[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]




 
              LEGISLATIVE HEARING ON H.R. 949, H.R. 1075,
              H.R. 2698, H.R. 2699, H.R. 2879, H.R. 3926,
                     H.R. 4006, H.R. 84, AND THREE
                           DISCUSSION DRAFTS

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 25, 2010

                               __________

                           Serial No. 111-69

                               __________

       Printed for the use of the Committee on Veterans' Affairs





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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

                                 ______

                         Subcommittee on Health

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               HENRY E. BROWN, Jr., South 
VIC SNYDER, Arkansas                 Carolina, Ranking
HARRY TEAGUE, New Mexico             CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas             JERRY MORAN, Kansas
JOE DONNELLY, Indiana                JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California           GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia               VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                             March 25, 2010

                                                                   Page
Legislative Hearing on H.R. 949, H.R. 1075, H.R. 2698, H.R. 2699, 
  H.R. 2879, H.R. 3926, H.R. 4006, H.R. 84, and Three Discussion 
  Drafts.........................................................     1

                           OPENING STATEMENTS

Chairman Michael Michaud.........................................     1
    Prepared statement of Chairman Michaud.......................    32
Hon. Henry E. Brown, Jr., Ranking Republican Member..............     2
    Prepared statement of Congressman Brown......................    32

                               WITNESSES

U.S. Department of Veterans Affairs, Gerald M. Cross, M.D., 
  FAAFP, Deputy Chief for Patient Care Services and Chief 
  Consultant for Primary Care, Veterans Health Administration....    23
    Prepared statement of Dr. Cross..............................    57

                                 ______

American Legion, Denise A. Williams, Assistant Director, Veterans 
  Affairs and Rehabilitation Commission..........................    14
    Prepared statement of Ms. Williams...........................    39
Boswell, Hon. Leonard L., a Representative in Congress from the 
  State of Iowa..................................................     5
    Prepared statement of Congressman Boswell....................    36
Brown-Waite, Hon. Ginny, a Representative in Congress from the 
  State of Florida...............................................     7
    Prepared statement of Congresswoman Brown-Waite..............    38
Disabled American Veterans, Joy J. Ilem, Deputy National 
  Legislative Director...........................................    18
    Prepared statement of Ms. Ilem...............................    47
Filner, Hon. Bob, Chairman, Committee on Veterans' Affairs, and a 
  Representative in Congress from the State of California........     3
    Prepared statement of Congressman Filner.....................    33
Giffords, Hon. Gabrielle, a Representative in Congress from the 
  State of Arizona...............................................     9
    Prepared statement of Congresswoman Giffords.................    34
Kirkpatrick, Hon. Ann, a Representative in Congress from the 
  State of Arizona...............................................    11
Paralyzed Veterans of America, Blake C. Ortner, Senior Associate 
  Legislative Director...........................................    15
    Prepared statement of Mr. Ortner.............................    41
Scalise, Hon. Steve, a Representative in Congress from the State 
  of Louisiana...................................................     3
    Prepared statement of Congressman Scalise....................    33
Veterans of Foreign Wars of the United States, Eric A. Hilleman, 
  Director, National Legislative Service.........................    17
    Prepared statement of Mr. Hilleman...........................    44

                       SUBMISSIONS FOR THE RECORD

American Federation of Government Employees, AFL-CIO.............    65
National Association of Government Employees (SEIU/NAGE), David 
  J. Holway, National President..................................    67
National Federation of Federal Employees, William R. Dougan, 
  National President.............................................    68


              LEGISLATIVE HEARING ON H.R. 949, H.R. 1075,
              H.R. 2698, H.R. 2699, H.R. 2879, H.R. 3926,
                     H.R. 4006, H.R. 84, AND THREE
                           DISCUSSION DRAFTS

                              ----------                              


                        THURSDAY, MARCH 25, 2010

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:05 a.m., in 
Room 334, Cannon House Office Building, Hon. Michael H. Michaud 
[Chairman of the Subcommittee] presiding.

    Present: Representatives Michaud, Brown of South Carolina, 
and Boozman.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I want to thank everyone for coming out this 
morning.
    Today's legislative hearing is an opportunity for Members 
of Congress, veterans, and the U.S. Department of Veterans 
Affairs (VA) and other interested parties to provide their 
views and discussions on recently introduced legislation within 
this Subcommittee's jurisdiction. This is an important part of 
the legislative process that will help encourage frank 
discussions and new ideas.
    We have a number of bills before us today. They cover a 
wide range of important issues dealing with access to VA health 
care; collective bargaining rights for VA employees; mental 
health care and counseling for individuals discharged or 
released from active duty; emotional and peer support for 
family members of the Armed Services; breast cancer among 
members of the Armed Forces and veterans; and rural health 
issues including the unique needs of Native American veterans. 
We also have draft bills before us today on reimbursement for 
continuing education, mental health counseling and bargaining 
rights and performance criteria.
    I would ask unanimous consent that my full opening remarks 
be submitted for the record. Are there any objections? Hearing 
none, so ordered.
    I look forward to hearing the views of the different panels 
today and at this time I would like to recognize Ranking Member 
Mr. Brown for any opening statement he may have.
    [The prepared statement of Chairman Michaud appears on p. 32
.]

         OPENING STATEMENT OF HON. HENRY E. BROWN, JR.

    Mr. Brown of South Carolina. Thank you, Mr. Chairman. I 
appreciate your holding this hearing today and look forward to 
working with you and the rest of our esteemed colleagues on 
these important legislative subjects.
    The ten bills being discussed this morning cover a wide 
array of veterans' issues and I look forward to learning more 
about them. Of particular interest to me is H.R. 1075, the 
``RECOVER Act,'' introduced by Mr. Scalise. H.R. 1075 would 
provide medical service to veterans in a disaster area by 
allowing VA to contract with one or more non-VA facilities.
    Making sure our veterans have access to the very finest 
care is always a top priority of this Committee, but in times 
of real emergency, that priority takes on a whole new level of 
importance. Serving a district with facilities that are 
vulnerable, to the sometimes destructive whims of nature, as I 
do in Charleston and along the coast of South Carolina, makes 
this a personal issue for me and I support Mr. Scalise in his 
efforts.
    I am also excited to hear more about H.R. 84, the 
``Veterans Timely Access to Health Care Act,'' introduced by my 
friend Ms. Brown-Waite.
    Among other provisions, this bill would make the standards 
of access to care for a veteran seeking primary care from the 
VA 30 days from the date the veteran contacts the Department. 
Ms. Brown-Waite has long been committed to making sure 
America's veterans do not have to endure long waiting periods 
before they can have access to VA care and I applaud her 
efforts.
    To all the witnesses appearing in front of us this morning, 
thank you for your dedication to improving the lives of our 
veterans. Your work does not go unnoticed, and I am eager to 
begin our discussion on the matters at hand.
    It is only by working together to advance meaningful and 
appropriate legislation that we can completely fulfill the 
promise we made to provide veterans with the best care 
anywhere. The men and women who served so bravely in uniform 
deserve nothing less.
    Again, thank you, Mr. Chairman. I yield back.
    [The prepared statement of Congressman Brown appears on 
p. 32.]
    Mr. Michaud. Thank you very much, Mr. Brown.
    So we may as well begin. I will recognize the distinguished 
Chairman of the full Committee on Veterans' Affairs, Bob Filner 
of California. I want to thank you, Mr. Chairman, for all the 
hard work that you have done over the years fighting for our 
veterans. We have made a lot of progress under your leadership 
and look forward to continuing to work with you as we move 
forward to take care of the needs of those who have bravely 
served this great Nation of ours.
    Mr. Filner.

