (NAVREF) thanks Veterans Affairs Committee Chairman Bob
Filner for introducing H.R. 2770, the Veterans Research and Education
Corporations Enhancement Act of 2009, on June 9. We also thank Ranking
Member Steve Buyer for collaborating with Mr. Filner to finalize and
co-sponsor this legislation. We are grateful to Chairman Mike Michaud,
Ranking Member Henry Brown and the Members and staff of the Health
Subcommittee for holding a hearing on this and other important health-
related legislation.
Upon enactment, H.R. 2770 will update and clarify provisions of the
law authorizing the VA-affiliated nonprofit research and education
corporations. The Senate counterpart of H.R. 2770 is title VI of S. 252
which was introduced by Chairman Daniel Akaka on January 15, 2009.
Subsequently, it was the subject of a Senate Committee on Veterans'
Affairs hearing on April 22 and was marked up by the Senate Committee
on Veterans' Affairs on May 21. The substantive provisions of S. 252
and H.R. 2770 are identical. The only differences between the two bills
are in the clause numbering and in a few provisions, the lead-in
phrasing.
NAVREF is the membership organization of the 82 VA-affiliated
nonprofit research and education corporations (NPCs) originally
authorized by Congress under Public Law 100-322, and currently codified
at sections 7361 through 7366 of the United States Code. NAVREF's
mission is to promote high quality management of the NPCs and to pursue
issues at the Federal level that are of interest to its members. NAVREF
accomplishes this mission through educational activities for its
members as well as interactions and advocacy with agency and
congressional officials. Additional information about NAVREF is
available on its Web site at www.navref.org.
Background About the NPCs
In 1988, Congress allowed the Secretary of the Department of
Veterans Affairs to authorize ``the establishment at any Department
medical center of a nonprofit corporation to provide a flexible funding
mechanism for the conduct of approved research and education at the
medical center'' [38 U.S.C. Sec. 7361(a)]. Currently, 82 NPCs provide
their affiliated VA health care systems and medical centers with a
highly valued means of administering non-VA Federal research grants and
private sector funds in support of VA research and education.
The fundamental purpose of the nonprofits is to serve veterans by
supporting VA research and medical education to improve the quality of
care that veterans receive. For example, a seed grant provided by the
Palo Alto Institute for Research and Education (PAIRE) to a
gastroenterology clinician-investigator resulted in his finding that an
easily overlooked type of abnormality in the colon is the most likely
type to turn cancerous, and is more common in this country than
previously thought. This finding, reported on the front page of the
March 5, 2008, New York Times and in the Journal of the American
Medical Association, is changing colonoscopy practices and may well
lead to widespread earlier detection of a cancer that is preventable or
curable through surgery. During 2008 PAIRE made nine similar awards to
VA Palo Alto investigators in the hope of equally significant research
success down the road. Similarly, a few years ago funds administered by
the Seattle Institute for Biomedical and Clinical Research (SIBCR)
allowed a psychiatry clinician-investigator to test use of Prazosin, an
inexpensive, already approved drug, for treatment of veterans with
debilitating post-traumatic stress-related nightmares. The SIBCR
funding allowed the investigator to accumulate positive preliminary
data that then led to DoD and NIH awards to further test this promising
treatment.
Last year, the NPCs collectively administered more than $250
million with expenditures that supported approximately 4,000 VA-
approved research and education programs. These nonprofits are
dedicated solely to supporting VA and veterans. This includes providing
VA with the services of nearly 2,500 without compensation (WOC)
research employees who work side-by-side with VA-salaried employees,
all in conformance with the VA background, security and training
requirements such appointments entail.
Beyond administering VA-approved research projects and education
activities, these nonprofits support a variety of VA research
infrastructure and administrative expenses. As described above, they
have provided seed and bridge funding for investigators; staffed animal
care facilities; funded recruitment of clinician researchers; paid for
research administrative and compliance personnel; supported staff and
training for institutional review boards (IRBs); and much more.
Legislation Would Enhance and Clarify NPC Authorities
The purpose of H.R. 2770 is to modernize and clarify the 1988
statute after 20 years of experience under its current terms. The NPCs
have already proven themselves to be valued and effective ``flexible
funding mechanisms for the conduct of approved research'' [38 U.S.C.
Sec. 7361(a)]. VA's most recent annual report to Congress regarding the
NPCs stated, ``The VA-affiliated NPCs continue to make a substantial
contribution to the VA research and education missions.'' This
legislation will further enhance their value to VA.
The objectives of this legislation are consistent with the findings
in the May 2008 VA Office of Inspector General (OIG) review of five
NPCs and VHA's oversight of them. VHA is working hard to address the
shortcomings in oversight that the OIG identified. NAVREF and the NPCs
are working equally hard to ensure that NPCs have appropriate controls
over funds and equipment (including strengthening the documentation for
all transactions), and that all NPC officers, directors and employees
are certifying their awareness of the applicable Federal conflict of
interest regulations. While NAVREF firmly believes that NPC boards and
administrative employees strive to be conscientious stewards of NPC
funds, NAVREF thanks the OIG for its thorough review of those five NPCs
and for bringing to light these areas in need of improvement.
It is noteworthy that the OIG report cited no misuse of funds or
instances of conflicts of interest, no dual compensation of Federal
employees and no fraud. However, we take very seriously the OIG finding
that these NPCs nonetheless may not have had adequate controls over
some of the funds they manage. Two major provisions in H.R. 2770
directly address this finding:
First, section 2(a) allows voluntary formation of ``multi-medical
center research corporations.'' That is, two or more VA medical centers
may share one NPC, subject to board and VA approval, while preserving
their fundamental nature as medical center-based organizations. This
provision--the centerpiece of the legislation--will allow interested VA
facilities with small research programs to join voluntarily with larger
ones. Or several smaller facilities may pool their resources to support
management of one NPC with funds and staffing adequate to ensure an
appropriate level of internal controls, including segregation of
financial duties.
Second, the last item in section 5(a)--``(f) Policies and
Procedures''--addresses the OIG criticism by broadening VA's ability to
guide NPC expenditures. The only constraint on VA is that such guidance
must be consistent with other Federal and State requirements as
specified in laws, regulations, Executive orders, circulars and
directives--of which there are many--applicable to other 501(c)(3)
organizations. The purpose of this limitation is to prevent the
possibility of imposing on NPCs conflicting requirements and to ensure
that they remain independent ``flexible funding mechanisms.''
H.R. 2770 provides a number of other welcome enhancements to the
NPC authorizing statute.
Section 4(b) of the bill broadens the qualifications for
the two mandatory non-VA board members beyond familiarity with medical
research and education. This will allow NPCs to use these board
positions to acquire the legal and financial expertise needed to ensure
sound governance and financial management.
Section 4(c) deletes the overly broad stipulation in the
current statute that these non-VA board members may not have ``any
financial relationship'' with any for-profit entity that is a source of
funding for VA research or education. This absolute prohibition
conflicts with regulations applicable to Federal employees with respect
to conflicts of interest, which are invoked for all NPC directors and
employees in section 7366(c)(1) of title 38, United States Code. Unlike
the standard currently applied to NPC board members, Federal conflict
of interest regulations provide means of recusal as well as de minimus
exceptions. Additionally, the current prohibition may be applied to any
individual who has accepted compensation or reimbursement from a for-
profit sponsor of VA research for purposes unrelated to VA research,
thereby eliminating many otherwise desirable and qualified individuals
from serving on NPC boards.
Section 5(a) ``(b) ``(1) ``(C) increases the efficiency
of NPC administration of funds generated by educational activities.
This clause allows NPCs to charge registration fees for the education
and training programs they administer, and to retain such funds to
offset program expenses or for future educational purposes. However, it
also explicitly sustains the existing prohibition against NPCs
accepting fees derived from VA appropriations.
Section 5(a) ``(b) ``(1) ``(D) provides NPCs with
authority to reimburse the Office of General Counsel (OGC) for legal
services related to review and approval of Cooperative Research and
Development Agreements (CRADAs), the form of agreement used to
establish terms and conditions for industry-funded studies performed at
VA medical centers and administered by NPCs. Although OGC is already
obligated to review these agreements without reimbursement, the funds
generated under this provision would help OGC to staff Regional Counsel
offices to accommodate the substantial workload these agreements entail
and to provide training for VA attorneys in CRADA requirements and
related VA policies. The NPCs support making these reimbursements.
Section 5(a) ``(b) ``(2) of the legislation provides VA
with authority to reimburse NPCs for the salary and benefits of NPC
employees loaned to VA under Intergovernmental Personnel Act (IPA)
assignments conducted in accordance with section 3371 of title 5,
United States Code. This provision responds to recent OIG questions
asking whether such reimbursements are allowable and permits VA to
continue to benefit from this efficient and cost-effective mechanism to
acquire the temporary services of skilled research personnel.
Section 5(a) ``(c) ``(3) establishes explicit authority
for VAMCs to accept funds provided by NPCs that may fall outside of
VA's gift acceptance authority. It also allows VAMCs to retain such
funds locally and to deposit them in the appropriate VA account without
having to route them through the Treasury, necessitating cumbersome
steps to get the funds to the right VA account. Finally, this provision
makes these reimbursements ``no year'' money to give VAMCs needed
flexibility in timing for use of the funds.
Although VA has broad authority to accept gifts (38 U.S.C.
Sec. 8301), many NPC payments to VAMCs are more accurately
described as reimbursements to the VAMC or payments for
services and may not be consistent with VA's gift acceptance
authority. For example, NPCs typically reimburse VAMCs for the
cost of clinical services provided exclusively for research
purposes; VA employees' time spent on NPC-administered
programs; and animal per diems. This clause also will allow VA
to resolve longstanding VAMC uncertainty about how to treat
such reimbursements and will let the VAMC that incurred the
cost retain the amounts reimbursed. Currently, VAMCs must send
such reimbursements to the Treasury and then the Fiscal Office
must use a cumbersome process to bring the funds back to the
VAMC.
H.R. 2770 also contains a number of useful clarifications of NPC
status and purposes.
Sections 2(b), (c) and (d) codify--without changing--the
legal status of the NPCs as State-chartered, independent organizations
exempt from taxation under section 501(c)(3) of the Internal Revenue
Service (IRS) code and subject to VA oversight and regulation. Clause
(c) of this section codifies the congressional intent, previously
expressed in the House report that accompanied the original NPC
authorizing statute (H. Rept. 100-373), that nonprofits established
under this authority would not be corporations controlled or owned by
the government. As a result, this legislation resolves longstanding
differences of opinion among stakeholders, overseers and funding
sources about the legal status of NPCs.
Section 3(a)(1) of the legislation establishes that in
addition to administering research projects and education activities,
NPCs may support ``functions related to the conduct of research and
education.'' This resolves differences of opinion about the
appropriateness of NPC expenditures that support VA research and
education generally, such as purchase of core research equipment used
by many researchers for multiple projects, and enhances the value of
NPCs to VA facilities.
Section 5(a) ``(d) ascertains that all NPC-administered
research projects must undergo ``scientific'' rather than ``peer''
review. This change recognizes that peer review is not necessary or
appropriate for all research projects administered by NPCs. However,
the legislation leaves in place the overarching requirement for VA
approval and the medical center's Research and Development Committee
remains in a position to determine on a case-by-case basis whether a
project also requires peer review as a condition of VA approval.
In addition to these enhancements and clarifications, H.R. 2770
reorganizes the NPC authorizing statute to put all provisions regarding
their establishment and status in one section; describes their purposes
in another; and gathers in one section the clauses enumerating their
powers. Other revisions are largely technical and conforming
amendments.
Proposed Legislation Preserves Measures Providing Oversight of NPCs
H.R. 2770 makes no changes in VA's power to regulate and oversee
the NPCs. Further, NPC records remain fully available to the Secretary
and his designees; to the Inspector General; and to the Government
Accountability Office (GAO). Likewise, NPCs are still required to
undergo an annual audit by an independent auditor in accordance with
the sources--Federal or private--and the amount of their prior year
revenues, and they must submit to VA an annual report that includes the
resulting audit report along with detailed financial information and
descriptions of accomplishments.
In the wake of the Sarbanes-Oxley Act and changing Federal
Accounting Standards Board (FASB) auditing standards, even the most
basic form of nonprofit audit has become an effective means for
assessing an organization's financial controls. Additionally, the
percentage of NPC funds subject to audits conducted in accordance with
OMB Circular A-133, the most rigorous level of applicable auditing
standards, will continue to increase as more NPCs assume responsibility
for non-VA Federal grants. According to reports submitted to VA in June
2008, nearly 80 percent of prior year NPC expenditures were subject to
an A-133 audit and overall, 99.7 percent of NPC expenditures were
subject to an audit of one type or another. These audits are
comprehensive and provide a sound framework for examining an
organization's controls over funds as well as compliance with program
requirements.
Conclusion
In conclusion, NAVREF urges the Congress to pass H.R. 2770 at the
earliest possible opportunity. The NPCs are already a highly efficient
means to maximize the benefits to VA of externally funded research
conducted in VA facilities, ably serving to facilitate research and
education that benefit veterans. Additionally, they foster vibrant
research environments at VA medical centers, enhancing VA's ability to
recruit and retain clinician-investigators and other talented staff who
in turn apply their knowledge to state-of-the-art care for veterans.
Twenty years after the VA-NPC public-private partnership was first
authorized by Congress, this is a timely opportunity to update and
clarify the NPCs' enabling legislation. This legislation will
accomplish those objectives. Experience working within the current
statute has brought to light its many strengths, but also areas that
will benefit from modification, enhancement and updating, particularly
in light of the increasing complexity of both research and nonprofit
compliance. We believe enactment of H.R. 2770 will allow NPCs to better
achieve their potential to support VA research and education while
ensuring VA and congressional confidence in their management.
NAVREF thanks the Health Subcommittee of the House Committee on
Veterans Affairs and its staff members, as well as the Full Committee
staff, for their work on H.R. 2770. We look forward to working with the
Members of the Committee toward enactment of this bill. Please direct
any questions you may have to NAVREF Executive Director Barbara West at
301-656-5005 or [email protected].
Prepared Statement of Barbara Cohoon,
Government Relations Deputy Director, National Military Family
Association
The National Military Family Association is the leading nonprofit
organization committed to improving the lives of military families. Our
40 years of accomplishments have made us a trusted resource for
families and the Nation's leaders. We have been at the vanguard of
promoting an appropriate quality of life for active duty, National
Guard, Reserve members, retired servicemembers, their families, and
survivors from the seven uniformed services: Army, Navy, Air Force,
Marine Corps, Coast Guard, Public Health Service, and the National
Oceanic and Atmospheric Administration.
Association Representatives in military communities worldwide
provide a direct link between military families and the Association
staff in the Nation's capital. These volunteer Representatives are our
``eyes and ears,'' bringing shared local concerns to national
attention.
The Association does not have or receive Federal grants or
contracts.
Our Web site is: www.MilitaryFamily.org.
__________
Chairman Michaud and Distinguished Members of the Subcommittee on
Health of the U.S. House of Representatives Committee on Veterans'
Affairs, the National Military Family Association would like to thank
you for the opportunity to submit for the record for your legislative
hearing. The National Military Family Association will take the
opportunity to discuss our views on pending legislation to this
Subcommittee.
Wounded servicemembers and veterans have wounded families. The
system should provide coordination of care; VA and DoD need to work
together to create a seamless transition. Our Association recommends
there be a comprehensive approach to caregiver support services to
ensure everything is covered and there are no gaps in the support
system. We need one overall approach rather than having DoD, VA, and
Members of Congress making ad hoc fixes as they arise. We cannot
continue to approach the problem in a vacuum. We ask this Subcommittee
to assist in meeting that responsibility.
`Veterans Nonprofit Research and Education Corporations Enhancement Act
of 2009'
The National Military Family Association supports this proposed
legislation that will modify and update provisions of the law that
relate to nonprofit research and education corporations. We appreciate
the amended section that will now include ``education and training for
patients and families.'' The provision allowing the established
corporation to accept, administer, retain, and spend funds derived from
gifts, contributions, grants, fees, reimbursements, and bequests from
individuals and public and private entities would create an environment
of flexibility allowing the corporation to receive and spend funds in
the most efficient and beneficial manner.
Our Association would like to see a provision added creating an
overview by the Under Secretary for Health to ensure there is a
coordination of research projects done across the multi-medical center
research corporations. This provision would prevent the potential for
the duplication of research projects and allow for the opportunity for
projects to be expansions of existing research projects.
`Disabled Veterans Home Improvement and Structural Alteration Grant
Increase Act of 2009'
The National Military Family Association supports this proposed
legislation increasing the funds available to disabled veterans for
improvements and structural alterations as part of home health
services. We appreciate the monetary increase; however, our Association
recommends the amount in this provision not be tied to a flat fee. The
amount should be flexible and allow for regional differences in costs
across the United States for improvements and alterations. There are
variations on how much $6,800 can provide in services depending on
where the veteran lives. We believe this benefit should be equal in
purchase power regardless of where the veteran resides.
`Medal of Honor Health Care Equity Act of 2009'
The National Military Family Association supports this proposed
legislation assigning a higher priority status for hospital care and
medical services provided through the Department of Veterans Affairs
(VA) for veteran recipients of the Medal of Honor. This provision
recognizes the distinguished service these veterans provided for our
Nation.
Establishes the Position of Director of Physician Assistant Services
The National Military Family Association has no position on this
proposed legislation.
Prohibits the Collection of Certain Co-payments from Catastrophically
Disabled Veterans
The National Military Family Association supports this proposed
legislation to prevent the VA from collecting certain co-payments from
catastrophically disabled veterans. This provision recognizes the
severity of injury and its potential financial impact on these veterans
when receiving hospital or nursing home care. However, this provision
prevents the collection for only in-patient care. Our Association would
like to see this provision expanded to include out-patient services for
catastrophically disabled veterans.
`Caring for Veterans with Traumatic Brain Injury Act of 2009'
The National Military Family Association supports the intent of
this proposed legislation directing the Secretary of Veterans Affairs
to establish the Committee on Care of Veterans with Traumatic Brain
Injury (TBI). Traumatic Brain Injury has been referred to as the
signature wound of this current conflict. Many of our servicemembers
and now veterans have sustained this type of wound. However, we have
some concerns. Currently, there exists a joint Center to address TBI in
both active duty servicemembers and veterans. This Center is called the
Defense Center of Excellence (DCoE). There is also a state-of-art
health care facility being built in the National Capitol Region called
the National Intrepid Center of Excellence (NICoE) that will provide
evidence-based health care for servicemembers and veterans with TBI and
post-traumatic stress disorder (PTSD). We are wondering how this newly
established committee will interface with these two already established
entities.
Another concern is that many of our wounded are affected by more
than one injury. Who will ensure there is a system or committee in
place to oversee continuity of care for those veterans with polytrauma?
Seamless care will be difficult to obtain if we continue to create one-
injury focused committees. We must be cognizant of our resources and
acknowledge our injured veterans begin as active duty servicemembers.
Members of Congress and the VA must work closely with the Department of
Defense (DoD) to ensure there is coordination of services and that we
are not creating duplicate services. We recommend these concerns be
considered as Congress and the VA move forward in the creation of
additional committees to address injuries affecting our veterans.
`Health Care for Family Caregivers Act of 2009'
The National Military Family Association supports the intent of
this proposed legislation to provide medical care to family members of
disabled veterans who serve in the role as caregiver. Our Association
recommends caregivers of our veterans be recognized for the important
role they play in maintaining the wellbeing of the disabled veteran,
often resulting in personal financial sacrifices. Providing access to
medical care for caregivers would go a long way in recognizing their
important contribution. However, the bill's language needs further
clarification.
We appreciate the inclusion of ``family members'' in the definition
of caregiver. Most individuals and government agencies recognize and
understand the blood and marriage connection. However, the definition
of caregiver needs to be expanded to include those who are normally not
considered a ``member of the family,'' such as a girlfriend, fiancee or
fiance, and significant other. We frequently hear they are part of the
caregiver structure. The difference between DoD and VA in regards to a
caregiver definition and eligibility is important because the choice or
self selection of the caregiver begins while the wounded, ill, and
injured servicemember is still on active duty. According to the VA, ``
`informal' caregivers are people such as a spouse or significant other
or partner, family member, neighbor or friend who generously gives
their time and energy to provide whatever assistance is needed to the
veteran.'' We would like to make sure DoD and VA have the same
definition of caregiver and the eligibility is broad enough to capture
additional individuals.
We believe we also need to know what constitutes a ``caregiver.''
We need to have a better understanding of their roles and the scope of
responsibilities that would allow them to be considered a caregiver?
This proposal as written would allow for a wide range of caregivers to
qualify for this benefit and receive medical care.
Another area of concern involves the provision for the family
caregiver to not be subject to ``deductibles, premiums, co-payments,
cost sharing, or other fees for medical care.'' Given the broad
definition of caregiver, this provision could be very costly for the
VA. Is the VA adequately funded to provide these services for free? We
recognize the potential financial strain the caregiver may be under;
however, we ask about the widow whose husband made the ultimate
sacrifice. They too have experienced tremendous financial impact
following the loss of their loved one, but are subject to these fees.
According to this proposal's language, they would not be eligible for
this generous benefit.
Our Association feels we need further clarification on what is
currently being offered as a medical care benefit for caregivers. For
example, the National Defense Authorization Act for Fiscal Year 2008
(NDAA FY08) section 1672 provides for medical care at DoD Military
Treatment Facilities (MTFs) or VA facilities on a space-available basis
authorized for certain family members, not otherwise eligible for
medical care, caring for a recovering servicemember. According to a
briefing by General Elder Granger, Deputy Director and Program
Executive Officer for TRICARE Management Activity, on April 13, 2009,
DoD has implemented this section of the NDAA FY08. This law allows for
non-emergent care. How has the VA complied with this provision in
allowing access to care for caregivers? We need to have a better
understanding of the eligibility and availability of medical care for
our caregivers before we can identify areas of quality care and where
gaps still exist.
Provides Travel Expenses for Family Caregivers Accompanying Veterans to
MTFs
The National Military Family Association supports this proposed
legislation to provide travel expenses for family caregivers
accompanying veterans to MTFs. This proposed legislation recognizes the
important services the caregiver provides in assisting our
servicemembers and veterans by acknowledging the fact that the
caregiver often accompanies the wounded, ill, or injured servicemember
and veteran to their medical appointments at the various MTFs. Often
caregivers find themselves having to pay out of their own pockets for
lodging and other unintended expenses, such as for meals. There are
many benefits being created by DoD, VA, and Members of Congress to help
address many of the issues arising from care of our wounded, ill, and
injured servicemembers and veterans. Our Association appreciates
everyone's commitment to do the right thing; however, we must be aware
that these solutions need to be seamless when addressing these
problems. For example, a benefit created by the DoD to address travel
expenses should be equal to the one offered by the VA. Our military and
veteran families do not understand that there are two different
agencies caring for them. The families, along with the servicemember
and veterans, should only feel as though there is one system of care.
On June 17th the House Armed Service Committee approved the NDAA FY10.
This legislation would provide for travel and transportation assistance
for three designated persons, including non-family members and enable
seriously injured servicemembers to use a non-medical attendant for
help with travel for medical treatment. Our Association recommends
there be coordination of caregiver travel benefits, making it work
seamlessly for our wounded, ill, and injured servicemembers, veterans,
their families, and caregivers.
Provides Continued Health Care for Certain Vietnam-era Veterans
The National Military Family Association supports this proposed
legislation to direct the Secretary of Veterans Affairs to provide,
without expiration, hospital care, medical services, and nursing home
care for certain Vietnam-era veterans exposed to herbicide and veterans
of the Persian Gulf War. This provision recognizes the need for
uninterrupted medical care for veterans who were exposed to herbicides.
This legislation also acknowledges the important service these veterans
provided for our Nation at a time of war.
Provides Support Services for Family Caregivers of Disabled Veterans
The National Military Family Association supports the intent of
this proposed legislation to provide support services for family
caregivers of disabled veterans. However, our Association would like to
make a few comments. First of all, we should not be duplicating
services. Currently, the National Resource Directory established by DoD
and the Department of Labor provides a Web-based service for obtaining,
tracking, and maintaining important support services for the caregiver
and the wounded, ill, and injured servicemember and veteran. This
service is already being provided and this proposal will be a
duplication of service.
We understand the intent to limit the availability for training to
the current wounded, ill, and injured population. However, we would
recommend this program be expanded to capture all caregivers of
veterans regardless of where or when the wound, injury, or illness took
effect.
A caregiver curriculum is currently being developed for family
caregivers of servicemembers and veterans with TBI. This curriculum is
being created by a panel of experts, per guidance in the NDAA FY07
section 744. Our Association recommends this caregiver curriculum be
expanded to cover all types of wounds, illness, and injuries of
servicemembers and veterans.
Conduct a Survey of Family Caregivers
The National Military Family Association supports this proposed
legislation to annually conduct a survey of family caregivers of
disabled veterans. Our Association believes this survey will help the
VA gain a better understanding of this population. This information can
then be used to develop and implement better benefits to assist the
caregivers in performing their duties. However, we recommend the survey
should capture a wider range of information than what is currently
included in this proposal. We suggest the survey start with caregiver
demographics, and include additional items, such as the financial
impact, identify gaps and successes in the support system, and the
disruption to the family unit, especially children. Also, the survey
should capture data on caregivers' experiences with both the VA and DoD
support programs and benefits. We would also encourage the
establishment of a panel of experts to help with the survey's design
and implementation. This panel would consist of, but not be limited to,
members representing: Veteran Service Organizations; Military Service
Organizations; caregivers of our wounded, ill, and injured
servicemembers and veterans; staff from the VA and DoD who work on
caregiver issues; and members from each of the Services' wounded
warrior programs.
The National Military Family Association would like to thank you
again for the opportunity to provide testimony on proposed legislation.
We look forward to working with you to improve the quality of life for
veterans, their families, and caregivers.
Prepared Statement of Christopher Needham,
Senior Legislative Associate, National Legislative Service,
Veterans of Foreign Wars of the United States
MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
On behalf of the 2.2 million men and women of the Veterans of
Foreign Wars of the U.S. and our Auxiliaries, I would like to thank you
for the opportunity to testify at today's legislative hearing. Before
us is a wide range of health care related bills, all of which would
make improvements to the system that benefits America's veterans.
H.R. 1197
This legislation would change the VA health care enrollment status
of veterans who were awarded the Medal of Honor. It would put them in
Category 3, putting them on par with veterans who are former POWs and
those who were awarded the Purple Heart.
There is no doubt about the sacrifice and bravery of the recipients
of the Medal of Honor. They clearly have given everything they could
for this country and for their fellow service men and women. Changing
their enrollment status--which would also exempt them from having to
pay hospital care co-payments--is an acknowledgement of the deep debt
we as a Nation owe them, and it is a small price to pay for these true
heroes.
H.R. 1293
The Disabled Veterans Home Improvement and Structural Alteration
Grant Increase Act would increase the amounts payable under VA's Home
Improvement and Structural Alteration (HISA) program. The VFW strongly
supports this legislation.
HISA was created to provide funding for home adaptations to allow
veterans to receive care at home. These grants help make houses more
accessible through small, but necessary improvements. With the number
of severely disabled servicemembers returning from Iraq and
Afghanistan, it is a program that will continue to grow in importance
and relevance.
Despite this, Congress has not raised the amount of the grants--
$4,100 for service-connected veterans and $1,200 for those without
service connections--since 1992. It is time to change that. The
increases in this bill--to $6,800 and $2,000--reflect an annual 3-
percent increase since the last adjustment and are a step in the right
direction for what we need to do for these severely injured men and
women. This small improvement would make a meaningful impact in the
lives of hundreds of veterans.
H.R. 1302
This legislation would create a full-time Director of Physician
Assistant Services to report to the Under Secretary of Health with
respect to the training, role of, and optimal participation of
Physician Assistants (PA). We are pleased to support it.
Congress created a PA Advisor role when it passed the Veterans
Benefits and Health Care Improvement Act of 2000 (P.L. 106-419). The
law required the appointment of a PA Advisor to work with and advise
the Under Secretary of Health ``on all matters relating to the
utilization and employment of physician assistants in the
Administration.'' Since that time, however, the Veterans Health
Administration (VHA) has not appointed a full-time advisor, instead
appointing a part-time advisor who serves in the role in addition to
his or her regularly scheduled duties while working in the field, far
from where VA makes its decisions.
The current PA Advisor role is likely not what Congress envisioned
when it created the role, and the PA Advisor has had little voice in
the VA planning process; VA has not appointed the PA Advisor to any of
the major health care strategic planning committees.
With the role that PAs play in the VA health care process, it only
makes sense to invite their participation and perspective. VA is the
largest employer of PAs in the country, with approximately 1,600. They
provide health care to around a quarter of all primary care patients,
treating a wide variety of illnesses and disabilities under the
supervision of a VA physician. Since they play such a critical role in
the effective delivery of health care to this Nation's veterans, they
should have a voice in the larger process. We urge passage of this
legislation and the creation of a full-time PA Director position within
the VA Central Office.
H.R. 1335
The VFW strongly supports this legislation, which would exempt
catastrophically disabled veterans from paying certain co-payments. The
VFW has had a longstanding resolution in support of this concept.
Veterans who are deemed catastrophically disabled--typically those
with severe spinal cord injuries--are placed in VA enrollment Category
4. Despite this enhanced enrollment status, they still must pay a co-
payment for hospital and nursing home care. These men and women require
complex, specialized health care. The nature of their injuries requires
frequent, intensive uses of VA services throughout their lifetime as VA
is typically better positioned to provide care to them than other
health care facilities and insurance programs.
Enacting this legislation would reduce the heavy financial burden
these men and women face. Since we already acknowledge their special
circumstances by providing them an enhanced health care enrollment
status, we should exempt them from hospital and nursing home co-
payments as well.
H.R. 1546
The VFW supports this bill, which would create a Committee on Care
of Veterans with Traumatic Brain Injury within VA. This committee would
be a part of the Veterans Health Administration and would be comprised
of VA employees with expertise in TBI. It would evaluate the care,
services, gaps in care, and treatment options for veterans suffering
from TBI, making recommendations to VHA leadership.
With TBI being described as the signature wound of the war, this is
the right thing to do. Emphasizing the treatment and study of TBI--
especially in its milder forms--should be a high priority, especially
because there is much we still do not know about its effects, and these
men and women are likely to be in the VA system for many years. Getting
on top of the problem will better allow VA to manage their care and
improve outcomes.
H.R. 2734
This legislation would provide medical care to family members who
serve as caregivers to disabled veterans. The VFW supports this
measure.
This bill would give the same level of access to care to these
family caregivers as is provided to surviving spouses and children of
disabled servicemembers who die from service-connected conditions. It
would apply only to those who lack private health insurance. Since most
private health insurance is provided through a person's employer, and
being a family caregiver is the family member's full-time job, it
ensures that they have access to the basic care and services they need
to lead healthy lives.
Numerous studies of other caregiver programs have shown that
caregivers often have more severe health problems than others in their
peer group. Providing this level of care is a stressful experience that
affects their mental and physical health, as documented by the 1996
National Caregiver Survey.
Giving them access to care and services helps them deal with these
difficulties, which, in turn, improves the level of care they are
providing to the disabled veteran.
H.R. 2738
The VFW is pleased to support this bill, which would provide a
lodging and subsistence allowance to family caregivers who accompany
disabled veterans to medical facilities.
The disabled veterans eligible for the family caregiver program are
likely to require lifelong care, and many trips to VA. They are
unlikely to be able to travel alone, and will need their caregiver to
accompany them. This is a compassionate change in policy that
recognizes the unique circumstances faced by these veterans and their
caregivers, and we urge its passage.
H.R. 2770
The VFW endorses the Veterans Nonprofit Research and Education
Corporations Enhancement Act. This legislation would make several
changes, which would strengthen and improve the nonprofit research
corporations affiliated with VA. These NPCs help VA to conduct research
and education and assist in the raising of funds for VA's essential
projects from sources VA otherwise might not have access to, including
private and public funding sources.
Included in the legislation is a section that would reaffirm that
these NPCs are 501(c)(3) organizations that are not owned or controlled
by the Federal Government. This is important to ensure that they are
able to receive funding from all intended sources and to clarify their
purpose in accordance with various State laws or private foundation
regulations.
It would also allow for the creation of multi-medical center NPCs
to streamline and make the administration of these important
organizations more efficient. Ultimately, this should make more funds
available for critical research purposes. Additionally, it would
improve the accountability and oversight of these corporations,
requiring more information in their annual reports and periodic audits
of their activities. As these corporations continue to expand, we urge
continued oversight of their actions to ensure that they continue to
serve the best interest of America's veterans.
The legislation would address some of the concerns laid out in the
recent VAOIG report, ``Audit of Veterans Health Administration's
Oversight Nonprofit Research and Education Corporations.''
Draft Bill, Family Caregivers Support
The VFW is pleased to support the draft bill on family caregivers.
Section 1 of the bill would expand support services for family
caregivers by providing Internet-based training on caregiver
techniques, strategies and skills. It would also require the Secretary
to give access to information from public, private and nonprofit
agencies that offer support for caregivers, as well as requiring VA to
perform more outreach so that families are aware of the range of
services available to them.
These resources would be of great use to the loved ones of disabled
servicemembers, and they would provide them with information,
resources, and personal connections with others dealing with the
challenges of being a caregivers.
Section 2 would expand the counseling and mental health services VA
already provides to immediate family members to any family member who
provides caregiver services, to include step- and extended-family
members. This is clearly the right thing to do.
Section 3 would require VA to provide respite care to assist family
caregivers. This would help to alleviate the burden on family
caregivers, giving them a much-deserved break when they need it. It
also would serve as another incentive for a loved one to provide these
necessary services to their disabled veteran family member, since they
know they could receive the occasional break.
Draft Bill, Family Caregivers Survey
VFW supports the draft bill that would require the VA Secretary to
conduct an annual survey of family caregivers. The information from the
survey could be useful to help shape the critical program, allowing VA
and Congress to make adjustments to better meet the demands of
critically wounded servicemembers and their families.
Draft Bill, Health Care for Gulf War and Herbicide Exposures
The VFW supports the draft bill that would indefinitely offer
hospital care, medical services and nursing home care to certain
Vietnam-era veterans exposed to herbicides and veterans of the Persian
Gulf War.
Both groups have unique health needs that often manifest over a
lifetime. And there is still much we do not know about the condition of
these men and women. By eliminating the sunset dates for their
eligibility for care, we can ensure that these former servicemembers
will continue to have access to the health care and services they need
because of the exposures and illnesses they may have encountered during
their service to this country.
Mr. Chairman, this concludes my testimony. I would be happy to
answer any questions that you or the Members of this Subcommittee may
have.
Prepared Statement of Bernard Edelman,
Deputy Director for Policy and Government Affairs,
Vietnam Veterans of America
Good morning, Chairman Michaud, Ranking Member Miller, and other
Members of this distinguished Subcommittee. We appreciate your giving
Vietnam Veterans of America (VVA) the opportunity to testify today on
legislation that relates to improving the health care of veterans and
issues involving their caregivers. And on behalf of the members and
families of VVA, we thank you for the stellar work this Subcommittee
has been doing.