STATEMENT OF HON. BOB FILNER, CHAIRMAN, COMMITTEE ON VETERANS' 
  AFFAIRS, AND A REPRESENTATIVE IN CONGRESS FROM THE STATE OF 
 CALIFORNIA; HON. STEVE SCALISE, A REPRESENTATIVE IN CONGRESS 
    FROM THE STATE OF LOUISIANA; HON. GABRIELLE GIFFORDS, A 
REPRESENTATIVE IN CONGRESS FROM THE STATE OF ARIZONA; HON. ANN 
  KIRKPATRICK, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF 
ARIZONA; HON. LEONARD L. BOSWELL, A REPRESENTATIVE IN CONGRESS 
     FROM THE STATE OF IOWA; AND HON. GINNY BROWN-WAITE, A 
      REPRESENTATIVE IN CONGRESS FROM THE STATE OF FLORIDA

                  STATEMENT OF HON. BOB FILNER

    Mr. Filner. Thank you, sir. Mr. Chairman, we thank you for 
your leadership on this Subcommittee and your fine working 
relationship with Mr. Brown. We appreciate the leadership that 
both of you have shown and I know I speak for all of my 
colleagues in saying that we appreciate the opportunity to talk 
about our legislation today.
    The bill that I am speaking on, H.R. 949, would improve the 
collective bargaining rights and procedures for reviews of 
adverse actions of certain VA employees. This bill is about 
ensuring equity amongst the health care professionals employed 
at VA so that the providers such as doctors, nurses, dentists, 
chiropractors, optometrists, and podiatrists who are hired 
under the so-called ``pure title 38'' system have the same 
rights as their fellow VA health care professionals hired under 
different hiring systems.
    Without this bill, the ``pure title 38'' providers do not 
have the right to challenge errors in pay computations and lack 
other key bargaining rights enjoyed by their colleagues at the 
VA.
    To address this problem, H.R. 949 would clarify that these 
``pure title 38'' providers have equal rights to collective 
bargaining. This means they would be able to challenge 
personnel actions through such methods as grievances, 
arbitrations, and labor-management negotiations.
    This bill would also require the VA to review the adverse 
personnel action and issue a final decision no later than 60 
days after the employee appeals the adverse personnel action.
    Finally, the bill would subject the VA's final decision on 
the employee's appealed adverse personnel action to judicial 
review in the appropriate U.S. District Court or the U.S. Court 
of Appeals for the Federal Circuit.
    I know the VA has some concerns with this and they are in 
discussions with the stakeholders. I look forward to working 
with all of them as we move forward on this legislation.
    Again, thank you again for the opportunity of sharing these 
thoughts with you.
    [The prepared statement of Congressman Filner appears on p. 
33.]
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Mr. Scalise.

                STATEMENT OF HON. STEVE SCALISE

    Mr. Scalise. Thank you, Mr. Chairman and Ranking Member 
Brown, as well as all the distinguished Members of the 
Subcommittee for the opportunity to testify. I want to just let 
you know this bill, H.R. 1075 is bipartisan legislation with 
over 19 cosponsors. It seeks to maintain vital health services 
to veterans in the event that a VA hospital is closed due to a 
federally declared disaster.
    Before I begin discussing my bill, I would like to thank 
you and all of the Members of the Committee for the work that 
you do on behalf of our Nation's veterans. The welfare of our 
veterans and their families is of great importance to me. I 
first filed this legislation during the 110th Congress when I 
served as a Member of the Veterans' Affairs Committee.
    Our Nation is grateful for the courage our veterans have 
displayed and the sacrifices they have made in order to protect 
America and the freedoms we enjoy today. I believe as you do, 
that it is our obligation to provide them the same honor and 
dedication that they provided us during their service.
    Hurricane Katrina flooded and closed the New Orleans VA 
Medical Center, leaving our veterans without the full services 
of their medical home. Unfortunately, nearly 5 years later, our 
VA hospital still remains closed. As a result, veterans 
throughout Southeast Louisiana face increased challenges and 
hardship to obtain the quality health care they deserve. The VA 
made a commitment to open a new hospital, which won't occur 
until as early as 2013, but with the current delays, I remain 
concerned about the status of veterans health care in the 
interim and want to make sure this doesn't happen again to any 
of our Nation's veterans in the future.
    That is why I introduced H.R. 1075, the ``RECOVER Act.'' My 
bill would ensure that the VA must establish a contract with at 
least one non-VA facility to provide inpatient services in the 
event that a VA hospital will be closed for at least 6 months 
due to any federally declared disaster.
    Nothing in this bill would prevent a veteran from seeking 
care within the VA system, if he so chooses.
    Just last week I spoke with a veteran who had to travel to 
another State for post-operative care because the New Orleans 
VA Hospital is still not open. Veterans still have to travel 
more than 350 miles for cardiac surgery and also have to travel 
to other States for mental health care as well.
    Several veterans with chronic conditions did not seek care 
after the storm because they did not know what their options 
were. This concerns me very much, and my bill seeks to 
eliminate these hardships. The RECOVER Act will also prevent 
families from having to travel hundreds of miles just to visit 
their loved ones who are undergoing treatment in the hospital.
    As the respected group Disabled American Veterans (DAV) 
said, when they expressed their support for this Act, ``Family 
support and caregiving have been shown to accelerate recovery 
time and reduce costs and length of hospital stays.''
    In the aftermath of a disaster, the last thing our veterans 
and their families should have to worry about is where to seek 
basic care. I commend the Southeast Louisiana Veterans Health 
Care System for the initiative they have taken to provide 
health care in light of the hospital's closure. The community 
outpatient clinics have been extremely valuable in delivering 
primary care and other services. We learned valuable lessons 
after Hurricane Katrina, and I want to make certain that no 
veteran has to travel long distances or experience long wait 
times to receive basic care in the event that their local VA 
hospital is closed due to a natural disaster, whether it be a 
hurricane, tornado, earthquake or any other disaster.
    My office is working with the veterans service 
organizations (VSOs) to address any issues they have as this 
bill moves through the legislative process. Let me also 
emphasize that this in no way undermines our strong commitment 
to the VA health care system. Our goals are the same. Veterans 
and their families need to have options for receiving quality 
care close to home in the most convenient way possible, all 
while working to expedite the rebuilding of our VA hospital 
that was closed due Hurricane Katrina.
    I continue working hard to cut through the red tape and 
expedite the rebuilding of the New Orleans Medical Center that 
was devastated and closed by Hurricane Katrina's devastation. I 
look forward to working with you and Members of the full 
Committee as we move forward.
    Again, I thank you for your dedication to our Nation's 
military veterans and I appreciate this opportunity to testify 
before the Subcommittee. I yield back.
    [The prepared statement of Congressman Scalise appears on 
p. 33.]
    Mr. Michaud. Thank you very much for your testimony.
    Mr. Boswell.