We would like first to comment on H.R. 1197, the ``Medal of Honor
Health Care Equity Act of 2009.'' VVA supports enactment of this bill
unequivocally. We would like to offer a bit of commentary as to why.
Americans are hungry for heroes. We confer this status on people
who lead their sports teams to championships to the adoration of their
fans: guys who can throw for 50 touchdowns or run for 2,000 yards in a
season; guys who can rocket baseballs into the stands 50 times a
season; guys who score 30 points a game; guys who drive race cars
really fast. We tend, too, to overuse this term when we honor men and
women in uniform.
In reality, all who serve are not heroes. Yes, they don the uniform
and, during times of war or conflict, put themselves in harm's way.
Some are killed. Others are wounded, some grievously. Mostly, though,
they are men and women doing the jobs for which they've been trained
(and oftentimes doing jobs for which they haven't been trained).
While this gesture--dubbing them heroes--may be understandable, and
even commendable, it in some ways diminishes what a hero really is: one
who puts his (and as more women serve in the military, her) life in
danger, and sometimes loses it, attempting to protect or save the lives
of his comrades.
We have heroes--true heroes--who have met this standard. Their
heroism, their selfless acts of valor and bravery in the chaos of
combat, has been acknowledged with the awarding of the Medal of Honor.
Others who have committed heroic acts have been honored with the Silver
Star, the Navy Cross, the Distinguished Service Cross.
These heroes are deserving of our enduring appreciation and honor.
This is what, in one small way, H.R. 1197 seeks to do. To accord all of
these men, and women, who obtain their health care from VA facilities
higher priority status is warranted. We are willing to bet, however,
that most will not take advantage of this. Humble as most tend to be,
they will not flaunt a medal to ``get to the head of the line.'' They
will stand in line, with the rest of their comrades, awaiting their
turn.
H.R. 2770, the ``Veterans Nonprofit Research and Education
Corporations Enhancement Act of 2009.'' This bill, introduced by
Chairman Filner and Ranking Member Buyer in what we wish was a
permanent display of bipartisanship, seeks to modify and update
provisions of law relating to nonprofit research and education
corporations by facilitating the conduct of research, education or both
at more than one VA medical center. If enacted, this bill should help
facilitate research projects, the fruits of which can help not only
veterans and their families but so many others as well.
VVA supports passage of H.R. 2770.
H.R. 1293, introduced by Mr. Buyer and designated the ``Disabled
Veterans Home Improvement and Structural Alteration Grant Increase Act
of 2009,'' in effect acknowledges the realities of inflation by
increasing the amount available to disabled veterans for improvements
and structural alterations furnished as part of home health services.
VVA supports the enactment of H.R. 1293.
As physician assistants have come to play increasingly important
roles in the Veterans Health Administration, it seems to us a logical
if somewhat belated effort with H.R. 1302 to establish the position of
Director of Physician Assistant Services under the Under Secretary of
Veterans Affairs for Health. As stipulated in this bill, the Director,
who would be a qualified physician assistant, ``shall be responsible to
and report directly to the Under Secretary for Health on all matters
relating to the education and training, employment, appropriate
utilization, and optimal participation of physician assistants within
the programs and initiatives of the Administration.'' The last three
persons to occupy the position of Under Secretary of Health have
refused to accord Physician Assistants, most of whom are veterans,
equal prestige and respect with Nurse Practitioners (most of whom are
not veterans). The reasons are puzzling, and to say the aforementioned
individuals and their functionaries have been less than honest in
discussing this issue with Congress, veterans' service organizations,
and organized labor would be an understatement.
Whomever President Obama ultimately selects as the next Under
Secretary of Health must be an individual who will be open,
transparent, respectful of the clear will of the Congress (as in the
case of the status of Physician Assistants within the Veterans Health
Administration), and above all truthful and honest. It is frankly
shameful that this bill needs to be enacted to get the VHA to act
decently, honestly, and as common sense would dictate, but this is the
case.
VVA applauds Congressman Hare for having introduced this
legislation, thanks him for his leadership on this and so many other
issues, and supports its enactment without reservation.
It is a stark reality that as the military is able to save more and
more troops who have received catastrophic wounds or injuries on the
battlefield, more and more veterans will survive who are
catastrophically disabled. H.R. 1335, introduced by Mrs. Halvorson,
would prohibit the Secretary of Veterans Affairs from collecting
certain co-payments and other fees for hospital or nursing home care
from these veterans.
This bill is right-minded and forward-thinking. As such, VVA
endorses for enactment H.R. 1335.
While we are not thrilled about creating yet another committee to
focus on yet another facet of combat injury, H.R. 1546, the ``Caring
for Veterans with Traumatic Brain Injury Act of 2009,'' would meet a
growing and highly visible need if enacted. As TBI has become the
``signature wound'' of the fighting in Iraq and increasingly in
Afghanistan, it has garnered a great deal of attention in the media as
well as in the medical and veterans' communities. Millions of dollars
have been appropriated to learn more about it. Is this money being
spent wisely and well? Which treatment modalities are working? Which
aren't? What ought to be the role of community-based organizations in
caring for veterans with such wounds?
Establishment of a Committee on Care of Veterans with TBI does make
sense and we commend Congressmen McNerney and Boozman for introducing
it. However, such a committee should be comprised not only of VA
employees ``with expertise in the care of veterans with'' TBI. It
should integrate outside experts with perhaps differing expertise who
might offer other and perhaps better ideas, along with representatives
of veteran consumers and their families, who should be appointed by the
Secretary of Veterans Affairs. Further, VVA recommends that we ensure
that the operations of this committee are transparent, and that all
deliberations and notes of this committee be open for public scrutiny.
As a general comment, the secrecy of the last 8 years, and the
unwarranted arrogance that has taken hold in the culture of the VA,
particularly within the VHA, needs to be reversed and transparency,
full public disclosure, consultation with veterans and veterans'
advocacy groups, and meaningful measures of accountability must be
written into all areas. Frankly, it will take the Congress working
closely in a bi-partisan manner with the new leadership team to undo
the considerable damage that has been done, and to begin to resurrect
significant gains and progress that could have been achieved in so many
areas.
With these caveats, VVA endorses H.R. 1546.
H.R. 2734, the ``Health Care for Family Caregivers Act of 2009,''
would provide medical care to family members of disabled veterans who
serve as caregivers to such veterans. As noted above, more and more
troops who survive catastrophic wounds face life with extraordinary
needs for medical services and home care. Home care is provided by a
parent, or a spouse, in some cases a child, in others some other family
relation, significant other, or other companion. To make life easier
for these individuals, Mr. Perriello's bill would inure such caregivers
from ``deductibles, premiums, co-payments, cost sharing, or other fees
for medical care provided to such caregiver.''
Even though a family member will take on the burden of caring for
these veterans out of love and familial obligation, H.R. 2734 would
provide a small measure of assistance to them. As such, VVA endorses
this bill.
H.R. 2738, introduced by Congressman Teague, would also assist
family caregivers accompanying veterans to medical treatment
facilities, in this case by paying for ``lodging and subsistence'' as
well as ``expenses of travel'' to and from such facilities.
As this seems eminently fair, VVA supports enactment of this bill.
Two of the three Draft Bills relate to family caregivers. The bill
that would direct the Secretary of Veterans Affairs to conduct annual
surveys of such caregivers makes eminently good sense. If properly
conducted with well-thought-out questionnaires, it can help provide the
VA with information that will better help caregivers assist the
veterans for whom they are caring.
The bill that would ``provide support services for family
caregivers'' contains some important and viable clauses. One
potentially valuable clause is (b)(2), which would provide caregivers
with an Internet-based service containing ``a directory of services
available at the county level; message boards and other tools that
provide family caregivers with the ability to interact with each other
and disabled veterans for the purpose of fostering peer support and
creating support networks; and comprehensive information explaining
health-related topics and issues relevant to the needs of disabled
veterans and family caregivers.''
We do not, however, agree that to accomplish this, the VA must
``contract with a private entity.'' This ought to be done in-house, by
folks with the necessary expertise and technical savvy. To do so will
eliminate an unnecessary layer of bureaucracy, and a potentially costly
one at that.
Similarly, in the ``Information and Outreach'' clause, which would
direct the Secretary to mount what is in effect a multi-faceted media
campaign, ought to be done in-house. However, we would advocate that
such a campaign be coordinated with other VA health care outreach
efforts. In this realm, we have advocated a major effort by the VA to
use various media and methods to communicate with veterans and their
families about health conditions that may have derived from their
service while in the military and the care and other benefits to which
veterans are entitled to by virtue of their service. In the past, the
VA's attempts at outreach have been, to be generous, an embarrassment.
The VA needs budget lines for its outreach activities, which must go a
lot further than booklets and brochures in kiosks in VA health care
facilities, and in-house media productions that are rarely, if ever,
actually viewed by patients at these facilities.
We also would encourage this Subcommittee to meld the bills
relating to family caregivers into a single ``Disabled Veterans Family
Caregivers Support Act of 2009.''
It is our understanding that the Draft Bill that would direct the
VA Secretary ``to provide, without expiration, hospital care, medical
services, and nursing home care for certain Vietnam-era veterans
exposed to herbicide and veterans of the Persian Gulf War'' would
codify in statute what the VA already is doing. The bill would
basically grant permanent authorization for the VA to provide this care
for herbicide-exposed Vietnam-era veterans and Gulf War-era veterans
who have insufficient medical evidence to establish a service-connected
disability by placing them in Priority Group 6.
VVA will support this legislation.
Mr. Chairman, we again thank you for the opportunity to present our
thoughts before this Subcommittee, and we welcome the opportunity to
respond to any questions you might have.
Prepared Statement of Wounded Warrior Project
Chairman Michaud, Ranking Member Brown and Members of the
Subcommittee:
Thank you for inviting the Wounded Warrior Project (WWP) to provide
views regarding proposals before the Subcommittee today, and for
including measures of concern to family caregivers, WWP's highest
legislative priority. In candor, we are disappointed that H.R. 2342,
the Wounded Warrior Project Family Caregiver Act, is not among the
measures under consideration today, as it provides comprehensively for
the needs of family caregivers. In our view, the Subcommittee's hearing
of June 4th underscored the importance of family caregiving to the
well-being and rehabilitation of wounded warriors, and the compelling
need for comprehensive caregiver assistance, as provided for in H.R.
2342.
The Department of Veterans Affairs' Veterans Health Administration
can have no higher obligation than providing for the treatment,
rehabilitation, and long-term care needs of veterans who have been
severely injured in war, including providing these warriors' the
fullest opportunity for meaningful, productive lives in the community.
The experience of this war, however, has been unique in exposing gaps
in the services VA provides. Among the most profound of those gaps is
the absence of a comprehensive VA program to ensure that family members
who have given up jobs, lost health insurance, and otherwise sacrificed
to care for wounded warriors at home have the supports needed to
sustain that lonely vigil.
Needs of Family Caregivers of Wounded Warriors
Each warrior's situation and each family's experience is unique.
But all face the very real danger that without solid supports
caregiving will become unsustainable--whether due to utter exhaustion,
severe interpersonal strain, incapacitating illness, personal
bankruptcy, or nervous breakdown. And when family caregiving cannot be
sustained, there may be no other alternative for the veteran than
institutional care. Such an outcome would not only be tragic for
wounded warriors and their families, but could become enormously costly
to the VA health care system which will likely be called upon to care
for them.
More Comprehensive Support through Medicaid than VA
Congress provides for generous programs of support for low-income
caregivers through Medicaid, notably through what is generally known as
its Cash and Counseling program. (See Public Law 109-171, section
6087.) Surely the Department of Veterans Affairs should provide no less
for family caregivers of severely wounded warriors. These families need
comprehensive supports, and should not have to impoverish themselves to
become eligible for a caregiver program.
We did note VA's June 4th testimony before this Subcommittee that
it has begun to purchase home care services for family caregivers
through a partnership with the Administration on Aging (AoA). While a
positive step in that this may be a helpful option for some families,
the initiative is being mounted in only a limited number of States.
Moreover, it offers no assurance that those in greatest need would even
be accepted into the ``program,'' given that the VA/AoA program
standards explicitly state that ``Aging Network Agencies can refuse to
accept veteran participants and their family caregivers when it is
anticipated that the services required would exceed the scope of the
Agency's ability to meet the veteran's needs.'' In short, despite this
initiative, VA has no comprehensive solution to offer wounded warriors'
family caregivers.
That program gap is critical given that certain fundamental needs
must be met to sustain family caregiving. These include basic support
services:
an ongoing source of assistance to meet routine,
specialized, and emergency needs;
access to needed mental health services;
provision for age- and medically-appropriate respite
care;
provision of needed medical care; and
some modest level of economic support.
WWP strongly supports H.R. 2342, the Wounded Warrior Project Family
Caregiver Act, because it would meet those needs.
Proposed Legislation
We appreciate that several of the proposals under consideration
today address aspects of caregiving. However, none of those measures,
individually or collectively, provide the level of support required to
sustain caregiving for veterans with the kinds of needs identified in
H.R. 2342.
Family caregivers from around the country, taking a few precious
days away from their caregiving roles, will share their experiences
with legislators next month as they come to the Nation's Capital to
attend a WWP-sponsored caregiver summit. Most have been caring for
wounded warriors for years, and would not need the training and
informational services provided for in the discussion draft bill before
the Subcommittee. Caregivers already have access to informational
services addressed in the draft bill, but what they need are
comprehensive support services that are rarely available in the
community, and not provided for through VA. Most caregivers would get
little benefit from other provisions of the draft bill, which (in
amending relatively limited provisions of law) fall short of providing
the extent of respite or mental-health support many families need.
Moreover, the measure would not provide the comprehensive supports so
critical to sustaining caregiving. In short, while we appreciate the
effort to help family caregivers, this well-intentioned proposal is not
a solution.
VA is certainly remiss in not having systematically compiled
information on the needs of veterans' caregivers and on the services
they provide. But while we see no objection to the draft bill that
proposes an annual survey on family caregiving, we believe enough is
known about the burdens wounded warriors' caregivers are shouldering--
often full time and with only the most limited respite--that Congress
can and must move beyond piecemeal measures immediately.
To illustrate, we appreciate the recognition in H.R. 2734 that
family caregivers are at increased health risk, and that health
coverage under the CHAMPVA program is an important, needed support. But
health coverage, important as it is, is but one of the core needs
experienced by caregivers of severely wounded veterans. Moreover, the
bill does not fully answer that need as it would limit this benefit to
family caregivers of veterans who receive compensation under
subsections (r) or (s) of section 1114 of title 38, U.S. Code. Yet many
OIF/OEF veterans with profound service-incurred wounds who require
full-time personal care receive, or would be entitled to, special
monthly compensation, but not under those particular provisions of
section 1114.
There can be no question that severely wounded veterans continue to
depend on loved ones for round-the-clock care. While the numbers of
those veterans is not large, their needs are great--as is the debt we
owe them. That debt is not discharged simply because the veteran has
left a hospital and returned to the community and home. We must support
their rehabilitation and long-term care needs. Surely we best serve
those veterans--and honor their service--by enabling their families to
care for them at home.
We call on the Committee to fill this critical gap by taking up and
moving H.R. 2342 at the earliest possible date.
Finally, we welcome the opportunity to supplement this statement in
the days ahead with additional views on other measures under
consideration today.
POST-HEARING QUESTIONS FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
June 22, 2009
Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, D.C. 20420
Dear Secretary Shinseki:
Thank you for the testimony prepared by Dr. Robert A. Petzel,
Acting Principal Deputy Under Secretary for Health, at the U.S. House
of Representatives Committee on Veterans' Affairs Subcommittee on
Health Legislative Hearing that took place on June 18, 2009.
Please provide answers to the following questions by August 3,
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on
Health.
1. Dr. Petzel's testimony noted that the cost of H.R. 1197 is
insignificant. Does this mean that the cost is estimated to be below
$500,000? How many living Medal of Honor recipients are there?
2. H.R. 1302 would establish a full-time Director of Physician
Assistant Services, who reports directly to the Under Secretary for
Health. Which positions currently report directly to the Under
Secretary for Health? In other words, is there a comparable, full-time
Central Office position for other health professions? Please provide
the Committee with a visual organizational chart outlining the
positions that report directly to the Under Secretary for Health.
3. What efforts are being made to recruit and retain physician
assistants, presently and in the foreseeable future?
4. If H.R. 1335 eliminated all co-payments for nursing home care,
pharmacy, and outpatient care, would VA continue to support this
proposal?
5. How many veterans were enrolled in Priority Group 4 in 2008? Of
this total, how many were veterans who are catastrophically disabled
from nonservice-connected causes and have income levels that would have
placed them in Priority Group 7 or Priority Group 8?
6. I have several questions on VA's position on H.R. 2734.
a. You note that defining this group as veterans who receive
special monthly compensation for aid and attendance or homebound care
may include veterans who do not need caregiver support. Please explain.
Doesn't aid attendant and homebound care only include veterans who are
the most severely disabled and cannot function on their own?
b. Is there a way of targeting the intended beneficiaries of
this bill by linking it to the existing disability evaluation system in
VBA so that VHA does not have to set up a new system for evaluating the
eligibility criteria for this benefit?
c. How many individuals would newly qualify under the provisions
in H.R. 2734?
d. What is your response to VSO recommendations that the
eligible veteran be redefined to capture more individuals?
7. H.R. 2738 authorizes lodging and subsistence payments to family
caregivers of veterans. Under current law, what services are available
under the VA's beneficiary travel authority? Who is eligible for these
services under current law?
8. VA has conducted several demonstration projects to provide
supportive services to family caregivers. Please provide the Committee
with a brief summary and copies of the detailed reports on what VA
found from these projects.
9. Providing some type of relief and services to the caregiver is
an issue that every organization on the VSO panel supports. However,
how to provide this relief and what the benefits should look like has
been an ongoing discussion for years. Congressional hearings have been
held on this issue. Despite this intense focus, VA did not provide
views on two pieces of caregiver legislation, with the stated rationale
that VA is currently undertaking a comprehensive review of existing
benefits to determine potential gaps.
a. Besides the demonstration projects underway, what else is VA
doing?
b. How is the comprehensive review structured and who is
responsible for the final recommendations of this review? When will the
review be completed?
c. For the two pieces of caregiver legislation that VA did not
comment on, why was VA unable to submit views? The Subcommittee would
like VA's views and cost estimates on these two pieces of legislation.
10. VA established the Caregiver Advisory Board in June 2008 to
develop caregiver assistance programs that address issues facing
caregivers of veterans. Please provide an update on the activities of
the Advisory Board, including a summary of the caregiver needs the
Board identified and any initial recommendations to expand support
services for caregivers. In addition, please share all internal reports
and memorandums authorized by this Advisory Board.
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by August 3, 2009.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Questions for the Record
The Honorable Michael H. Michaud, Chairman
Subcommittee on Health, House Committee on Veterans' Affairs
June 18, 2009
Legislative Hearing
Question 1: Dr. Petzel's testimony noted that the cost of H.R. 1197
is insignificant. Does this mean that the cost is estimated to be below
$500,000? How many living Medal of Honor recipients are there?
Response: The Department of Veterans Affairs (VA) estimates that
the fiscal 2010 cost to provide care to the 17 living Medal of Honor
recipients currently not already enrolled in or eligible for enrollment
in a higher VA health care priority group would be $216,520 if all were
placed in Priority Group 1. According to the official Congressional
Medal of Honor Society Web site (www.cmohs.org), there were 96 living
Medal of Honor recipients as of July 2, 2009.
Question 2: H.R. 1302 would establish a full-time Director of
Physician Assistant Services, who reports directly to the Under
Secretary for Health. Which positions currently report directly to the
Under Secretary for Health? In other words, is there a comparable,
full-time Central Office position for other health professions? Please
provide the Committee with a visual organizational chart outlining the
positions that report directly to the Under Secretary for Health.
Response: Currently, the Associate Deputy Under Secretary for
Health for Quality and Safety, the Chief of Staff, the Principal Deputy
Under Secretary for Health, the Medical Inspector, and the Chief
Officer for Research Oversight report directly to the Under Secretary
for Health. The most comparable position to that proposed is the Chief
Nursing Officer. Section 7306, of title 38, provides that the Director
of Nursing Service shall report directly to the Under Secretary for
Health. The Veterans Health Administration's (VHA) Chief Nursing
Officer reports to the Under Secretary through the Principal Deputy
Under Secretary for Health. Other clinical care providers, such as
optometry and podiatry, report to the Chief Officer for Patient Care
Services, who reports to the Principal Deputy Under Secretary for
Health. VHA has attached an organizational chart of chief officers,
current as of June 25, 2009.
VA would like to note an error in the Department's June 18, 2009,
testimony on H.R. 1302. The testimony indicated that all clinical
leadership positions are aligned within the Office of Patient Care
Services. As illustrated by the attached VHA organizational chart, the
Chief Nursing Officer reports to the Principal Deputy Under Secretary
for Health, not Patient Care Services. However, VA remains opposed to
the proposed realignment of the Director of Physician Assistant
Services as the position's current placement within Patient Care
Services provides the necessary access to the Under Secretary for
Health.
Question 3: What efforts are being made to recruit and retain
physician assistants presently and in the foreseeable future?
Response: VA continues significant efforts to recruit and retain
physician assistants to meet patient care workload demands. Physician
assistant recruitment efforts are coordinated by the VA Health Care
Recruitment and Retention Office. VA recruitment exhibits at major,
national physician assistant events have proved to be a very effective
recruitment tool. The Education Debt Reduction Program which assists VA
employees in repayment of student loans and the Employee Incentive
Scholarship Program, providing tuition assistance to VA employees who
wish to obtain advanced degrees are available to physician assistants
in difficult to recruit areas. VA facilities also have the option of
requesting special pay rates for physician assistants to offset any
labor market salary discrepancies. VA continues to explore other
recruitment and retention initiatives to ensure sufficient numbers of
physician assistants are available to meet VHA's patient care needs.
Question 4: If H.R. 1335 eliminated all co-payments for nursing
home care, pharmacy, and outpatient care, would VA continue to support
this proposal?
Response: VA has no objection to eliminating all co-payments for
those veterans determined to be catastrophically disabled. VA estimates
that it would incur lost collections amounting to $7.8 million in
fiscal year (FY) 2010, $7.9 million in FY 2011, $40.5 million over 5
years, and $85.2 million over 10 years.
Question 5: How many veterans were enrolled in Priority Group 4 in
2008? Of this total, how many were veterans who are catastrophically
disabled from nonservice-connected causes and have income levels that
would have placed them in Priority Group 7 or Priority Group 8?
Response: In FY 2008, 237,208 veterans were enrolled in Priority
Group 4. The number of veterans placed in Priority Group 4 based on a
catastrophic determination that would have otherwise been placed in a
Priority Group 7 or 8 based on income is 7,978.
Question 6(a): I have several questions on VA's position on H.R.
2734. You note that defining this group of veterans who receive special
monthly compensation for aid and attendance or homebound care may
include veterans who do not need caregiver support. Please explain.
Doesn't aid and attendance and homebound care only include veterans who
are the most severely disabled and cannot function on their own?
Response: The statutes regulating entitlement to additional
compensation based on the need for aid and attendance or housebound
care are found in subsections (r) and (s) of section 1114 of title 38,
United States Code. While it is true that subsections (r) and (s) apply
to veterans with severe injuries or illnesses, VA believes that the
population of veterans who qualifies for one or both of these benefits
is not synonymous with the population of veterans that is the focus of
H.R. 2734 and other pending caregiver legislation.
The language in subsection (r) concerning aid and attendance
benefits supports this view. Clause (r)(1) states that veterans
eligible for regular aid and attendance shall be paid a monthly aid and
attendance allowance. Clause (r)(2) goes farther and asserts that ``if
the veteran, in addition to such need for regular aid and attendance,
is in need of a higher level of care, such veteran shall be paid
monthly aid and attendance [at a much higher rate].'' Subsection (r)
then states that ``for the purposes of clause (2) of this subsection,
need for a higher level of care shall be considered to be need for
personal health care services provided on a daily basis in the
veteran's home. . . .'' Therefore, it is VA's position that a veteran
who qualifies for benefits under clause (1) would not be eligible for
caregiver benefits, whereas a veteran who qualifies for the higher
level benefits under clause (2) most likely would be eligible for
caregiver benefits.
Subsection (s) relates to eligibility for additional compensation
based on a veteran's status as housebound. For the purposes of this
subsection, the requirement of ``permanently housebound'' is considered
to have been met when the veteran is substantially confined to such
veteran's house . . . due to a service-connected disability or
disabilities which it is reasonably certain will remain throughout such
veteran's lifetime.'' It is VA's view that many veterans who would
qualify for caregiver benefits would not qualify for housebound
benefits: for example, veterans who have severe mental disabilities
resulting from post-traumatic stress disorder (PTSD) or Traumatic Brain
Injury (TBI). Indeed, in many cases, the need for a caregiver might be
justified precisely because such caregiver would allow the veteran a
level of support that would prevent the veteran from having to be
housebound.
These examples demonstrate that H.R. 2734 and other caregiver
legislation should not define an eligible veteran as being one who
would qualify for either aid and attendance benefits or housebound
benefits. In the case of subsection (r), eligibility would include
veterans who should not qualify for a caregiver while restriction to
subsection (s) qualifications would exclude many veterans who should be
entitled to a caregiver.
Question 6(b): Is there a way of targeting the intended
beneficiaries of this bill by linking it to the existing disability
evaluation system in VBA so that VHA does not have to set up a new
system for evaluating the eligibility criteria for this benefit?
Response: VA believes eligibility criteria for the special monthly
compensation administered by the Veterans Benefits Administration (VBA)
are appropriate for financial support decisions but are inappropriate
for clinical decisionmaking. VA would not need to develop new
eligibility criteria if factors such as activities of daily living or
instrumental activities of daily living were used to determine
caregiver benefits. VA already uses these clinical factors to determine
eligibility for home maker and home health aide services and other
benefits through the Geriatrics and Extended Care program, and
consequently would not need to set up a new system for evaluation.
Moreover, VA could define severely injured veterans as those in need of
a higher level of care, due to injury or illness suffered in the line
of duty, and in the absence of such care, would require
hospitalization, nursing home level care, or other residential,
institutional care. This population would include fewer than 2,500
veterans of all combat eras. The definition suggested above is very
similar to those receiving special monthly compensation at the R2 level
under section 1114 of title 38, U.S.C.
Question 6(c): How many individuals would newly qualify under the
provisions in H.R. 2734?
Response: VA estimates that if the legislation is passed as
written, 47,049 additional beneficiaries would receive Civilian Health
and Medical Program of VA (CHAMPVA) benefits in FY 2010, increasing to
60,009 by FY 2019.
Question 6(d): What is your response to VSO recommendations that
the eligible veteran be redefined to capture more individuals?
Response: VA is sensitive to the growing need of veterans for
caregivers as the population of enrolled veterans continues to age. We
also understand that, as the population of enrolled veterans increases,
the costs of caregiver benefits will continue to grow. VA believes
resources appropriated by Congress for the medical care of America's
veterans must be used efficiently and effectively to care for those
with the greatest need. Therefore, we believe that caregiver benefits
should primarily be provided to caregivers of veterans with certain
service-connected disabilities.
Question 7: H.R. 2738 authorizes lodging and subsistence payments
to family caregivers of veterans. Under current law, what services are
available under VA's beneficiary travel authority? Who is eligible for
these services under current law?
Response: Current VA beneficiary travel regulations at 38 CFR Part
70 authorize VA to pay for certain travel costs of an attendant when VA
medically determined that an attendant is required to assist the
veteran during travel. Benefits include the actual cost of travel
(unless traveling with the veteran in a shared personal vehicle), and
lodging and per diem at 50 percent of the area Federal employee rate
during the actual period of travel. Should a veteran be admitted to a
VA facility for care following travel and VA determines the veteran no
longer needs a non-VA attendant, per diem and incidental costs have
usually been at the caregiver's or attendant's expense.
Question 8: VA has conducted several demonstration projects to
provide supportive services to family caregivers. Please provide the
Committee with a brief summary and copies of the detailed reports on
what VA found from these projects.
Response: Section 214 of Public Law 109-461 authorized VA to
allocate $5,000,000 for FY 2007 and 2008 to carry out a pilot program
on improvement of caregiver assistive services. VA conducted a robust
review of 52 applications based on a request for proposals and selected
8 caregiver assistance pilot programs. These pilots represented
projects from across the country (including rural areas), different
patient populations, different clinical needs and different approaches.
VA designed these pilots to assess the feasibility and advisability of
various mechanisms to expand and improve caregiver assistance services.
The caregiver assistance pilot programs were launched in October 2007
and will end in September 2009. A 1-year extension of the legislative
authority was approved through Public Law 110-329 Appropriations Act of
2009. VA will submit its final report to Congress in the first quarter
of FY 2010 and may replicate or expand successful initiatives in other
locations. A brief description of each program follows:
1. Resources for enhancing Alzheimer's caregiver health (REACH)
VA. The coordinating site is Memphis, Tennessee.
Eligibility for participation and description of services
provided: Caregivers of veterans diagnosed with dementia enrolled in
home-based primary care. REACH VA is currently piloted in 24 home-based
primary care programs across the country in 15 States. This program
provides an intervention translated from a similar, evidence-based
National Institutes of Health initiative that provides education,
support and skills building to help caregivers manage both patient
behaviors and their own stress. In October 2008, REACH VA won the
Rosalynn Carter Institute Leadership in Caregiving Award.
2. Transition assistance program. The coordinating site is
Gainesville, Florida, while actual pilots are underway at the Stroke
Centers of Excellence in Houston, Texas, and San Juan, Puerto Rico.
Eligibility for participation and description of services
provided: Caregivers of veterans with stroke-related disabilities.
Caregivers are taking part in a transition assistance program, which
provides skills training, education and supportive problem solving
using videophone technology for new stroke patients or patients with
stroke-related disabilities and their caregivers.
3. Use of caregiver advocates to develop, expand and coordinate
services for veterans' caregivers. The pilots are underway in
Cincinnati and Dayton, Ohio.
Eligibility for participation and description of services
provided: Caregivers of frail impaired veterans at highest risk for
institutionalization, including veterans with multiple chronic
conditions such as chronic obstructive pulmonary disease, congestive
heart failure, hypertension, diabetes mellitus and dementias. Veterans
Integrated Service Network (VISN) 10 has established a 24/7 hotline
titled, Caregiver Advocates. Caregiver advocates assist caregivers in
identifying, accessing and coordinating between VA and existing
community providers in home-based primary care programs and augmented
caregiver support services and providing therapeutic interventions to
the caregiver. This pilot also provides additional hours for adult day
health care, in-home respite and inpatient respite care.
4. VA California Office on Caregiving. VISNs 21 and 22.
Eligibility for participation and description of services
provided: Caregivers of veterans with Traumatic Brain Injury (TBI),
post-traumatic stress disorder (PTSD), or dementia. VA is working with
a community coalition to provide interventions that support caregivers
for veterans with TBI, PTSD or dementia across the State of California
using telehealth, Web, telephone and video tele-conferencing.
Interventions are provided by VA and the State of California caregiver
resource centers, the caregiver training program (Powerful Tools), and
Stanford University's Internet-based caregiver self management program.
5. Communicating Effectively with Health Care Professionals.
Albany, New York.
Eligibility for participation and description of services
provided: Caregivers of veterans having a chronic disease and who have
received care in a VA facility within a period of 12 months prior to
the start of the study. This pilot program converted a 3-hour workshop
developed by the National Family Caregivers Association, Communicating
Effectively with Health Care Professionals, into a DVD and manual.
Face-to-face workshops have been implemented to offer an additional
delivery method. If this program proves effective, VA may be able to
add this content to the My HealtheVet Web site to promote further
distribution.
6. Telehealth Technology to Support Family Caregivers. Atlanta,
Georgia.
Eligibility for participation and description of services
provided: Caregivers to veterans 60 years old or older who have at
least one chronic illness requiring daily activity of daily living or
instrumental activity of daily living assistance. Caregivers must live
with the veteran. This pilot uses a model telehealth program adapting
Health Buddy devices, which are existing technologies used by VA, to
provide help and emotional support for caregivers who live in remote
areas or cannot leave the veteran by him or herself.
7. Joint program between the Tampa and Miami medical centers to
provide support to caregivers of high-risk veterans.
Eligibility for participation and description of services
provided: Tampa's existing respite program is being expanded to provide
24-hour in-home respite care for temporary relief to caregivers (up to
14 days per calendar year) and emergency respite in local assisted
living or medical foster care facilities. The Miami program provides
and coordinates comprehensive community-based care services including
respite, home companions, adult day care, and use of an emergency
response system for high risk veterans.
8. Heroes of the heart. VA Pacific Islands Health Care System.
Eligibility for participation and description of services
provided: Caregivers of veterans who meet the criteria for respite and
live on the more rural, less populated islands of Hawaii, Kauai and
Maui in the State of Hawaii. The medical foster home concept is used to
provide overnight respite for veterans in areas where no other
inpatient respite options are available, particularly in remote and
rural service areas. Currently, overnight respite care can only be
provided at the VA Pacific Islands Health Care System Center for Aging
in Honolulu or in contract nursing homes located on Oahu.
Question 9(a): Providing some type of relief and services to the
caregiver is an issue that every organization on the VSO panel
supports. However, how to provide this relief and what the benefits
should look like has been an ongoing discussion for years.
Congressional hearings have been held on this issue. Despite this
intense focus, VA did not provide views on two pieces of caregiver
legislation, with the stated rationale that VA is currently undertaking
a comprehensive review of existing benefits to determine potential
gaps. Besides the demonstration projects underway, what else is VA
doing?
Response: VA is committed to providing clinically appropriate home
health care services as an integral component of medical care services.
VA provides in-home services to enhance or build a comprehensive array
of resources necessary to address the short-term or long-term care
needs of enrolled veterans. All enrolled veterans are eligible for a
comprehensive array of medically necessary in-home services as
identified in VA's medical benefits package (see title 38 CFR
17.38(a)(1)(ix)). These in-home services support the caregiver in
meeting the needs of the veteran whose desire is to remain in his or
her own home setting. Below is a description of the Veterans Health
Administration (VHA) and VBA programs that support caregivers.