              STATEMENT OF HON. LEONARD L. BOSWELL

    Mr. Boswell. Thank you, Mr. Chairman and Mr. Brown. We have 
spent a few hours together and I know both of you are patriots 
and you care about veterans and I thank you for your service 
and I appreciate the kind words you said to Chairman Filner.
    This Committee has done a lot of good work the last several 
years and you are to be commended.
    That's why I thank you for inviting me here today to share 
some of the things with you that I want to talk about. As you 
know, women are currently the fastest growing veteran 
population, today, representing 8 percent of the population.
    As the demographics of the military continue to change, we 
find our VA system is struggling to serve the unique needs of 
this growing population and it is believed that by 2020, 15 
percent of veterans using the VA for health care will be women, 
and I would like to maybe step out of order a bit and introduce 
to you, if I could, Mr. Chairman, Alexis Taylor.
    Alexis, please stand up. I hope I don't embarrass her too 
much, but she's my Legislative Director, she's an Iraqi veteran 
and because of what I am about to share with you has a lot to 
do with why I hope that this legislation will get serious 
consideration.
    What this means is veterans health care, which is now 
primarily tailored to men needs to undergo significant changes 
and needs to do it quickly. In particular, one health concern 
that has been largely ignored is the prevalence of breast 
cancer in our servicewomen and women veterans. So that is why 
we have introduced, and I say ``we,'' Alexis and I, H.R. 3926, 
the ``Armed Forces Breast Cancer Research Act.''
    This legislation would require the Secretary of Defense and 
the Secretary of Veterans Affairs to collaboratively study the 
incidence rate of breast cancer in servicemembers and veterans. 
This study would focus on the number of servicemembers who have 
deployed in support of Operation Iraqi Freedom and Operation 
Enduring Freedom, the demographic information of those 
servicemembers and veterans, an analysis of the clinical 
characteristics of breast cancer diagnosed and possible 
exposures to cancer-at-risk factors.
    The idea of this bill came about when a member of my staff, 
which you have just met, Alexis, who is an Iraq veteran, went 
back to Iowa for a 5 year post-deployment reunion with her unit 
and others, and one of the women of her unit had returned home 
from serving her country, and was diagnosed with breast cancer 
and had to undergo a double mastectomy at age 25.
    Through the course of the night, the servicemembers at the 
reunion were able to piece together, talk to one another, about 
six women that were deployed, they were deployed with, who had 
come back from their deployment in Iraq with breast cancer, all 
between the ages of 25 to 35 years old.
    Also, there were another half a dozen women who returned 
with new lumps in their breasts and needed additional tests 
such as mammograms, ultrasounds and/or biopsies. With 70 women 
deployed at the battalion of about 700, the incidence rate in 
these young women seemed high and alarming as Alexis brought 
this to my attention.
    I would like to note that this legislation has been 
endorsed by the Veterans of Foreign Wars (VFW) and the Iraq and 
Afghanistan Veterans of America (IAVA) and I would like to 
submit both letters, which I have here with me into the record.
    Mr. Michaud. Without objection, so ordered.
    Mr. Boswell. Thank you. In recent years the U.S. medical 
and research communities have stepped up their efforts on 
breast cancer detection, research and treatment in the 
country's civilian population. However, women who have served 
in our Nation's Armed Force have largely been excluded from 
these studies, despite their exposure to cancer risk factors 
and access to medical care.
    A recent study of U.S. Department of the Defense (DoD) and 
National Cancer Institute compose the prevalence of certain 
types of cancer among active duty military personnel of the 
general public. The study found that breast cancer among women 
is more common in the military than in the general population 
and that further studies are needed to confirm these findings 
and explore contributing factors.
    So that is our goal for this legislation, to find out if 
our servicewomen do have a higher risk of breast cancer than 
the rest of the women in the country and why that might be, so 
that ultimately we can determine if breast cancer, as a 
service-connected disability, which I truly believe it is, if 
it is, we need to know.
    At this moment in history it is particularly important to 
consider what we can do to better serve the brave individuals 
who fight for our security and liberty once they return home.
    And I would like to thank you again for allowing us to come 
before this Committee. And I have a personal passion about this 
somewhat. As you already know and I am not going to elaborate 
on it, I am a veteran, too, and I know that some of the 
maladies I have shared with you and you know about is because 
of a thing called Agent Orange, new at that time. This caused a 
lot of problems. I was very much exposed to it.
    And if something's going on in this theater of operations 
that exposed our women to breast cancer and we could do 
something about it and we don't, shame on us. I feel very 
strong about it and I know that you do, too. So I ask you to do 
everything we possibly can do to move forward on this issue, 
and I would look forward to any questions you might have. Thank 
you.
    [The prepared statement of Congressman Boswell, and the 
referenced letters, appear on p. 36.]
    Mr. Michaud. Thank you very much, Mr. Boswell. And Alexis, 
thank you for your service to our great country, as well as 
keeping Mr. Boswell. Thank you very much.
    Ms. Brown-Waite.