----------------------------------------------------------------------------------------------------------------
Eligibility for Description of Services
Name of Program Participation Provided Provision of Services
----------------------------------------------------------------------------------------------------------------
Respite Care Enrolled Of limited duration Provided in CLCs
veteran Inpatient (CLC,and adult day health care
Chronic acute or community facility) Contract:
condition Home respite nursing homes, home
Caregiver Adult day health health agencies, adult
who needs respite care day health care
----------------------------------------------------------------------------------------------------------------
Volunteer Enrolled Volunteer program Volunteer base,
veteran with
Home Res- providing full-time training materials
pite Care caregivers break to provided by Senior
perform required duties Companion Program and
outside home or for needed American Red Cross.
break Program is operational in
Recently expanded 8 sites, with over 60
to include buddy program service organizations
matching volunteers with briefed on the program to
veterans. Provides sup- generate potential
portsystemandadditional volunteers
services outside home
----------------------------------------------------------------------------------------------------------------
Home Based Enrolled Education and Provided by VHA
veteran training on staff
Primary care needs of veterans at 131 facilities and
Care Caregiver burden assess- more than 90 CBOCs *
ment annually and
follow up with resources as
indicated
----------------------------------------------------------------------------------------------------------------
Adult Day Enrolled Alternative setting Currently
veteran for provided on
Health Care who would other- respite care campus of 21 VAMCs *
(ADHC) wiserequirenurs- Caregiver support VA also
ing home care and education (e.g., instruc- contracts with community
tion on managing chal- providers in locations
lenging behaviors of vet- where the VAMC does not
erans with Alzheimer's) have onsite ADHC *
----------------------------------------------------------------------------------------------------------------
Veteran Enrolled Budget provided by Local VAMC
veteran local
Directed area agency on aging agreement with local
Home and (AAA) to veteran to AAA to arrange for
Community purchase own support home care of veteran
Based Care services
AAA provides case
management and fiscal
intermediary to assist with
purchase of services
----------------------------------------------------------------------------------------------------------------
Home-maker/ Eligible Provides personal Contracted home
veteran care
Home who is in need of and supportive services health agency (HHA)
Health nursing home care Employee of HHA
can be family caregiver
----------------------------------------------------------------------------------------------------------------
Temporary Veteran Persons VHA with support
with accompanying
Lodging appointment at veterans receiving VA from service and other
and Fisher VA medical medical care or C&P volunteer agencies
Houses facility to exams are provided
receive
health care or temporary lodging and
compensation & support. Provided in Fisher
pension (C&P) exam & Houses, non-used beds in
family member of vet- medical center or at
eran or person ac- community hotels/motels
companying vet- eran
to provide
equivalent of
familial support
----------------------------------------------------------------------------------------------------------------
Home Im- Enrolled Amount $4,100 for VHA benefit
veterans most
provement service-connected
and Struc- veterans, $1,200 for all
tural Alter- other enrolled veterans
ations
----------------------------------------------------------------------------------------------------------------
Beneficiary Eligible Mileage VHA travel
veterans reimbursement related
Travel & attendant under Special reimbursement
certain transportation reimbursement
circumstances
----------------------------------------------------------------------------------------------------------------
Special Service- Can be used 3 times VBA benefit
connected for a
Adaptive veterans who lifetime max of $60,000
Housing meet special Veteran must be on
criteria deed for the home
----------------------------------------------------------------------------------------------------------------
Special Service- Provides $12,000 VBA benefit
connected for
Housing veterans meeting temporary or permanent
Adaptation special criteria housing
Active Duty
----------------------------------------------------------------------------------------------------------------
Service- Active Duty Payments of up to VBA benefit
members participating in $100,000 according to a
Group Life Servicemembers schedule of traumatic
Insurance Group Life injuries
Traumatic Insurance
Injury
Protection
(TSGLI)
----------------------------------------------------------------------------------------------------------------
Automobile Veteran and 1 time benefit VBA benefit
automobile
Grant servicemembers grant up to $11,000 paid
with certain to seller
disabilities
----------------------------------------------------------------------------------------------------------------
* Acronyms: CLC, community living center; VAMC, VA medical center; CBOC, community-based outpatient clinic;
ADHC, adult day health care
Question 9(b): How is the comprehensive review structured and who
is responsible for the final recommendations of this review? When will
the review be completed?
Response: A VA caregiver support task force has been chartered by
the Office of Patient Care Services to develop a comprehensive model
for caregiver support across VHA. VA has implemented multiple programs
and services throughout the Department to address the needs of
caregivers. VA recognizes there is a need to better orchestrate
efforts, to establish a process to identify gaps, and to identify core
characteristics of a comprehensive model for caregiver support. The
caregiver support task force will develop an integrated approach to
caregiver support that encompasses all practice areas. The caregiver
support task force review and recommendations will be completed by
October 2009 for submission to VA senior leadership. The taskforce,
with support from other program offices in VA, has also developed
proposals for expanding benefits to caregivers of veterans severely
injured in the line of duty who would otherwise require institutional
care. VA estimates this population would include fewer than 2,500
veterans of all eras. These benefits would include travel and lodging
benefits, support services, and a triennial survey of caregivers. In
light of the current Federal efforts regarding comprehensive health
care reform, VA believes any proposals in this area may duplicate
coverage for individuals who may soon be granted such access without VA
incurring responsibility for caregiver medical services.
For the caregiver assistance pilot programs, a comprehensive review
is structured through the Caregiver Advisory Board, which is chaired by
the Caregiver Support Program Manager. Two subcommittees of the
Caregiver Advisory Board have been developed to start preliminary
comprehensive reviews of the caregiver assistance pilot programs to
assess the feasibility and advisability for nationwide implementation
and to review their final fiscal 2009 budgets. The Caregiver Support
Program Manager is responsible for the final recommendations, which
will be completed by November 30, 2009. A final report of the caregiver
assistance pilot programs will be written at this time and sent to
Congress by December 31, 2009.
Question 9(c): For the two pieces of caregiver legislation that VA
did not comment on, why was VA unable to submit views? The Subcommittee
would like VA's views and cost estimates on these two pieces of
legislation.
Response: VA was unable to provide views on the two draft pieces of
legislation because they were received later than the initial docket of
bills included in the Subcommittee's invitation letter and the
Administration was unable to fully analyze these issues in time. Below
is VA views and cost estimates on the two caregiver bills.
Views on Two Caregiver Bills (H.R. 2898 Supportive Services and Annual
Survey)
H.R. 2898: Supportive Services for Family Caregivers. H.R. 2898
would add a new section 1786 to title 38 to provide support services
for family caregivers. The term ``family caregiver'' is defined as a
member of the disabled veteran's family (including parents, spouses,
children, siblings, step-family members, and extended family members)
who provide caregiver services to the disabled veteran. Section 1 of
the bill would require the Secretary to make interactive training
sessions available for family caregivers and individuals who support
such caregivers. Such training must be available both in person and via
the Internet and should incorporate telehealth technologies to the
extent practicable. The bill provides that it should also teach
techniques, strategies and skills for caring for a disabled veteran
including effective methods for caring for veterans with PTSD, TBI, or
who deployed in support of Operation Enduring Freedom or Operation
Iraqi Freedom.
In addition, section 1 would require the Secretary to provide
family caregivers with information concerning public, private, and
nonprofit agencies that support caregivers. In providing this
information, the Secretary would be required to collaborate with the
Assistant Secretary for Aging for the Department of Health and Human
Services and contract with a private entity to provide family
caregivers an Internet-based directory of services at the county level,
message boards and other tools to allow caregivers to interact with
each other and disabled veterans, as well as comprehensive information
explaining health-related topics and issues relevant to the caregivers'
needs.
Pursuant to the bill, the Secretary would also be required to
conduct outreach to inform disabled veterans and their families about
these caregiver support services. The outreach must include public
service announcements, brochures, social networking sites, the VA Web
site and methods which target rural families.
Section 2 of the bill would also amend 38 U.S.C. 1782 to make
family caregivers eligible for counseling and mental health services.
Section 3 would amend 38 U.S.C. 1720B to allow the Secretary to provide
respite care to veterans who receive care from a family caregiver.
Before discussing our views on each of the sections, we must again
note our concern with the narrow definition of ``family caregiver.''
This definition applies to all three sections of the bill.
VA supports the concepts outlined in section 1 of the legislation
but does not support this provision as written because it is too
prescriptive. Section 1 requires VA to conduct outreach and information
sharing in specific means and through defined media, while an alternate
draft bill would require VA to conduct an annual survey of caregivers
to determine their needs. The results of this survey may provide
evidence that VA should adopt methods of outreach different than those
identified in this legislation. We agree that VA must do more to use
technologies and existing networks, but the agency should not become
committed in law and restricted to only specific approaches. We believe
an adaptive and responsive campaign will be the most effective way to
reach the changing demographics and needs of veterans and their
caregivers. We estimate the cost of section 1 to be $64.5 million in FY
2010, $68.5 million in FY 2011, $364.9 million over 5 years and $854.7
million over 10 years.
VA supports the concept behind section 2. This section would extend
counseling and mental health services to family caregivers. We
recognize that last year Congress expanded VA's authority to provide
mental health care as well as marriage and family counseling to the
members of the immediate family, the legal guardian of a veteran, and
the individual in whose household such veteran certifies an intention
to live. Care may only be provided under this authority as necessary in
connection with the treatment of the veteran. Section 2 would expand
this principle to include family caregivers as potentially eligible
participants. VA estimates that there would be no significant
additional costs associated with section 2 or H.R. 2898. We note that
H.R. 2734 would allow VA to satisfy both the mental and physical health
care needs of primary family caregivers through CHAMPVA.
VA supports section 3, which would extend eligibility for respite
care to veterans receiving services from a family caregiver. VA
believes this authority would largely duplicate existing authorities,
as any veteran with another caregiver would already receive these
services. As such, VA anticipates there would be no significant costs
associated with this proposal.
Discussion Draft: Annual Survey of Caregivers. This discussion
draft would require the Secretary to conduct an annual survey of family
caregivers to determine the number of family caregivers, the range of
caregiver services provided by family members, the amount of time spent
providing such services and the support services needed by family
caregivers. The draft would also require the Secretary to report to
Congress the findings of the survey as well as a summary of the
services available to family caregivers, the number of family
caregivers receiving such services, and the cost of each service. The
term ``family caregiver'' in this draft is limited to members of the
disabled veteran's family (including parents, spouses, children,
siblings, step-family members, and extended family members) who provide
caregiver services to the veteran for their disability.
VA supports this bill in concept but recommends the survey be
required less frequently. VA has previously testified that the exact
number of caregivers is currently unknown, but that caregivers fill an
important role. Receiving such feedback from family caregivers would
provide important insights into their needs and help us better care for
severely injured or ill veterans. This legislation would ensure VA
monitors and identifies caregiver needs and would provide valuable data
to help VA better develop, enhance, or implement programs benefiting
caregivers and veterans. However, we would like to note that the
definition of ``family caregiver'' is quite narrow and will exclude
veterans who may not have family members available to serve as
appropriate caregivers. VA would prefer a broader definition that would
allow a veteran to select the appropriate caregiver of his or her
choice, including non-family members. We estimate the cost of this
provision to be $930,000 for FY 2010, $1.4 million for FY 2011, $9.8
million over 5 years, and $21.56 million over 10 years.
Question 10: VA established the Caregiver Advisory Board in June
2008 to develop caregiver assistance programs that address issues
facing caregivers of veterans. Please provide an update on the
activities of the Advisory Board, including a summary of the caregiver
needs the Board identified and any initial recommendations to expand
support services for caregivers. In addition, please share all internal
reports and memoranda authorized by this Advisory Board.
Response: The Caregiver Advisory Board has been focusing much of
its time on reviewing the caregiver assistance pilot programs,
determining program needs including infrastructure, and building
relationships with partners internal to VA with other Federal agencies
and national caregiver advocacy and support organizations. Legislative
proposals by Congress will also play a key role in how programs and
support services for caregivers are shaped.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
June 24, 2009
Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Secretary:
On Thursday, June 18, 2009, the Subcommittee on Health held a
legislative hearing and received testimony from Dr. Robert Petzel,
Acting Principal Deputy Under Secretary for Health. As a followup to
the hearing, I request that you respond to the following questions in
written form for the record:
1. Already in existence are the Defense Center of Excellence for
Psychological Health and Traumatic Brain Injury (TBI) and the Defense
and Veterans Brain Injury Center (DVBIC). DVBIC devotes significant
resources to its mission of providing education on the prevention,
treatment and rehabilitation of TBI. A DoD/VA workgroup recently
released clinical practice guidelines for the management of concussive
and mild TBI. Specifically, what advice and recommendations would a TBI
Committee, as required in H.R. 1546, provide that is not currently
being provided through existing resources?
2. One of the concerns with TBI is that it has co-morbidities,
including post-traumatic stress disorder (PTSD) and visual impairments.
Would the responsibilities of the committee that would be established
in H.R. 1546 include assessing care for co-morbid conditions?
3. The Vietnam Veterans of America (VVA) testified that the
organization is ``not thrilled about creating yet another committee to
focus on yet another facet of combat injury.'' Please respond to this
concern.
4. H.R. 2734 would establish a new health care benefit under the
Civilian Health and Medical Program of the Department of Veterans
Affairs (CHAMPVA) for ``primary'' family caregivers. Would it make
sense to carry out a study to have a better understanding of the
eligibility, availability, and health care service gaps of family
caregivers before enacting this legislation?
5. The average length of time that an eligible veteran may need a
primary caregiver can vary and a family caregiver could change
throughout the course of a veteran's life. Would H.R. 2734 obligate VA
to continue CHAMPVA coverage for a family caregiver that may no longer
be the veteran's family caregiver?
6. H.R. 2734 would exempt family caregivers from co-payments and
cost sharing as other CHAMPVA beneficiaries are required to pay,
resulting in family care- givers having a greater benefit
than the current CHAMPVA beneficiaries. What administrative, equity and
other challenges would this create for CHAMPVA?
7. H.R. 2734 would allow a broad array of family caregivers to
qualify for this benefit. Please describe in detail the obligations and
implementation challenges this legislation would create for the
Department.
8. Does H.R. 2734, in your view, provide an appropriate definition
of ``primary family caregiver?'' If not, how would you recommend
defining this term?
9. In your view, would it be prudent to require that a family
caregiver also have a ``medical power of attorney'' to be eligible for
benefits under H.R. 2734? If so, why? If not, why not?
10. H.R. 2734 limits eligibility to caregivers of veterans
receiving aid and attendance (38 U.S.C. 1114 (r)), or entitled to the
highest rate of Special Monthly Compensation (38 U.S.C. 1114 (s)), and
have no other health care coverage. What is the purpose of providing
aid and attendance and the special monthly compensation?
11. What challenges would VA face in implementing H.R. 2734?
12. Section 1672 of Public Law 110-181, provides for medical care
for certain family members caring for a wounded warrior that are not
otherwise eligible for medical care on a space-available basis in
military treatment and VA facilities. What and how much care has VA
provided in compliance with the law?
13. What are the current beneficiary travel benefits for a veteran
traveling to a medical center for care and benefits for an attendant
traveling with the veteran?
14. H.R. 2738 would allow VA to prescribe regulations to limit the
number of attendants and require that certain travel services be used.
However, it does not allow VA the authority to prescribe eligibility
regulations based on the need for a caregiver to accompany a veteran.
Would H.R. 2738 allow a veteran to travel to a VA medical center with
both an attendant and a family caregiver? Should there be limits on the
length of time a family caregiver could receive this benefit?
15. H.R. 2738 would require VA to provide ``lodging and
subsistence'' to eligible family caregivers. How would VA implement the
subsistence requirement--would VA pay a per diem similar to that which
is provided to Federal employees on official travel?
16. In your view, would H.R. 2738 require VA to provide an
eligible family caregiver lodging and subsistence if the veteran is
receiving inpatient treatment?
17. Section 744 of Public Law 109-364 required VA and DoD to work
together to develop a training curricula for family caregivers of
veterans with TBI. What is the status of this curriculum? When should
Congress expect to receive the report this law also requires? What
challenges did you face in developing this training?
18. H.R. 2898 would require VA to provide family caregivers such
consultation, professional counseling, marriage and family counseling,
training and mental health services as are necessary in connection with
that treatment. Please describe in detail the type and extent of
services VA would be providing under this requirement.
19. The National Resource Directory was created in collaboration
with DoD, VA, and the Department of Labor. The Directory is a Web-based
center of resources for wounded warriors and veterans and includes
maintaining important support and training services for family
caregivers. Would certain requirements under section 1 of H.R. 2898
duplicate the purpose of the National Resource Directory? Should
certain requirements under section 1 of the bill be changed to enable
servicemembers and veterans to have a centralized resource to further
our goal of achieving a true seamless transition?
20. H.R. 2898 would require VA to make available interactive
training sessions for family caregivers. Is it your view that the bill
would allow VA to meet this requirement using an independent entity
with expertise in training to meet this requirement?
21. A draft bill would require VA to conduct a survey of family
caregivers. Would this proposal capture the information that you
believe would be beneficial to developing better policies for family
caregivers?
22. Regarding the draft bill to conduct a survey of family
caregivers, please respond to the following recommendations included in
the National Military Family Association Statement for the Record of
June 18, 2009: ``However, we recommend the survey should capture a
wider range of information than what is currently included in this
proposal. We suggest the survey start with caregiver demographics, and
include additional items, such as the financial impact, identify gaps
and successes in the support system, and the disruption to the family
unit, especially children. Also, the survey should capture data on
caregivers' experiences with both the VA and DoD support programs and
benefits. We would also encourage the establishment of a panel of
experts to help with the survey's design and implementation. This panel
would consist of, but not be limited to, members representing: Veteran
Service Organizations; Military Service Organizations; caregivers of
our wounded, ill, and injured servicemembers and veterans; staff from
the VA and DoD who work on caregiver issues; and members from each of
the Services' wounded warrior programs.''
The attention to these questions is much appreciated, and I request
that they be returned to the Subcommittee on Health no later than close
of business, 5:00 p.m., Friday, July 3, 2009. If you or your staff have
any questions, please contact Dolores Dunn, Republican Staff Director
for the Subcommittee on Health, at 202-226-1293.