              STATEMENT OF HON. GINNY BROWN-WAITE

    Ms. Brown-Waite. Thank you, Mr. Chairman and Ranking Member 
Lamborn. I, as you can tell, I have a little bit of laryngitis, 
which my husband used to call ``a husband's prayers answered.''
    First of all, I want to say that the Committee does great 
work and I truly miss being on this Committee.
    As of November 2009, there were nearly 8 million veterans 
enrolled in the VA health system. With new veterans entering 
the system every day and approximately 174,000 Operation 
Enduring Freedom and Operation Iraqi Freedom patients receiving 
VA care, it is clear that it is our duty, our Nation's duty to 
serve our veterans and I believe that that duty is as strong 
now as it ever was. Today, there are 153 VA medical centers and 
768 community-based outpatient clinics available to serve these 
veterans.
    When a veteran calls to schedule an appointment in one of 
these facilities, they should be able to receive an appointment 
that is timely and appropriate to their medical needs. 
Unfortunately, for many veterans this simply does not happen. 
The VA lauds itself for completing 99 percent of primary care 
appointments within 30 days of the desired date. However, this 
means if their figures are accurate, that nearly 32,000 
patients are still waiting beyond the 30 days.
    Additionally, there is a very discernable difference 
between existing patients and new patients as only 88.8 percent 
of new patients complete their appointments within 30 days of 
their desired date. We all know that health care delayed is 
health care denied and our Nation's veterans deserve much 
better than this.
    In September of 2007, the VA Office of the Inspector 
General found that the Veterans Health Administration's method 
of calculating waiting times of new patients understates the 
real waiting times. In this report, the Inspector General made 
five recommendations to reduce these wait times. To date, four 
of the five recommendations remain unresolved.
    When I was first elected to Congress, I inquired about wait 
times from my local VA community-based outpatient clinics and 
hospitals. The numbers the VA gave me, both for Veterans 
Integrated Services Network (VISN) 8 and nationwide, quite 
honestly did not match the stories that I was hearing from my 
veterans. I challenged them on it and I told them that I was 
going to be in their offices watching and waiting and talking 
to individuals.
    What was happening was, they were making the appointments 
within 30 days, but then around the 20th day they would call 
and change the appointment to a later date, so it would be 
maybe 40, maybe 50 days.
    For this reason, I introduced the bill H.R. 84, the 
``Veterans Timely Access to Health Care Act.'' It would make 
the standard for a veteran seeking primary care from the 
Department of Veterans Affairs 30 days from the date the 
veteran actually contacts the Department with no games allowed 
to be played. Veterans shouldn't have to wait more than 30 days 
to receive an appointment.
    The VA does provide a high level of care to all of the 
veterans who are enrolled in the system. This is why the 
majority of patients actually rank their care, their overall 
satisfaction as ``very good'' or ``excellent,'' regardless of 
whether they are receiving inpatient or outpatient care.
    I want to make sure that it is clear that this bill is not 
a scheme to move the VA toward privatization. I simply want to 
make sure that the veterans receive care in a very timely and 
appropriate manner.
    As Members of Congress, we have an obligation to ensure 
that those veterans do receive the best health care available 
to them. If they are having problems receiving it within 30 
days, then Congress needs to allow them to look for an 
alternative, and that's exactly what this bill does. And I 
appreciate this hearing today to determine whether the VA is 
meeting the goal of timely access to health care.
    You know, our Nation's veterans did not wait 30 days to 
answer the call of duty. They answered the call, took up arms 
and protected our very freedoms. They deserve that same 
dedication and steadfastness from us.
    With over 116,000 veterans living in my district, I have 
the distinguished honor to meet with these true American heroes 
on a regular basis. And over and over again, I still hear about 
how difficult it is to schedule an appointment with a doctor in 
a timely manner.
    Congress recently allowed for advanced appropriations for 
the VA, and I think that is an excellent idea. This new funding 
structure should allow the VA to properly manage their funds 
and hire the necessary staff to meet the demand at the VA 
facilities.
    Congress and the administration must not turn the care of 
our Nation's veterans into a political issue. Instead, we must 
all work together to ensure that they receive health care they 
risked so much to earn. We must continue these practices that 
already work and improve on those that may be failing. H.R. 84 
does just that.
    And with that, Mr. Chairman and Members, I yield back the 
balance of my time.
    [The prepared statement of Congresswoman Brown-Waite 
appears on p. 38.]
    Mr. Michaud. Thank you very much, Ms. Brown-Waite and also 
thank you for your years serving on this Committee as well.
    Ms. Giffords.

              STATEMENT OF HON. GABRIELLE GIFFORDS

    Ms. Giffords. Good morning, Mr. Chairman. Thank you and 
Ranking Member Brown for allowing me the opportunity to 
testify. I'd like to talk to this Committee because this is the 
Committee that has been specifically looking at supporting the 
needs of America's veterans, and I look forward to working with 
all of you on this Committee toward this endeavor.
    I also want to thank the veterans service organizations 
that are in attendance today or perhaps watching, for their 
commitment to the men and women in uniform and their lifetime 
of service to our country.
    The two bills that I have brought before you today that I 
have sponsored, H.R. 2698 and H.R. 2699, will have a direct 
impact on improving the behavioral health of our Nation's 
heroes and their families in our communities.
    As a Member of the House Armed Services Committee who 
represents more than 25,000 servicemembers and dependents and 
nearly 96,000 veterans and retirees in my southern Arizona 
district, we have really seen firsthand the trials and 
tribulations of our servicemembers who are returning home from 
the frontlines.
    I know this issue is one that is close to all of our 
hearts, and I am hopeful that today's hearing signifies an 
important step in moving this vital legislation forward and 
passing it this Congress.
    There is no cause more honorable than service to our 
country. As our Nation's warriors bravely step into the breach, 
we must be prepared to care for them when they return home, no 
matter what condition they return home in.
    In war, our soldiers, sailors, airmen and marines face 
unspeakable horrors, sometimes on a daily basis, and 
readjusting to every day life is a long and complicated 
process. Every day thousands of our Nations bravest men and 
women are suffering from different degrees of post-traumatic 
stress disorder (PTSD). In recent years, diagnosed cases of 
PTSD have increased by more than 50 percent for servicemembers 
returning from overseas deployments, and many experts believe 
that the actual number is much higher because a large number of 
servicemembers are reluctant to seek care and seek treatment.
    For an untold many diagnosed with the worst warning signs 
of PTSD, there simply are no easy fixes. We see each month the 
unfortunate and deeply saddening results of the Department of 
Defense when it releases its numbers of servicemember suicides. 
The trend is currently hovering slightly above the national 
average, more than double what it was 5 years ago.
    PTSD and other related behavioral health issues severely 
affect an individual's ability to perform every day functions 
that we take for granted. PTSD, though, is treatable through a 
variety of methods, including behavioral therapy and medication 
with the majority of servicemembers seeing an improvement after 
just one or two sessions with a behavioral therapist.
    Unfortunately, we all know there are not enough of these 
behavioral health care providers within the military or the VA 
to treat our servicemembers, their families or surviving 
spouses for the anguish that they are suffering. What is worse 
still is that there aren't enough therapists to treat one 
another.
    Ultimately, our ailing heroes or the families they leave 
behind, must wait to see a caregiver, they often receive 
incomplete or inadequate care or in some cases do not receive 
care at all, leading to one of the few inevitable conclusions--
depression, anger management problems, substance abuse or, the 
worst case, death.
    This is the first of many clear signs the system is failing 
our men and women in uniform and badly needs to be fixed. H.R. 
2698 establishes a scholarship for service program that 
provides educational benefits to those training in behavioral 
health care specialties critical to the operations at Vet 
Centers. These individuals would then pay back the investment 
by serving as a behavioral health care specialist at Vet 
Centers across the country.
    Because of the unprecedented nature and a lingering lack of 
understanding surrounding PTSD and its symptoms, many former 
servicemembers do not realize they are suffering until long 
after they have left service. My bill, H.R. 2699, would permit 
our Nation's Guardsmen and Reservists to access behavioral 
health care at Vet Centers even after they have been released 
from active duty and it will then provide referrals to assist 
them to the maximum extent possible in obtaining behavioral 
health care and services from sources outside of the 
Department.
    H.R. 2698 and H.R. 2699 will ensure that the Veterans 
Administration carries out a competitive grant program for non-
profit organizations that provide peer-to-peer emotional 
support services for servicemembers, veterans, and survivors, 
including members of the National Guard and Reserve who are 
often left out because of the changing nature of their service 
or the accessibility of care in local communities.
    I underscore that.
    Mr. Chairman, you have been to my district. It is over 
9,000 square miles. Many of these servicemembers return home to 
areas that are very far from any local Vet Center and 
partnering with non-profits that have the training and 
expertise so that they don't have to drive 3, 4, 5 hours to 
receive treatment is critical.
    The unfortunate fact is that 10 years ago, we hardly 
understood the existence of PTSD, we didn't understand it quite 
to the extent that we do today and today we have only a 
patchwork quilt of treatments, forms and meetings, training 
seminars and online courses that these servicemembers must 
complete, alongside other regular recertifications and 
proficiency tests.
    What we are not doing is taking a comprehensive look at 
this problem and designing a smarter and more realistic 
solution.
    I am committed to fixing these problems and I know Mr. 
Chairman and Members of this Committee are committed as well, 
and I just want to thank you for allowing me the opportunity to 
share the story and to introduce these bills because I really 
do think it would make a significant difference to our 
servicemembers. Thank you.
    [The prepared statement of Congresswoman Giffords appears 
on p. 34.]
    Mr. Michaud. Thank you, too, for your commitment to helping 
our veterans.
    Mrs. Kirkpatrick.