Sincerely,
Henry Brown
Ranking Republican Member
__________
Questions for the Record
The Honorable Henry Brown, Ranking Member
Subcommittee on Health, House Committee on Veterans' Affairs
June 18, 2009
Legislative Hearing
Question 1: Already in existence are the Defense Center of
Excellence for Psychological Health and Traumatic Brain Injury (TBI)
and the Defense and Veterans Brain Injury Center (DVBIC). DVBIC devotes
significant resources to its mission of providing education on the
prevention, treatment and rehabilitation of TBI. A DoD/VA workgroup
recently released clinical practice guidelines for the management of
concussive and mild TBI. Specifically, what advice and recommendations
would a TBI Committee, as required in H.R. 1546, provide that is not
currently being provided through existing resources?
Response: The Department of Veterans Affairs (VA) Committee on Care
of Veterans with Traumatic Brain Injury (TBI) to be established by H.R.
1546 would specifically advise the Secretary of up-to-date information
on optimizing the quality of clinical care, maintaining superior
training programs in TBI-specific specialties, providing contemporary
education to the field in TBI rehabilitation advances, and recommending
research priorities for the Department. The Committee would be
comprised of VA employees from multiple specialty areas of care with
expertise in TBI, including: physical medicine and rehabilitation,
neurology, mental health, care management and social work, telehealth,
readjustment counseling, public health, research and development, and
academic affiliations. This interdisciplinary structure would
facilitate support for veterans across the entire VA health care system
and would serve as a consultative body with specific and direct
knowledge of VA's benefits and services. Representatives from
Department of Defense (DoD) and the civilian sector, who represent a
broad national perspective on the care needs and are recognized as
experts in TBI rehabilitation, could also be used to provide input to
VA as requested.
The Defense and Veterans Brain Injury Center and the Defense Center
of Excellence for Psychological Health and TBI fulfill important but
complementing roles. The DVBIC's mission is to serve active duty
military, their dependents and veterans with TBI through state-of-the-
art medical care, innovative clinical research initiatives and
educational programs. The Defense Center of Excellence for
Psychological Health and TBI's mission is to assess, validate, oversee
and facilitate prevention, resilience, identification, treatment,
outreach, rehabilitation and reintegration for psychological health and
TBI to ensure DoD meets the needs of the Nation's military communities,
warriors and families.
Question 2: One of the concerns with TBI is that it has co-
morbidities, including post-traumatic stress disorder (PTSD) and visual
impairments. Would the responsibilities of the committee that would be
established in H.R. 1546 include assessing the care for co-morbid
conditions?
Response: Yes. The VA TBI/polytrauma system of care (PSC)
represents the largest system of treatment and management for TBI in
the United States. VA is currently using the knowledge and experience
of interdisciplinary TBI experts within this system of care to evaluate
and stratify the assessment, treatment, and investigation of co-
occurring symptoms with TBI, such as post-traumatic stress disorder
(PTSD), depression, chronic pain, and other symptoms. This committee
can readily assume responsibility for overseeing this effort.
Question 3: The Vietnam Veterans of America (VVA) testified that
the organization is ``not thrilled about creating yet another committee
to focus on yet another facet of combat injury.'' Please respond to
this concern.
Response: VA greatly values the opinion of Vietnam Veterans of
America (VVA) and is pleased to respond to the concerns. TBI is a high
priority program for VA, Congress, and the American public. TBI-related
impairments and disability significantly impact a large number of
veterans, and the previous Vietnam Head Injury Study represents one of
the largest medical investigations conducted for that cohort of
veterans. Improved trauma care and an aging population are resulting in
increasing numbers of veterans who sustain TBI and have long-term
survival. Other conditions and problems that frequently co-occur with
TBI (such as PTSD and chronic pain) can readily lead to increased
probability for secondary problems, such as depression, substance
abuse, coping problems, and social integration problems. Also, the
science of TBI management is a rapidly growing field that requires
rigorous clinical, research and academic collaboration. As previously
explained, the multi-disciplinary VA Committee on Care of Veterans with
TBI not only would facilitate better understanding of the complexities
and medical effects of TBI, but also focus efforts on addressing these
secondary and co-occurring issues.
Question 4: H.R. 2734 would establish a new health care benefit
under the Civilian Health and Medical Program of the Department of
Veterans Affairs (CHAMPVA) for ``primary'' family caregivers. Would it
make sense to carry out a study to have a better understanding of the
eligibility, availability, and health care service gaps of family
caregivers before enacting this legislation?
Response: VA acknowledges there are many issues related to family
caregivers, including their access to available health care coverage,
where more information is needed. VA agrees that a study to have a
better understanding of the eligibility, availability, and health care
service gaps of family caregivers before enacting this legislation
would be helpful to determine the impact of increased access and scope
of eligibility for family caregivers.
Question 5: The average length of time that an eligible veteran may
need a primary caregiver can vary and a family caregiver could change
throughout the course of a veterans' life. Would H.R. 2734 obligate VA
to continue CHAMPVA coverage for a family caregiver that may no longer
be the veteran's family caregiver?
Response: It is unclear to VA if the intent of H.R. 2734 would
require VA to continue CHAMPVA coverage for a family caregiver that may
no longer be the veteran's family caregiver, or how many family
caregivers a severely injured veteran could elect at one time or over a
period of time. It is similarly unclear if CHAMPVA benefits would
continue if a veteran died or no longer needed caregiver services. VA
believes these issues would require further study, and either need to
be resolved through regulations or through amendment to the legislation
to properly define and limit the scope of this benefit to those with
genuine need.
Question 6: H.R. 2734 would exempt family caregivers from co-
payments and cost sharing as other CHAMPVA beneficiaries are required
to pay, resulting in family caregivers having a greater benefit than
the current CHAMPVA beneficiaries. What administrative, equity and
other challenges would this create for CHAMPVA?
Response: VA is concerned that H.R. 2734 would result in equity and
administrative challenges. CHAMPVA is a cost-sharing program. H.R. 2734
specifies family caregivers would not be subject to the same
deductibles, premiums, co-payments, cost-sharing and other fees for
medical care that are available to the existing population. The
language in the legislation provides the family caregiver a benefit
that the dependent children, spouse, or surviving spouse of permanently
and totally disabled veterans or those veterans who died as a result of
their service-connected disability do not have. VA recommends there be
parity of benefits for the family caregivers and the existing program
beneficiaries, rather than preferential benefits for family caregivers.
VA is also concerned about the lack of clarity concerning whether
or not benefits expire if a veteran identifies a new caregiver or if a
veteran no longer requires caregiver services. If only one family
caregiver is eligible for benefits at a time, there would be some
administrative burden to VA in designating a new beneficiary if the
veteran switches caregivers. The legislation as written does not limit
the veteran's ability to change caregivers. VA believes that for such a
mechanism to work properly, veterans should be provided a periodic
opportunity to identify a new caregiver, except for cases of patient
safety or well-being, when a veteran should be allowed to immediately
identify a different caregiver. Additionally, when a new caregiver is
identified, CHAMPVA benefits should end for the previous caregiver and
begin for the newly appointed caregiver. This approach would balance
the interests of the veteran, the caregiver and VA.
Question 7: H.R. 2734 would allow a broad array of family
caregivers to qualify for this benefit. Please describe in detail the
obligations and implementation challenges this legislation would create
for the Department.
Response: As noted above, VA is concerned with an open-ended
commitment to an identified caregiver, even if the veteran later
selects another person to perform as his or her caregiver. VA believes
a system that allows veterans a periodic opportunity to select a new
caregiver, much like an open season for selecting new health insurance
benefits available to employers, would facilitate the administration of
this program and allow veterans and caregivers sufficient flexibility.
This would also not be as administratively burdensome as an at-will
assignment of caregivers where a veteran could change caregivers
whenever and as often as he or she pleased. VA believes that veterans
who qualify should have equal latitude in determining their appropriate
caregiver, be it a family member or non-family member. This latitude
would not be unduly burdensome to VA.
Question 8: Does H.R. 2734, in your view, provide an appropriate
definition of ``primary family caregiver?'' If not, how would you
recommend defining this term?
Response: VA is concerned the definition of ``family caregiver''
included in H.R. 2734 is too narrow as it limits the scope of possible
caregivers to a veteran's family. VA is concerned such a limitation
would unfairly disadvantage veterans who do not have available or
appropriate family members for their day-to-day care, but are in need
of caregiver services, or veterans whose family members are unable or
unwilling to participate as the veteran's primary caregiver. Caregiver
services sometimes involve intimate care that a veteran may be
unwilling to have a family member perform.
VA recommends defining eligible caregivers as the spouse, dependent
child of a veteran, parent, legal guardian, or other as determined by
the veteran (including an individual in whose household a veteran
certifies an intention to live).
Question 9: In your view, would it be prudent to require that a
family caregiver also have a ``medical power of attorney'' to be
eligible for benefits under H.R. 2734? If so, why? If not, why not?
Response: VA does not believe requiring a family caregiver to have
medical power of attorney is appropriate. We understand the Committee
is interested in ensuring caregivers are invested in the treatment and
well-being of the veteran, but this recommendation is unnecessary for
that purpose. A medical power of attorney is often given to a family
member in a position to make the hard health care decisions required
for health care providers to care for a family member. However, this
family member is not always the individual taking care of the veteran
on a daily basis. A veteran could prefer a situation where one family
member provides caregiver services and another holds medical power of
attorney. VA believes it is not prudent to require a family caregiver
to also have a medical power of attorney to be eligible for benefits
under H.R. 2734. To do so would place a veteran in the position of
choosing a benefit for his family caregiver over another family member
who, in the veteran's opinion, would best represent his or her medical
interests.
Question 10: H.R. 2734 limits eligibility to caregivers of veterans
receiving aid and attendance (38 United States Code 1114(r)), or
entitled to the highest rate of Special Monthly Compensation (38 U.S.C.
1114(s)), and have no other health care coverage.
What is the purpose of providing aid and attendance and the special
monthly compensation?
Response: Initially, we want to point out that the highest rate of
special monthly compensation (SMC) is provided at 38 U.S.C. 1114(r)(2).
Compensation under section 1114(s) is lower than under many of the
other subsections in section 1114.
Many of the current eligibility criteria for SMC date back to 1933,
including compensation provided under subsection (l) based on need for
aid and attendance. SMC differs from disability compensation in that
the rates provided take into account other factors in addition to loss
of earning capacity. For example, the lowest level of SMC, which
provided under subsection (k), includes as eligibility criteria
anatomical loss or loss of use of a creative organ and certain losses
of breast tissue. These disabilities may not result in significant
earnings loss. SMC based on need for aid and attendance is based on the
veteran's need for the personal assistance of another individual in
performing the basic activities of daily living, such as bathing,
eating, attending to the needs of nature, and protecting him or herself
from the hazards of daily living. Congress has recognized the
additional expense of securing the personal care needed by veterans who
require such assistance by authorizing increased compensation benefits.
Question 11: What challenges would VA face in implementing H.R.
2734?
Response: H.R. 2734 does not define the scope or limitation of
these benefits. As noted above, VA is concerned with an open-ended
commitment to an identified caregiver, even if the veteran later
selects another person to perform as his or her caregiver. VA believes
a system that allows veterans a periodic opportunity to select a new
caregiver, much like an open season for selecting new health insurance
benefits available to employers, would facilitate the administration of
this program and allow veterans and caregivers sufficient flexibility.
This would also not be as administratively burdensome as an at-will
assignment of caregivers where a veteran could change caregivers
whenever and as often as he or she pleased. VA believes veterans should
have equal latitude in identifying an appropriate caregiver, be it a
family member or non-family member. This latitude would not be unduly
burdensome to VA. These limits would need to be defined through
regulation if the legislation as written became law. Additionally, the
legislation needs to define whether family caregiver eligibility and
benefits would extend to those severely injured veterans and their
caregivers living abroad. VA is also concerned about the technology
required to support this initiative across multiple agencies and
business lines for real-time eligibility management. This level of
technology may be difficult to achieve within the timeframe defined in
the legislation for program implementation.
Question 12: Section 1672 of Public Law 110-181 provides for
medical care for certain family members caring for a wounded warrior
that are not otherwise eligible for medical care on a space-available
basis in military treatment and VA facilities. What and how much care
has VA provided in compliance with the law?
Response: This provision is currently in the regulatory process;
however, VA already has authority to provide care on a humanitarian and
emergency basis. At this point, VA does not track care provided to such
specificity.
Question 13: What are the current beneficiary travel benefits for a
veteran traveling to a medical center for care and benefits for an
attendant traveling with the veteran?
Response: Current VA beneficiary travel regulations at 38 CFR Part
70 authorize VA to pay for certain travel costs of an attendant when VA
had medically determined that an attendant is required to assist the
veteran during travel. Benefits include the actual cost of travel
(unless traveling with the veteran in a shared personal vehicle), and
lodging and per diem at 50 percent of the area Federal employee rate
during the actual period of travel. Should a veteran be admitted to a
VA facility for care following travel and VA determines the veteran no
longer needs a non-VA attendant, per diem and incidental costs have
usually been at the caregiver's or attendant's expense.
Question 14: H.R. 2738 would allow VA to prescribe regulations to
limit the number of attendants and require that certain travel services
be used. However, it does not allow VA the authority to prescribe
eligibility regulations based on the need for a caregiver to accompany
a veteran. Would H.R. 2738 allow a veteran to travel to a VA medical
center with both an attendant and a family caregiver? Should there be
limits on the length of time a family caregiver could receive this
benefit?
Response: VA would not require new regulations to limit the scope
of H.R. 2738 because the bill would modify VA's existing statutory
authority to provide travel benefits to someone accompanying a veteran.
Essentially, this legislation would only authorize benefits to
caregivers comparable to what attendants who would otherwise be
eligible under VA's beneficiary travel authority would receive. If a
veteran is not eligible for attendant benefits under VA's existing
beneficiary travel authority, his or her caregiver would not be
eligible to receive benefits under this legislation.
It is unlikely that a family caregiver would not also be the
appropriate attendant during the majority of veteran travel where an
attendant is medically required. In such situations where a more
skilled attendant is required, it is likely that special mode transport
(e.g., ambulance, wheelchair van, air medical evacuation, etc.) would
be used, and in such cases, the scope of H.R. 2738 would provide for car
egiver travel.
Question 15: H.R. 2738 would require VA to provide ``lodging and
subsistence'' to eligible family caregivers. How would VA implement the
subsistence requirement--would VA pay a per diem similar to that which
is provided to Federal employees on official travel?
Response: Current VA beneficiary travel regulations at 38 CFR Part
70 authorizes VA to reimburse eligible attendants during a period of
travel up to 50 percent of the area Federal employee lodging and
subsistence rates. If H.R. 2738 became law, it would provide a per diem
to caregivers accompanying a veteran for care. It is unclear whether a
per diem rate similar to DoD per diem benefits for family members
accompanying an injured servicemember on special travel orders, the
same per diem benefit provided to Federal employees, or the current
regulated 50 percent of Federal employee per diem rate would be
appropriate. VA notes an exception that would waive any applicable
monetary payments if available facilities such as a Fisher House or VA
lodging are available.
Question 16: In your view, would H.R. 2738 require VA to provide an
eligible family caregiver lodging and subsistence if the veteran is
receiving inpatient treatment?
Response: VA believes H.R. 2738 would require VA to provide an
eligible family caregiver lodging and subsistence benefits if the
veteran is receiving inpatient treatment. VA notes that DoD's authority
for providing benefits in these situations is capped to a specific
number of days per year.
Question 17: Section 744 of Public Law 109-364 required VA and DoD
to work together to develop a training curricula for family caregivers
of veterans with TBI. What is the status of this curricula? When should
Congress expect to receive the report this law also requires? What
challenges did you face in developing this training?
Response: The DoD/VA TBI family caregiver project panel, with
oversight by the Defense and Veterans Brain Injury Center (DVBIC), has
developed a four-module written curriculum entitled, A Caregiver's
Guide to Traumatic Brain Injury: Roadmap to Recovery. A Web version of
the curriculum is also under development with the Center of Excellence
for Medical Multimedia (CEMM). Focus groups to evaluate the curriculum
are scheduled to be completed July 31, 2009, with a full report to the
panel due August 31, 2009. Feedback from the focus groups must be
evaluated and subsequent revisions completed before the vendor can
format the curriculum into the various modalities for distribution. The
complete curricula package is due to Congress with a full report by
December 31, 2009. DVBIC has requested an extension to meet the
standards recommended by the panel to effectively evaluate the
curriculum. The panel faced challenges in determining the scope of the
curriculum, identifying family preferences for the content, depth and
modality of the curriculum, identifying qualified medical writers to
assist in the editing and compilation of the curriculum, and in the
development of a contract to conduct the focus groups.
Question 18: H.R. 2898 would require VA to provide family
caregivers such consultation, professional counseling, marriage and
family counseling, training and mental health services as are necessary
in connection with that treatment. Please describe in detail the type
and extent of services VA would be providing under this requirement.
Response: Public Law 110-387, the Veteran's Mental Health and Other
Care Improvement Acts of 2008 (enacted October 10, 2008), added
marriage and family counseling to the list of suggested services
available for veterans. Such services include consultation,
professional counseling, and other mental health services considered
necessary in connection with treatment of the veteran. This law also
removed the contingency that the non-service connected veteran needed
to be hospitalized before their family members would be eligible for
these services. Immediate family members, guardians, or individuals in
whose home the veteran intends to reside are eligible for this benefit.
Examples of these services include behavioral family therapy, multiple
family group therapy, the support and family education program, the
National Alliance on Mental Illness family-to-family education program
and family consultation.