               STATEMENT OF HON. ANN KIRKPATRICK

    Mrs. Kirkpatrick. Mr. Chairman, Ranking Member Brown and 
Members of the Committee, thank you for holding this hearing 
and providing me with the opportunity to address two bills that 
I have introduced, H.R. 4006, the ``Rural, American Indian 
Veterans Health Care Improvement Act of 2009,'' and H.R. 2879, 
the ``Rural Veterans Health Care Improvement Act of 2009.''
    The Rural, American Indian Veterans Health Care Improvement 
Act will make it easier for many Native American veterans 
living in rural areas to access quality health care options. So 
many Native Americans have sacrificed and given their lives in 
service to this country throughout our Nation's history with 
the brave and honorable service of the Navajo Code Talkers 
being just one example.
    In fact, the VA estimates that 22 percent of Native 
Americans are veterans or are currently serving, more than any 
other ethnic group. America has a sacred obligation to keep its 
promises to them. Too often Washington has not met that 
obligation and Native American veterans frequently struggle to 
get the benefits they have earned.
    For instance, my district is home to 11 tribal communities 
spread out across an area larger than 26 States and yet it is 
served by only one VA medical center. Many veterans in Arizona 
who live on tribal lands have to drive for hours to get basic 
care. My bill directs the VA to establish Indian Health 
Coordinators in areas with a high population of Native American 
veterans.
    These coordinators will work directly with Native American 
veterans to find innovative ways to improve outreach to tribal 
communities and help those veterans work with the VA. My bill 
would also explore common sense ways for the VA to coordinate 
with the Indian Health Service (IHS).
    At the national level, the Secretary of Veterans Affairs 
would be directed to work with the Secretary of the Interior to 
streamline the electronic transfer of health records for Native 
American veterans between the VA and IHS.
    At the local level, Indian Health Coordinators would work 
with their IHS counterparts to better serve the medical needs 
of veterans in tribal communities.
    Finally, my bill would require a joint report by the 
Secretaries of Veterans Affairs and Health and Human Services 
(HHS) to find other methods to expand service to Native 
American veterans including through the establishment of new 
clinics.
    My other bill, the Rural Veterans Health Care Improvement 
Act builds on the Rural, American Indian Veterans Health Care 
Improvement Act with an even more comprehensive effort at 
allowing veterans living in rural areas to access medical 
services.
    The health care provided by the VA is undeniably among the 
best in the world, but that does little good to veterans in 
rural areas who have trouble making the trip to the clinic. 
This bill helps them address this challenge by making it easier 
and cheaper for veterans to actually get to VA health care 
providers. This bill would lock in the current health care 
travel reimbursement rate for disabled veterans at 41.5 cents 
per mile, up from 11 cents just a few years ago.
    Further, it authorizes the VA to award grants to veterans 
service organizations that transport veterans to their 
appointments, making it possible for them to expand and improve 
these helpful services.
    When I visited with our troops in Afghanistan last May, I 
was told time and again that our brave men and women need 
better access to mental health services. That is why this bill 
also expands peer support programs and allows the VA to 
cooperate with community providers already in place to ensure 
that those who need care can get it.
    I believe that it is our Nation's sacred duty to pay back 
the eternal debt of gratitude we owe to our veterans, starting 
at the very moment a citizen signs up to serve.
    As the daughter and niece of veterans, this is incredibly 
important to me personally and I am determined to push 
Washington to live up to its responsibilities. I believe that 
these two bills are important steps in the right direction.
    I thank you again for this chance to discuss these measures 
and I stand ready to answer any questions you may have.
    Mr. Michaud. Thank you very much, Mrs. Kirkpatrick. I want 
to thank all the panel members for bringing forward these very 
important pieces of legislation. I look forward to working with 
you as we move forward with markups later this year.
    I have no questions for the panel. I understand neither 
does Mr. Brown, so I would recognize the Ranking Member of the 
Economic Opportunity Subcommittee, Mr. Boozman, who has done a 
phenomenal job, along with Chairwoman Herseth Sandlin, in that 
Subcommittee and I want to thank you for working very hard with 
our Congresswoman Herseth Sandlin to move forward legislation 
on your Subcommittee in such a bipartisan manner, Mr. Boozman?
    Mr. Boozman. Well, thank you very much, Mr. Chairman. First 
of all, I would like to introduce--I have three students here 
that have come by. They are up here trying to figure out how 
Washington works, which is kind of scary, but let me introduce 
them real quick--Kaity Dye, Christopher Jordan and Caleb 
McDaniel. And these are all students from Arkansas that are 
part of a program that is learning more about--I think it is so 
neat that they are here today in the Veterans' Affairs 
Committee because we hear so much about all the rancor that is 
going on here and the lack of working together, but truly in 
this Committee, it comes down to veterans and we are totally, 
Mr. Filner's left, but under his leadership and Mr. Buyer, who 
truly are committed to helping veterans and I appreciate your 
leadership on this Subcommittee.
    I would like to just--you guys can go ahead and sit down. I 
know you have to go. Again, thank you for being here.
    I would like to comment just briefly on Mr. Scalise's bill, 
H.R. 1075, and it brings to the forefront a very serious and 
important issue regarding how VA is providing care to veterans 
when a medical center is destroyed as a result of a natural 
disaster. Quite honestly in such cases, the entire VISN, not 
such that area but the entire VISN is impacted by the extra 
resources needed to provide fee basis care. It creates a 
shortfall for all of the medical facilities in the VISN. So I 
ask you when a disaster creates a need for a VISN to incur a 
substantial increase in fee basis care expenses, why that money 
comes from the VISN's budget. I am really not directing that to 
you, Congressman. I guess that--again, this a problem that I am 
asking that question since this is something that we have to 
figure out.
    The funding should come out of VA Central, the office 
budget, and I look forward to working with you, Steve, to see 
if we can maybe insert something or work with you with your 
legislation to really--we just have a number of different 
problems that are incurred as a result of these whenever 
incidents occur. So we look forward to working with you.
    Mr. Scalise. Thank you and I will continue to work with you 
and other groups. And I will commend--the Congresses over the 
last few years after Katrina have made a strong commitment to 
ensure that our VA hospital will be rebuilt and, in fact, the 
moneys have been appropriated. Unfortunately, there have been a 
lot of delays for a number of reasons why we haven't even still 
been able to break ground.
    So at the earliest it would be 2013 before this new 
facility is going to be built and our veterans have been in 
limbo for almost 5 years now, and you know, the funding issues 
we will continue to work on. I understand there are some 
agreements now that are being put in place by the VA to at 
least provide some alternative sources of care in that interim. 
Unfortunately, some of those agreements didn't even occur for 4 
years, and so this bill is just focused on making sure that the 
veterans are taking care of and can still get care without 
being shuttled around to other States in some cases, but not at 
the detriment of any other hospitals within the VISN. But 
clearly our commitment to making sure the rebuilding occurs is 
still strong. But in the meantime, we just want to make sure 
our veterans have somewhere to go to get that basic care and I 
will continue to work with you.
    Mr. Boozman. I agree with you totally. I guess, the problem 
is, is not only are you impacted in the New Orleans area by not 
having that facility, but your veterans' care throughout the 
entire State is impacted because instead of the money coming 
from the Central Office, it comes from all of our resources in 
the VISN, so it is kind of a two-edged sword. Not only are 
veterans impacted but your veterans in the rest of Louisiana 
and then Arkansas, the rest of the VISN, they are also impacted 
because instead of the money coming, like I say, from the 
Central Office, it is coming from the VISN, which is unfair. I 
mean, this is----
    Mr. Scalise. Right.
    Mr. Boozman [continuing]. This is not a VISN problem. This 
is a total----
    Mr. Scalise. It is a national problem.
    Mr. Boozman. It is a national VA problem, so, but we 
appreciate your leadership very, very much.
    Mr. Scalise. Thank you.
    Mr. Boozman. Thank you. I yield back.
    Mr. Michaud. Thank you very much, Mr. Boozman, and the 
Veterans Equitable Resource Allocation model is another big 
issue that we have been trying to get a handle on and we will 
continue to look forward to seeing what we can do to improve on 
that model to make sure that areas, especially rural areas, are 
not hampered in that effort, so thank you. Thank you very much.
    Mr. Buchanan, do you have any questions for the panel 
before we dismiss them?
    Mr. Buchanan. No.
    Mr. Michaud. Once again, I would like to thank the panel 
for coming today and for bringing forward your legislation. I 
look forward to working with each of you as we move forward 
later on this year. So once again, thank you very much. And 
thank you for your dedication in making sure that veterans get 
the help that they need. Thank you.
    I would ask the second panel to come forward, please. On 
the second panel we have Denise Williams from the American 
Legion, Blake C. Ortner from the Paralyzed Veterans of America, 
Eric Hilleman from the VFW, and Joy J. Ilem from the Disabled 
American Veterans. I want to thank all of you for coming here 
this morning. I look forward to your testimony and we will 
start with Ms. Williams.

STATEMENTS OF DENISE A. WILLIAMS, ASSISTANT DIRECTOR, VETERANS 
 AFFAIRS AND REHABILITATION COMMISSION, AMERICAN LEGION; BLAKE 
  C. ORTNER, SENIOR ASSOCIATE LEGISLATIVE DIRECTOR, PARALYZED 
   VETERANS OF AMERICA; ERIC A. HILLEMAN, DIRECTOR, NATIONAL 
  LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED 
STATES; AND JOY J. ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, 
                   DISABLED AMERICAN VETERANS

                STATEMENT OF DENISE A. WILLIAMS

    Ms. Williams. Mr. Chairman and Members of the Subcommittee, 
thank you for the opportunity to present the American Legion's 
views on the several pieces of legislation being considered by 
the Subcommittee.
    I will give oral comments on three pieces of legislation in 
the interest of time. H.R. 1075, timely and open access of 
quality care for veterans is a major priority for the American 
Legion and this legislation is consistent with our efforts in 
this regard.
    The American Legion does, however, have some concerns. 
Although such contracts would certainly be helpful during a 
disaster in which VA medical facilities are not available, we 
do not want such an arrangement to become a disincentive for VA 
to quickly repair or replace damaged facilities. This bill also 
does not address length of the contracted care, long-term care 
or how quality of care would be assessed.
    H.R. 3926, the ``Armed Forces Breast Cancer Research Act.'' 
The American Legion fully supports this timely and important 
legislation given the recent breast cancer incidents among male 
veterans that were stationed at Camp Lejeune. Moreover, 
according to the Clinical Breast Care Project at Walter Reed 
Army Medical Center, there have been over 2,000 cases of breast 
cancer diagnosed in both males and female active-duty 
servicemembers within the last decade.
    The Center further stated that breast cancer is the single 
greatest cause of cancer death among women under 40 and is a 
significant cause of mortality for women in the Armed Forces. 
The American Legion would also encourage inclusion of the 
Reserve component in this study.
    Proposed legislation to amend title 38 concerning mental 
health counselors.
    The American Legion believes VA should be staffed with the 
best qualified professionals to ensure this Nation's veterans 
receive timely access to quality health care, especially mental 
health services. With servicemembers returning from Iraq and 
Afghanistan with complex and overlapping illnesses and 
injuries, it is imperative VA maintains its charge to ensure 
its medical professionals are properly trained and fully 
qualified to provide quality care. According to the National 
Institutes of Health, injuries and illnesses such as mild 
traumatic brain injury (TBI) and post-traumatic stress disorder 
respectively, have several symptoms in common. Among these are 
irritability, concentration deficits, amnesia for the causal 
event, reduced cognitive processing ability and sleeping 
disturbances.
    Clearly, this situation adds to the difficulty in 
diagnosing PTSD in patients with TBI. The American Legion 
contends that due to the complexity of these illnesses and 
injuries, such as TBI and PTSD, the most qualified mental 
health professionals are required. Therefore, the American 
Legion is opposed to waiving current requirements relating to 
mental health counselors.
    Mr. Chairman, once again, the American Legion appreciates 
the opportunity to address these issues and looks forward to 
working with your colleagues and the staff in advancing 
legislation that will make a positive difference in the lives 
of our servicemembers, veterans and families. This concludes my 
written statement and I welcome any questions that you or your 
colleagues may have concerning the American Legion's views, 
comments and recommendations.
    [The prepared statement of Ms. Williams appears on p. 39.]
    Mr. Michaud. Thank you very much, Ms. Williams.
    Mr. Ortner.