In developing treatment plans and providing care, clinicians
consider whether there are problems or conditions experienced by a
member of the veteran's family that could result in health or mental
health problems for the veteran. VA clinicians also consider whether
relational problems for the veteran with a spouse or other family
member could exist or manifest. For example, being a caregiver for a
parent who has Alzheimer's disease could lead to high levels of stress
and negative health and mental health problems. Alternatively, a
veteran's spousal caregiver could experience stress that, in turn,
could affect the veteran and the veteran's marital relationship. With
the changes implemented by P.L. 110-387, VA clinicians can provide
marital or family counseling services for the veteran's benefit.
H.R. 2898 would not broadly extend services available for the
family. The only impact of this legislation would be to make available
these benefits to extended family members who do not provide housing to
the veteran or to a designated family caregiver.
Every veteran and their caregiver has access to a VA social worker
who provides an assessment of individualized needs of the family
caregiver with respect to the family caregiver's role, assistance with
the development of a plan for long-term care of the veteran, and
implementation of a treatment plan. Social workers also provide ongoing
counseling and education to veterans and family caregivers.
Question 19: The National Resource Directory was created in
collaboration with DoD, VA, and the Department of Labor. The Directory
is a Web-based center of resources for wounded warriors and veterans
and includes maintaining important support and training services for
family caregivers. Would certain requirements under section 1 of H.R.
2898 duplicate the purpose of the National Resource Directory? Should
certain requirements under section 1 of the bill be changed to enable
service members and veterans to have a centralized resource to further
our goal of achieving a true seamless transition?
Response: DoD, VA, and Department of Labor developed and maintain
the National Resource Directory (www.nationalresourcedirectory.org,
NRD), an online portal that provides access to information from over
11,000 services and resources from Federal, State, and local
governmental agencies; veteran service and benefit organizations; non-
profit community-based and faith-based organizations; academic
institutions, professional associations and philanthropic
organizations. The mission of the NRD is to provide a one-stop online
resource for up-to-date, easily accessible, information about services
and resources for servicemembers, veterans, their families and all who
support them. Available information is organized into six categories:
benefits and compensation; education, training & employment; family and
caregiver support; health, housing and transportation; services; and
resources.
The specific requirement of H.R. 2898 for the Secretary to contract
with a private entity could be interpreted to require a new and
separate effort apart from the current collaborative NRD structure.
Many of the specific elements required by H.R. 2898 have been discussed
by the NRD governance group and are in various stages of development as
future requirements.
The NRD is part of a larger effort to improve wounded warrior care
coordination and access to information, and provides a foundation for
the ongoing development of Web portals that will tailor resources upon
login. Additional improvements to the NRD site are under development
and include Web feeds, E-mail-A-Friend capability, and a Link to Us
page. All resources added to the NRD are evaluated and edited using a
25-point content management style guide, as well as guidance provided
by the site's partner agencies. To ensure the quality and acceptability
of posted content, as well as consistency and clarity of language, all
links uploaded to the NRD undergo a series of reviews and cross-
reviews. NRD content has recently been leveraged in other Web portal
development efforts including ebenefits.gov and the Wounded Warrior
resource center Web site.
Question 20: H.R. 2898 would require VA to make available
interactive training sessions for family caregivers. Is it your view
the bill would allow VA to meet this requirement using an independent
entity with expertise in training to meet this requirement?
Response: VA would likely need to contract with at least one
independent entity to fulfill the requirements of H.R. 2898 section 1.
Section 1 would require the Secretary to make interactive training
sessions available for family caregivers and individuals who support
such caregivers. Such training must be available both in person and via
the Internet and should incorporate telehealth technologies to the
extent practicable. VA provides training to family members or
caregivers related to the clinical needs of the veteran prior to his or
her discharge from a VA facility. However, VA would probably contract
with an independent entity to provide interactive training sessions
online.
The bill also provides that VA should teach techniques, strategies
and skills for caring for a disabled veteran including effective
methods for caring for veterans with PTSD, TBI, or who deployed in
support of Operation Enduring Freedom/Operation Iraqi Freedom. Again,
VA social workers and clinicians regularly work with family members to
identify concerns and treatment plans while the veteran is still
receiving care in VA. Our staff remains available to veterans and their
family members after their release to provide additional support as
needed.
In addition, section 1 would require the Secretary to provide
family caregivers with information concerning public, private, and
nonprofit agencies that support caregivers. In providing this
information, the Secretary would be required to collaborate with the
Assistant Secretary for Aging for the Department of Health and Human
Services and contract with a private entity to provide family
caregivers an Internet-based directory of services at the county level,
message boards and other tools to allow caregivers to interact with
each other and disabled veterans, as well as comprehensive information
explaining health-related topics and issues relevant to the caregivers'
needs. This requirement within the legislation specifically states VA
would contract with an independent entity, and VA would do so in
compliance with the law.
Pursuant to H.R. 2898, the Secretary would also be required to
conduct outreach to inform disabled veterans and their families about
these caregiver support services. The outreach must include public
service announcements, brochures, social networking sites, the VA Web
site and methods which target rural families. VA may be required to
contract for these services, specifically concerning public service
announcements.
VA recommends adopting less prescriptive language in section 1 to
allow VA the flexibility to adapt new methods of outreach as they
become available and as they are appropriate to different generations
of veterans. Communication technology changes rapidly and VA would
prefer to change outreach methods as necessary to best meet the varied
demographics and needs of family caregivers.
Question 21: A draft bill would require VA to conduct a survey of
family caregivers. Would this proposal capture the information that you
believe would be beneficial to developing better policies for family
caregivers?
Response: VA believes the survey required by the draft bill would
provide needed information to develop and tailor programs to the
specific needs of veterans and their caregivers. VA has previously
testified that the exact number of caregivers is currently unknown, but
that caregivers fill an important role. Receiving feedback from family
caregivers would provide important insights into their needs and help
us better care for severely injured or ill veterans. This legislation
would ensure VA monitors and identifies caregiver needs and would
provide valuable data to help VA better develop, enhance, or implement
programs benefiting caregivers and veterans. VA anticipates it would
conduct focus groups in the first year following enactment of this law
to develop appropriate questions and to refine the survey to best
gather the necessary data. This process would improve the quality of
the survey instrument and the quality of VA benefits and services.
Question 22: Regarding the draft bill to conduct a survey of family
caregivers, please respond to the following recommendations included in
the National Military Family Association's Statement for the Record of
June 18, 2009: ``However, we recommend the survey should capture a
wider range of information than what is currently included in this
proposal. We suggest the survey start with caregiver demographics, and
include additional items, such as the financial impact, identify gaps
and successes in the support system, and the disruption to the family
unit, especially children. Also, the survey should capture data on
caregivers' experiences with both VA and DoD support programs and
benefits. We would also encourage the establishment of a panel of
experts to help with the survey's design and implementation. This panel
would consist of, but not be limited to, members representing: Veterans
Service Organizations; Military Service Organizations; caregivers of
our wounded, ill and injured servicemembers and veterans; staff from VA
and DoD who work on caregiver issues; and members from each of the
Services' wounded warrior programs.''
Response: VA anticipates it would conduct focus groups in the first
year following enactment of this law to develop appropriate questions
and to refine the survey to best gather the necessary data. VA agrees
that the organizations identified by the National Military Family
Association could provide important insight and it anticipates working
with these groups and others to craft a survey that will be effective
and provide meaningful data.
VA would recommend modifying the legislation to specifically limit
the scope of this survey to only family caregivers of enrolled
veterans, rather than the entire population of family caregivers within
the United States. VA also notes the legislation could benefit from
providing flexibility to determine if annual surveys are necessary and
to modify the survey as needed from year to year, since new issues,
concerns or programs could warrant client feedback.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
June 22, 2009
Mr. Joseph L. Wilson
Deputy Director, Veterans Affairs and Rehabilitation Commission
The American Legion
1608 K Street, NW
Washington, D.C. 20006
Dear Mr. Wilson:
Thank you for the testimony you prepared on behalf of The American
Legion for the U.S. House of Representatives Committee on Veterans'
Affairs Subcommittee on Health Legislative Hearing that took place on
June 18, 2009.
Please provide answers to the following questions by August 3,
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on
Health.
1. What other health care legislation does your organization
recommend for this Subcommittee?
2. In a statement for the record, The Wounded Warrior Project
notes that the caregiver legislation we are considering today are not
as comprehensive as they should be. Additionally, they note that we
already know enough about the burdens of caregivers and that an annual
survey is not needed.
a. What are your thoughts on WWP's position? Do you believe that
modifications to the caregiver legislation are necessary?
b. Is it my understanding that VA does not currently collect any
data on family caregivers, such that we don't even know how many family
caregivers there are or the types of services they are receiving. While
I agree that we have many anecdotes to understand the burden of
caregiving, more information is needed to better help this population.
Do you believe that the annual survey and reporting requirements are
not necessary?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by August 3, 2009.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Joseph L. Wilson, Deputy Director,
Veterans Affairs and Rehabilitation Commission
The American Legion
Questions and Responses from:
Health Legislative Hearing on June 18, 2009
Question 1: What other health care legislation does your
organization recommend for this Subcommittee?
Response: The American Legion supports legislation to expand and
improve VA health care services for the 1.8 million women who have
served our country. We also ask that proper oversight be reimplemented
and/or maintained on issues such as increasing access to veterans
health care, especially in rural areas; to revisit efforts to address
the issues of an aging veteran population as well as veterans suffering
the effects of Gulf War illness, Traumatic Brain Injury, post-traumatic
stress disorder and exposure to toxic substances such as Agent Orange.
We must keep the woman veteran in mind when addressing the above-
mentioned pertinent issues and ensure all receive comprehensive care
when visiting VA Medical Centers.
Question 2: In a statement for the record, The Wounded Warrior
Project notes that the caregiver legislation we are considering today
are not as comprehensive as they should be. Additionally, they note
that we already know enough about the burdens of caregivers and that an
annual survey in not needed.
Question 2(a): What are your thoughts on WWP's position? Do you
believe that modifications to the caregiver legislation are necessary?
Response: It is The American Legion's position that a stronger
piece of legislation is required to ensure the Operation Enduring
Freedom/Operation Iraqi Freedom (OEF/OIF) Veteran Caregiver Program
includes but is not limited to, a comprehensive package, including,
respite care, to minimize complacency while caring for severely wounded
veterans, mental health counseling, health care coverage, and adequate
financial support.
Question 2(b): Is it my understanding that VA does not currently
collect any data on family caregivers, such that we don't even know how
many family caregivers there are or the types of services they are
receiving. While I agree that we have many anecdotes to understand the
burden of caregiving, more information is needed to better help this
population. Do you believe that the annual survey and reporting
requirements are not necessary?
Response: The American Legion believes the absence of a
recordkeeping system for those who care for this Nations' wounded
veterans contributes to the lack of oversight required to ensure
veterans are receiving adequate specialty and comprehensive care.
Therefore, it is essential an accountability system be in place to
ensure veterans' care remains adequate and seamless within their
respective communities as well. Adequacy and seamless care can be
maintained through the Department of Veterans Affairs continuous
communication with and education of the caregiver on caring for the
wounded veteran.
Please feel free to contact me @ 202-861-2700 ext. 2998 or
[email protected] if you have questions.
Thank you,
Joseph L. Wilson
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
June 22, 2009
Ms. Joy J. Ilem
Deputy National Legislative Director
Disabled American Veterans
807 Maine Avenue, SW
Washington, D.C. 20024
Dear Ms. Ilem:
Thank you for the testimony you prepared on behalf of Disabled
American Veterans for the U.S. House of Representatives Committee on
Veterans' Affairs Subcommittee on Health Legislative Hearing that took
place on June 18, 2009.
Please provide answers to the following questions by August 3,
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on
Health.
1. What other health care legislation does your organization
recommend for this Subcommittee?
2. In a statement for the record, The Wounded Warrior Project
notes that the caregiver legislation we are considering today are not
as comprehensive as they should be. Additionally, they note that we
already know enough about the burdens of caregivers and that an annual
survey is not needed.
a. What are your thoughts on WWP's position? Do you believe that
modifications to the caregiver legislation are necessary?
b. Is it my understanding that VA does not currently collect any
data on family caregivers, such that we don't even know how many family
caregivers there are or the types of services they are receiving. While
I agree that we have many anecdotes to understand the burden of
caregiving, more information is needed to better help this population.
Do you believe that the annual survey and reporting requirements are
not necessary?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by August 3, 2009.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Post-Hearing Questions for Joy J. Ilem,
Deputy National Legislative Director of the Disabled American Veterans
From the Subcommittee on Health Hearing
Committee on Veterans' Affairs
United States House of Representatives
June 18, 2009
Question 1: What other health care legislation does your
organization recommend for this Subcommittee?
Answer: As a partner organization in producing the Independent
Budget (IB) for fiscal year (FY) 2010, we have offered many new (and
some recurring) health care legislative and policy ideas to Congress
and the Administration. Some of them, such as improvements in caregiver
support, mental health services, women veterans health care, Department
of Veterans Affairs (VA) health care funding reform, Traumatic Brain
Injury services and related research, VA capital infrastructure,
medical and prosthetic research and its infrastructure, long term care
for veterans in VA and State sponsored facilities, and other relevant
topics, are being addressed in the regular order. We appreciate the
Subcommittee's attention to these critical issues and its efforts in
trying to address gaps in services for sick and disabled veterans and
their families.
We remain hopeful that Congress will enact, and that the President
will approve, the majority of bills addressing these issues hopefully
before Congress adjourns this year. With that prospect in mind,
Disabled American Veterans (DAV) proposes no additional bills for the
Subcommittee's consideration at this time however, we anticipate that
the IB for FY 2011, and our DAV Legislative Program for 2010 emerging
from DAV's upcoming National Convention, will include new ideas and
proposed legislation. We look forward to continuing to work with you
and your staff to enact these proposals to help sick and disabled
veterans and their caregivers.
Question 2: In a statement for the record, The Wounded Warrior
Project (WWP) notes that the caregiver measures we are considering
today are not as comprehensive as they should be. Additionally, they
note that we already know enough about the burdens of caregivers and
that an annual survey is not needed.
a. What are your thoughts on WWP's position? Do you believe that
modifications to the caregiver legislation are necessary?
b. Is it my understanding that VA does not currently collect any
data on family caregivers, such that we don't even know how many family
caregivers there are or the types of services they are receiving. While
I agree that we have many anecdotes to understand the burden of
caregiving, more information is needed to better help this population.
Do you believe that the annual survey and reporting requirements are
not necessary?
Answer: At the June 18th hearing, the Subcommittee considered four
bills aimed at enhancing services for caregivers of disabled veterans.
These measures included provisions to: provide Internet-based training
for caregivers; travel expenses for family caregivers accompanying
veterans to medical care appointments; expand outreach and ensure
access to mental health and respite services; extend eligibility for
CHAMPVA services; and to conduct an annual survey of family caregivers
of disabled veterans.
Collectively, if enacted, these measures would begin to form a
package of services to support caregivers of disabled veterans.
However, we concur with WWP and would have preferred that H.R. 2342,
the Wounded Warrior Project Family Caregiver Act, be considered during
the legislative hearing since this measure would provide a more
comprehensive caregiver support program. In addition, we urge the
Subcommittee to consider amending H.R. 2342 to expand the eligible
population beyond those who were injured in Operations Enduring and
Iraqi Freedom.
A more comprehensive package would be in line with DAV's position
that caregivers of severely disabled veterans should be seen as a
resource and fully supported in their role. During our most recent
National Convention, delegates approved resolution number 165, calling
for legislation that would provide comprehensive supportive services,
including but not limited to financial support, health and homemaker
services, respite, education and training and other necessary relief,
to family caregivers of veterans severely injured, wounded or ill from
military service. Likewise, the IB includes similar recommendations.
Additionally, Mr. Chairman, we believe the survey and reporting
features included in the draft measure are critically important and
should be included in the final caregiver legislation. The DAV believes
that in crafting a new program for veterans' caregiver support
services, it is important from a health policy standpoint, among other
factors, to clearly define the population to be served, and properly
assess that population. We believe it prudent to ensure that a new
caregiver support program, one that DAV strongly advocates, should be
evaluated to determine whether it is achieving its intended purposes of
addressing the impact of the imposition into their lives and on their
obligations and responsibilities as caregivers, including influences or
barriers on their ability to work or pursue other activities, and to
assess the social, psychological, physical and medical burdens that
caregiving places upon them.
Although the combined National Long-Term Care Survey (NLTCS) and
Informal Caregiver Survey (ICS) are not the only tools used to assess
caregivers, we included these surveys in our testimony as examples in
which data are being gathered. Information from NLTCS and ICS has
served the needs of the Department of Health and Human Services,
Congress, policymakers and researchers, to help produce and improve
successful programs and public policy interventions that have benefited
informal caregivers and their care recipients in other publicly-funded
programs.
The lack of information on this caregiver population within the VA
is a prime reason why the DAV recommends VA conduct a statistically
significant longitudinal survey. Accordingly, we recommend the draft
legislation be amended to require VA to conduct a longitudinal survey
that would allow VA to obtain information and develop a nationally
representative profile on the demographics, quality of life, available
social support services, health status and outcomes of people who care
for severely disabled veterans. With subsequent surveys, VA could look
at population-based public health outcomes of caregivers as one way to
ensure the support services it provides are effective. Also, with
statistically valid survey data, VA would be in a position to compare
and contrast its caregiver programs with those outside VA--something
that today VA cannot do.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
June 22, 2009
Mr. Fred Cowell
Senior Health Policy Analyst
Paralyzed Veterans of America
801 18th St., N.W.