                  STATEMENT OF BLAKE C. ORTNER

    Mr. Ortner. Mr. Chairman, Ranking Member Brown and Members 
of the Subcommittee, on behalf of Paralyzed Veterans of 
America, I would like to thank you for this opportunity to 
present PVA's position on the legislation before the 
Subcommittee.
    PVA generally supports most of the bills presented here 
today. In the interest of time, I will highlight details only 
for legislation with which we have specific issues.
    PVA cannot support H.R. 84, the ``Veterans Timely Access to 
Health Care Act,'' which would establish standards of access to 
care within the VA health system. PVA has testified on similar 
legislation in the past and is still unable to support it.
    Under the provisions of this legislation, VA will be 
required to provide a primary care appointment to veterans 
seeking health care within 30 days of a request for an 
appointment. If a VA facility is unable to meet the 30-day 
standard, then the VA must make an appointment with a non-VA 
provider, thereby contracting out the health care service.
    While access is indeed a critical concern of PVA, the 
number of veterans enrolled in the VA is continuing to 
increase. Unfortunately, funding for VA health care in the past 
has had difficulty keeping pace with the growing demand. Even 
with the passage of Advance Appropriations and the record 
budgets in recent years, funding is not guaranteed to be 
sustained at those levels. PVA is concerned that contracting 
health care services to private facilities when access 
standards are not met is not an appropriate enforcement 
mechanism for ensuring access to care. In fact, it may actually 
serve as a disincentive to achieve timely access for veterans 
seeking care.
    PVA is also concerned about the continuity of care. If 
veterans are shifted between the VA and non-VA facilities each 
time the imposed standard is not met, how will this affect the 
quality of care these veterans receive? This is neither an 
effective nor efficient way to supply health care and in the 
long run may be detrimental to the veteran. For these reasons, 
PVA cannot support H.R. 84.
    PVA supports H.R. 949 introduced by Chairman Filner that 
will more quickly resolve adverse actions and set deadlines for 
final decisions and strongly supports H.R. 1075, the ``RECOVER 
Act.''
    During periods of major disasters, ensuring veterans have 
uninterrupted access to health care is critical to their well-
being. PVA would only caution that this arrangement should not 
inadvertently lead to delays in repairing or replacing VA 
facilities damaged during the disaster. More critically, this 
contracting authority should not become the default health care 
policy for meeting the needs of veterans in a disaster area.
    PVA supports H.R. 2698, the ``Veterans and Survivors 
Behavioral Health Awareness Act,'' and H.R. 2699, the ``Armed 
Forces Behavioral Health Awareness Act.''
    While the scholarship provisions in the legislation are not 
targeted or reserved for veterans, PVA would encourage VA to 
market the scholarships to veterans who will best be able to 
relate to veterans visiting the Vet Centers or other 
facilities.
    PVA supports H.R. 2879, the ``Rural Veterans Health Care 
Improvement Act of 2009,'' and H.R. 4006, the ``Rural, American 
Indian Veterans Health Care Improvement Act of 2009.''
    PVA recognizes that there is no easy solution to meeting 
the needs of veterans who live in rural areas and that Native 
Americans often face even tougher challenges. These rural 
veterans were not originally the target population of men and 
women that the VA expected to treat. However, the VA decision 
to expand to an outpatient network through community-based 
outpatient clinics reflected the growing demand on the VA 
system from veterans outside typical urban or suburban 
settings.
    However, while these paths may show promise, they should 
still fit within the policies that promote the use of VA 
facilities and should not be used as a method to eliminate VA 
facilities in rural areas. While all of these ideas are 
welcome, the greatest need still is for qualified health care 
providers to be located in rural settings. Only significant 
incentives and opportunities for these professionals will bring 
them to these often remote areas.
    PVA strongly support H.R. 3926, the ``Armed Forces Breast 
Cancer Research Act.'' With the growing number of women that 
comprise members of the Armed Forces and their increasing 
involvement in forward operating areas and combat activities, 
it only makes sense to examine the potential increased risk of 
breast cancer among this population.
    Regarding the draft legislation before us today, PVA 
supports the legislation to raise the reimbursement rate for 
health professionals from $1,000 to $1,600 and cautiously 
supports the legislation to waive certain requirements relating 
to mental health counselors, but want to ensure that this is 
done only in the circumstances that will benefit veterans and 
VA health care.
    Regarding collective bargaining, PVA generally supports the 
provisions of the draft legislation that would improve the 
collective bargaining rights and procedures for certain health 
care professionals in the VA.
    VA must work with their employees to achieve a less hostile 
work relationship, but any changes or modifications to either 
side of the issue must first address the care of veterans. 
Furthermore, this care should not be used as a rallying cry on 
either side as an argument for their position. Veterans deserve 
better.
    PVA appreciates the opportunity to comment on these bills 
being considered and I would be happy to answer any questions 
that you may have. Thank you very much.
    [The prepared statement of Mr. Ortner appears on p. 41.]
    Mr. Michaud. Thank you very much.
    Mr. Hilleman.