Washington, D.C. 20006
Dear Mr. Cowell:
Thank you for the testimony you prepared on behalf of Paralyzed
Veterans of America for the U.S. House of Representatives Committee on
Veterans' Affairs Subcommittee on Health Legislative Hearing that took
place on June 18, 2009.
Please provide answers to the following questions by August 3,
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on
Health.
1. What other health care legislation does your organization
recommend for this Subcommittee?
2. In a statement for the record, The Wounded Warrior Project
notes that the caregiver legislation we are considering today are not
as comprehensive as they should be. Additionally, they note that we
already know enough about the burdens of caregivers and that an annual
survey is not needed.
a. What are your thoughts on WWP's position? Do you believe that
modifications to the caregiver legislation are necessary?
b. Is it my understanding that VA does not currently collect any
data on family caregivers, such that we don't even know how many family
caregivers there are or the types of services they are receiving. While
I agree that we have many anecdotes to understand the burden of
caregiving, more information is needed to better help this population.
Do you believe that the annual survey and reporting requirements are
not necessary?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by August 3, 2009.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Paralyzed Veterans of America
Washington, DC.
July 28, 2009
Honorable Michael H. Michaud
Chairman, Subcommittee on Health
House Committee on Veterans' Affairs
Room 335 Cannon House Office Building
Washington, DC 20515
Dear Mr. Chairman:
Thank you for the opportunity to respond to questions from
Paralyzed Veterans of America's (PVA) June 18, 2009 testimony on
pending legislation before the Committee.
Regarding your questions:
Question 1: What other health care legislation does your
organization recommend for this Subcommittee?
Response: PVA recommends several pieces of legislation for the
Subcommittee to consider. The best source for this is The Independent
Budget coauthored annually by AMVETS, Disabled American Veterans (DAV),
PVA and the Veterans of Foreign Wars (VFW). This document provides a
comprehensive overview of our concerns and recommendations for
legislation and policy changes and is endorsed by many Veterans Service
Organization supporters of the IB.
Question 2: In a statement for the record, The Wounded Warrior
Project notes that the caregiver legislation we are considering today
are not as comprehensive as they should be. Additionally, they note
that we already know enough about the burdens of caregivers and that an
annual survey is not needed.
Question 2(a): What are your thoughts on WWP's position? Do you
believe that modifications to the caregiver legislation are necessary?
Response: PVA agrees with the concerns of WWP that the legislation
may need modifications to make it more comprehensive, points clearly
identified in their statement for the record. PVA would also support
the passage of H.R. 2342, the Wounded Warrior Project Family Caregiver
Act. However, we see the legislation the Subcommittee is currently
working on as an important first step. We agree that more can always be
done and we encourage the Subcommittee to reach for a more
comprehensive goal.
Specifically, PVA agrees with WWP's position that the current VA
program in partnership with the Administration on Aging (AoA) is of
limited value by allowing the Aging Network Agencies to refuse to
accept veteran participants. This program can not be expected to meet
the needs of veterans if there is the option to exclude veterans.
PVA wants to work with the Subcommittee and other Veterans Service
Organizations to create the most comprehensive and complete legislation
possible that provides for support to veteran caregivers.
Question 2(b): Is it my understanding that VA does not currently
collect any data on family caregivers, such that we don't even know how
many family caregivers there are or the types of services they are
receiving. While I agree that we have many anecdotes to understand the
burden of caregiving, more information is needed to better help this
population. Do you believe that the annual survey and reporting
requirements are not necessary?
Response: Unfortunately, the VA collection of data on caregivers is
limited at best and as noted in our testimony, ``. . . VA can only
estimate how many of these [44 million] caregivers serve veterans.''
PVA supports the annual survey for two reasons. First, it is
critical that VA develop detailed information on the situation of
caregivers. Legislation can not be built on anecdotal background. As VA
understands the scope of the problem and the benefits provided to
veterans by family caregivers, it builds a stronger and more
sustainable case for legislation. Second, if the population of
caregivers is not surveyed, it is impossible to know if the programs
are working and what programmatic changes may be needed and ``Without
this information, it will be difficult for VA to honestly provide
recommendations on funding caregiver programs to the White House and
Congress.'' [PVA 18 June 09 testimony]
Sincerely,
Fred Cowell
Senior Health Policy Analyst
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
June 22, 2009
Mr. Christopher Needham
Senior Legislative Associate, National Legislative Service
Veterans of Foreign Wars
200 Maryland Avenue, N.E.
Washington, D.C. 20002
Dear Mr. Needham:
Thank you for the testimony you prepared on behalf of the Veterans
of Foreign Wars for the U.S. House of Representatives Committee on
Veterans' Affairs Subcommittee on Health Legislative Hearing that took
place on June 18, 2009.
Please provide answers to the following questions by August 3,
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on
Health.
1. What other health care legislation does your organization
recommend for this Subcommittee?
2. In a statement for the record, The Wounded Warrior Project
notes that the caregiver legislation we are considering today are not
as comprehensive as they should be. Additionally, they note that we
already know enough about the burdens of caregivers and that an annual
survey is not needed.
a. What are your thoughts on WWP's position? Do you believe that
modifications to the caregiver legislation are necessary?
b. Is it my understanding that VA does not currently collect any
data on family caregivers, such that we don't even know how many family
caregivers there are or the types of services they are receiving. While
I agree that we have many anecdotes to understand the burden of
caregiving, more information is needed to better help this population.
Do you believe that the annual survey and reporting requirements are
not necessary?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by August 3, 2009.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
VFW Responses to Questions for the Record of the Subcommittee on Health
With Respect to the June 18, 2009 Legislative Hearing
Question 1: What other health care legislation does your
organization recommend for this Subcommittee?
Response: We thank the Subcommittee for their actions this year.
The Subcommittee has taken action on a significant number of VFW
priorities, such as the Women Veterans' Health Care Improvement Act and
the exemption of catastrophically disabled veterans from having to pay
medical care co-payments. The Subcommittee has had an aggressive
agenda, which has addressed many of our highest priorities.
One issue that we feel could improve the consistency of the
delivery of health care is a consolidation of contracts within
Community-Based Outpatient Clinics (CBOCs), as we outlined on pages 81-
82 of the FY 2010 Independent Budget.
We are strongly supportive of CBOCs and their role in expanding the
availability of care to veterans throughout the country, especially to
those who are not located near a large VA Medical Center. CBOCs serve
as extensions of each Medical Center, and each VAMC establishes its own
requirements based upon local needs.
As they have expanded, the growth in these clinics has involved
multiple contracts with different entities to provide care. Along with
this, each contract can have different measurements of quality care,
pricing models and administration structure. Accordingly, there may not
be consistency within a VAMC's area, nor on the VISN level. There is
almost certainly no uniform standard throughout the health care system.
Consolidating contracts could offer VA many administrative
benefits, and it could improve the quality of care provided to
veterans. Benefits include: greater continuity of care and uniformity
of the benefits; simplified contract administration and oversight;
efficiency within contracts; improvements to access; efficiencies of
procurement; standardized reporting and assessments, etc.
Question 2: In a statement for the record, The Wounded Warrior
Project notes that the caregiver legislation we are considering today
are not as comprehensive as they should be. Additionally, they note
that we already know enough about the burdens of caregivers and that an
annual survey is not needed.
Question 2(a): What are your thoughts on WWP's position? Do you
believe that modifications to the caregiver legislation are necessary?
Response: We agree that veterans and their families need a more
comprehensive program for caregiving. P.L. 109-461 created a pilot
program for family caregivers, and we understand that VA has begun
programs at eight locations throughout the country.
We all understand the need for this type of program. With the
number of severely wounded servicemembers returning from Iraq and
Afghanistan continuing to grow, its importance will increase. As these
veterans stabilize in VA's polytrauma centers, most of these veterans
will be able to return home, at least on a part-time basis. Many others
will find comfort in therapeutic residential care settings. In all
these cases, family members of veterans often will be the key link to
providing care, helping their loved one deal with the challenges their
health care needs create.
The VFW strongly believes that we should implement a systemwide
program as soon as possible, implementing whatever lessons have been
learned from those pilot programs, combined with information from
caregiving programs run by other Federal and State agencies and lessons
learned from private-sector implementation. We feel that we have enough
information and data to implement a successful program, and that we
must not let the search for a perfect program become the enemy of the
good. We have laid out our vision of what a successful program looks
like in the Independent Budget. I would refer you to pages 157-163 of
the FY 2010 version for details.
In short, a family caregiver program must have several key
components, all of which stress quality of life issues for both the
veteran and the caregiver.
1. VA must provide training for family members to serve as the
caregiver, as well as certifying that they are able to provide care. VA
should provide regular training and provide information and resources
for caregivers so that they can understand the veterans' demands for
care. The Department must also ensure that the family member is capable
of meeting the intense demands for care. Caregiving has been shown to
provide immense physical, emotional, and psychological challenges, and
it is critical for these veterans that their caregivers are up to the
challenge.
2. VA must provide compensation to these certified family
caregivers. They often have to put their lives on hold to provide care.
It is not enough, as VA has sometimes suggested, for these family
members to work for providers who already contract care, especially
with the limitations VA provides on the contract care it provides.
3. VA must provide respite care services. Caregivers need a break
from time to time for their physical, emotional and psychological
health. Respite services help to alleviate caregiver burden and are
critical for the quality of care veterans receive.
4. VA must provide family caregivers access to mental health care
services and help provide other medical care services. Studies have
shown that caregivers experience increased likelihoods of stress,
depression, and other physical problems when compared to their peer
group who do not provide care. It is a difficult, stressful job. These
family members are serving on behalf of disabled veterans, to provide
services the veteran is entitled to through the VA system. Accordingly,
their well-being should be taken care of by the Department, if only to
ensure the quality of care for the veteran remains first rate.
These are just some of the principles of a comprehensive national
caregiver program that the VFW would like to see become law.
The VFW believes that H.R. 3155, which recently passed, is a step
in the right direction. Although we have concerns over who ultimately
is covered by this legislation, the overall program it would create is
in line with our recommendations.
Question 2(b): It is my understanding that VA does not currently
collect any data on family caregivers, such that we don't even know how
many family caregivers there are or the types of services they are
receiving. While I agree that we have many anecdotes to understand the
burden of caregiving, more information is needed to better help this
population. Do you believe that the annual survey and reporting
requirements are not necessary?
Response: We disagree with their position. We feel that collecting
information and input from caregivers and their families is going to be
critical to understanding and adapting the program in the future. It is
certainly true that we know many of the burdens and problems with
caregiving programs through numerous studies of other agencies and
organizations with caregiving programs. But it is likely that any VA
program will have unique challenges, and any information we can get to
improve and tailor the program in the future is beneficial.
What we do not want to see, however, is the demands for a study and
the calls for more information and data about caregiving programs being
used as a roadblock to implementing a program this session of Congress.
This study should look to the future with whatever program is
ultimately implemented for adaptation in the years to come. Congress
must not use this study to prevent passage of these critical
improvements.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
June 22, 2009
Mr. Bernard Edelman
Deputy Director for Policy and Government Affairs
Vietnam Veterans of America
8605 Cameron Street, Suite 400
Silver Spring, MD 20910
Dear Mr. Edelman:
Thank you for the testimony you prepared on behalf of Vietnam
Veterans of America for the U.S. House of Representatives Committee on
Veterans' Affairs Subcommittee on Health Legislative Hearing that took
place on June 18, 2009.
Please provide answers to the following questions by August 3,
2009, to Jeff Burdette, Legislative Assistant to the Subcommittee on
Health.
1. What other health care legislation does your organization
recommend for this Subcommittee?
2. In a statement for the record, The Wounded Warrior Project
notes that the caregiver legislation we are considering today are not
as comprehensive as they should be. Additionally, they note that we
already know enough about the burdens of caregivers and that an annual
survey is not needed.
a. What are your thoughts on WWP's position? Do you believe that
modifications to the caregiver legislation are necessary?
b. Is it my understanding that VA does not currently collect any
data on family caregivers, such that we don't even know how many family
caregivers there are or the types of services they are receiving. While
I agree that we have many anecdotes to understand the burden of
caregiving, more information is needed to better help this population.
Do you believe that the annual survey and reporting requirements are
not necessary?
3. For H.R. 1546, the ``Caring for Veterans with Traumatic Brain
Injury Act of 2009,'' you state that you are not ``thrilled'' about
creating another committee to focus on another facet of combat injury.
By this comment, do you mean that you believe that there are too many
committees focusing on combat veterans' issues? If so, do you have an
alternative recommendation regarding the care and treatment of veterans
with TBI?
4. In your testimony on H.R. 1546, you recommend that we must
ensure that the operations of the TBI Committee are transparent and
that all deliberations and notes of the Committee be open to public
scrutiny. Please elaborate and explain what you mean by this statement.
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by August 3, 2009.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Vietnam Veterans of America
Silver Spring, MD.
July 23, 2009
The Honorable Mike Michaud
Chairman
Subcommittee on Health
House Veterans' Affairs Committee
335 Cannon House Office Building
Washington, D.C. 20515
Dear Chairman Michaud:
In reply to your June 22nd letter following up on our written
testimony for the hearing on health care legislation conducted by your
Subcommittee on June 18th, let me respectfully submit to you the
following:
Question 1: What other health care legislation does your
organization recommend for this Subcommittee?
Response: Concerning other health care legislation, VVA would
suggest that the Subcommittee hold a hearing on the intergenerational,
or multigenerational, effects of a veteran's exposure to Agent Orange/
dioxin while serving in Vietnam and the cancers, birth defects, and
learning disabilities that have afflicted not only his/her children but
their children as well. We hear far too many stories from the daughters
(mostly) of veterans who wonder if the health conditions that they were
born with, and that now their children have as well, could derive from
their father's service in Vietnam. The results of such a hearing might,
we would hope, suggest specific legislation concerning research into
the association between exposures to dioxin and other toxic substances
with reproduction.
In this realm, your Subcommittee might also consider looking into
the studies on groundwater contamination at Camp Lejeune, North
Carolina, from which birth defects and childhood cancers may derive.
We also would suggest your Subcommittee, perhaps in concert with
Oversight and Investigations, look into Project HERO, a pilot program
in four VISNs, that is supposed to get a handle on fee-basis health
care expenditures. We have serious concerns about this program,
particularly with regard to its ability to effectively enlist
clinicians in rural/remote areas. (Currently, all of the health care
contracts have been ``won'' by Humana, and the dental contracts by
Delta Dental.) Is HERO part of the answer in getting a handle on the 1
in 10 health care dollars expended by the VA out of the VA system?
Question 2: In a statement for the record, the Wounded Warrior
Project notes that the caregiver legislation we are considering today
are not as comprehensive as they should be. Additionally, they note
that we already know enough about the burdens of caregivers and that an
annual survey is not needed.
Question 2(a): What are your thoughts on WWP's position? Do you
believe that modifications to the caregiver legislation are necessary?
Response: Concerning caregiver legislation, certainly a
comprehensive approach is needed, one that might incorporate the
various initiatives of the draft legislation as well as H.R. 2378 and
2734.
Question 2(b): Is it my understanding that VA does not currently
collect any data on family caregivers, such that we don't even know how
many family caregivers there are or the types of services they are
receiving. While I agree that we have many anecdotes to understand the
burden of caregiving, more information is needed to better help this
population. Do you believe that the annual survey and reporting
requirements are not necessary?
Response: Yes, we do believe that the annual survey and reporting
requirements concerning caregivers are both warranted and potentially
valuable. To argue that we know all we need to know because we know it,
doesn't hold up. Anecdotal evidence is fine. Having a database of solid
information can assist the VA in adapting to the needs of caregivers,
and in tracing how dollars are expended in this admirable effort.
Question 3: For H.R. 1546, the ``Caring for Veterans with Traumatic
Brain Injury Act of 2009,'' you state that you are not ``thrilled''
about creating another committee to focus on another facet of combat
injury. By this comment, do you mean that you believe that there are
too many committees focusing on combat veterans' issues? If so, do you
have an alternative recommendation regarding the care and treatment of
veterans with TBI?
Response: Perhaps my original testimony was a bit unclear as to
what I attempted to say concerning the creation of a committee to focus
on assisting troops who return home with Traumatic Brain Injury. Often,
committees and commissions are created when legislators and Governors
and Presidents don't want to make a hard decision on a particular
issue. In this case, however, such a committee is needed, to help
coordinate and get a handle on the multitude of efforts both public and
private aimed at helping troops/veterans afflicted with TBI.
As we wrote: ``Millions of dollars have been appropriated to learn
more about [TBI]. Is this money being spent wisely and well? Which
treatment modalities are working? Which aren't? What ought to be the
role of community-based organizations in caring for veterans with such
wounds?''
Question 4: In your testimony on H.R. 1546, you recommend that we
must ensure that the operations of the TBI Committee are transparent
and that all deliberations and notes of the Committee be open to public
scrutiny. Please elaborate and explain what you mean by this statement.
Response: The discussions and deliberations during meetings should
be open to the public, and to public scrutiny, just as hearings are for
(most) Committees and Subcommittees in Congress. I think the ``and
notes'' may be a bit misleading. We do not mean that all notes and e-
mails from one Committee Member to another should be laid out to be
examined by anyone. Certainly, we recognize the necessity for private
communications between Committee Members and staff if such a Committee
is to function properly.
We hope that these responses to your questions, Mr. Chairman, offer
some illumination as to what we said in our written testimony. And we
appreciate your efforts, and that of your colleagues and staff, in a
most important undertaking.
Sincerely,
Bernard Edelman
Deputy Director for Policy and Government Affairs