                 STATEMENT OF ERIC A. HILLEMAN

    Mr. Hilleman. Thank you, Chairman Michaud, Ranking Member 
Brown, Members of the Subcommittee.
    On behalf of the 2.1 million men and women of the Veterans 
of Foreign Wars and our auxiliaries, I thank you for the 
opportunity to testify before you today on the bills pending 
before the Subcommittee.
    The VFW supports the draft bill for continuing education at 
Veterans Health Administration (VHA), of VHA staff. We also 
support the draft bill to improve performance pay and 
bargaining rights.
    The VFW further supports H.R. 2698, the ``Veterans and 
Survivors Behavioral Health Awareness Act,'' and H.R. 2699, the 
``Armed Forces Behavioral Health Awareness Act.''
    Further, VFW supports H.R. 2879, the ``Rural Veterans 
Health Care Improvement Act of 2009,'' and we strongly support 
H.R. 3926, the ``Armed Forces Breast Cancer Research Act,'' and 
we support H.R. 4006, the ``Rural, American Indian Veterans 
Health Care Improvement Act of 2009.''
    If I may, Mr. Chairman, I would like to speak exclusively 
to our support for one piece of legislation that is of 
particular importance to the overall preparedness of the VA 
hospital network, H.R. 1075. This bill would require the VA 
Secretary to seek outside contacts in the event a VA hospital 
is closed for greater than 180 days due to a national disaster. 
Currently, when VA hospitals are closed, veterans must travel 
long distances to other VA facilities, which may be impractical 
or impossible following a disaster. This bill ensures that the 
VA secures alterative arrangements for local medical care to 
include non-emergency care and inpatient services.
    The VFW supports this legislation. However, we feel 180 
days is far too long for a veteran to wait for medical 
services. We urge the Veterans' Affairs Committee to hold 
hearings elevating VA's current disaster contracting 
provisions. Allowing a veteran to wait 180 days for medical 
care is unacceptable. Contracts to provide health care must be 
in place before a VA hospital shutters its doors due to a 
national disaster. The VFW believes that plans need to be 
implemented immediately in the event of disasters.
    Now, moving on to H.R. 84, the ``Veterans Timely Access to 
Health Care Act.'' The VFW supports the intent of this 
legislation, Veterans Timely Access to Health Care Act. 
However, we cannot support this bill.
    This legislation would require the Secretary to contract 
for care for any veteran who would wait more than 30 days for 
primary care. The VFW has supported guaranteed access standards 
for VA health care for a number of years, but we remain 
concerned about the quality and the cost of care.
    With the advent of advanced appropriations, VA now has the 
capacity to ensure the ability to properly plan and manage 
these dollars. Additionally, on-time funding should allow VA to 
recruit, train and hire doctors, nurses and other health care 
providers, ensuring that VA is sufficiently staffed to keep up 
with demand. Congress has made great strides in improving the 
stream of veterans' health care for which the VFW applauds your 
efforts, but a greater attention is needed to ensure health 
care dollars are spent appropriately in each medical facility.
    We strongly support the reporting requirements in H.R. 84. 
The reporting mechanisms on wait times would help gain a better 
accurate measure by which to analyze wait times and access to 
care. Better numbers would allow us to understand the problems 
and prevent them in the future.
    Moving on to H.R. 949, the VFW has no position on this 
legislation.
    Finally, Draft Bill Waiving Requirements for Mental Health 
Counselors. The VFW opposes this legislation to allow the 
Secretary to waive licensure or certification requirements. The 
VA may be facing shortages of mental health professionals, but 
we believe making exceptions in lieu of valid State-issued 
certifications undermines the quality of care and the 
confidence that veterans have in speaking with VA mental health 
professionals.
    State licensure and certification demonstrates that an 
individual meets the State requirements in which areas of 
prerequisite education and knowledge and is culpable under the 
law for any malpractice or abuse of the unique trust placed in 
that specific position.
    Thank you for the opportunity to testify today, Mr. 
Chairman and we welcome any questions.
    [The prepared statement of Mr. Hilleman appears on p. 44.]
    Mr. Michaud. Thank you.
    Ms. Ilem.

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Thank you, Mr. Chairman and Members of the 
Subcommittee.
    DAV also appreciates the opportunity to offer our views on 
the bills under consideration today.
    The stated goal of H.R. 84 is to provide timely access to 
VA health care. Under this bill, if VA failed to substantially 
comply with the 30-day standard, the facilities in that area 
would be required to contract for care.
    DAV has always had concerns about automatic contracting of 
VA care to solely meet access standards. Those patients lose 
the quality, safety and other protections VA provides in its 
specialized medical programs. Additionally, we have stressed 
the need for VA to develop a comprehensive and systemwide 
process for contract care to ensure the quality of care of 
veterans seen by contractors is on par with that provided to 
veterans using VA.
    While DAV does not support the automatic contract for care 
mechanism in this measure, we would endorse an amendment to 
H.R. 84 to enact data and reporting requirements of the bill. 
We also recommend adding provisions to identify the underlying 
causes for any current delays in access to VA care, an issue 
that is critical to VA's developing an effective solution to 
reducing and managing minimum waiting times.
    H.R. 949 seeks to restore bargaining rights for certain VA 
health professionals. As a partner organization in The 
Independent Budget, DAV endorses the need for VA to address 
employee's concerns about their working conditions to make VA a 
better workplace for the best care of sick and disabled 
veterans. For these reasons, we support the intent of the bill, 
but continue to urge both VA and Federal unions to seek and 
find a basis for compromise on these issues.
    I was pleased to see in VA's testimony this morning that a 
workgroup has been established to address the specific issues 
included in the bill. This appears to be a positive step 
forward and we are hopeful this process will lead to an 
agreement that is acceptable to both sides and one that keeps 
the focus squarely on the best interest of veterans' care.
    H.R. 1075 requires that in the event of an officially 
declared disaster where a VA medical center is unable to 
provide inpatient care services for at least 180 days, VA must 
contract with one or more non-VA facilities in that area to 
provide those services.
    This Subcommittee is aware of DAV's general cautionary 
position on contract care. However in the case of a significant 
disaster with long-term consequences in the affected area, VA 
should establish more temporary contracts with private 
facilities outside the affected city area for inpatient 
services. For this reason DAV supports the purposes of this 
bill as a contingency only and we recommend the issues related 
to improve contract care coordination be addressed before the 
bill advances.
    H.R. 2698 aims to improve and enhance mental health care 
benefits available to all veterans, as well as to enhance 
counseling to survivors of veterans. In the fiscal year 2010 
Independent Budget section on human resource challenges, we 
recommend that Congress, and VA work to strengthen and energize 
its human resource management programs to recruit, train and 
retain qualified employees. Therefore, we support enactment of 
section 2 of the bill pertaining to health professional 
scholarships. We have no objection to the remaining provisions 
in the measure.
    H.R. 2699 would make certain active servicemembers eligible 
for readjustment counseling in VA Vet Centers and enhance 
counseling available to their family members. We support a 
seamless transition for servicemembers to veteran status and 
improved collaboration between the two Departments. Therefore, 
we have no objection to this bill.
    However, we ask the Subcommittee to consider amending 
section 2 of the measure to require cost sharing with DoD or to 
authorize additional VA resources needed to provide these 
services to active duty personnel.
    H.R. 2879 with some concern outlined in our full statement, 
we support enactment of this bill in accordance with DAV's 
resolutions related to VA's beneficiary travel reimbursement 
policy and improving rural care services and access.
    H.R. 3926 would direct the secretaries of DoD and VA to 
jointly conduct a study on the incidents of breast cancer among 
members of the Armed Forces and veterans. We support the 
passage of this bill in accordance with DAV resolution 252 
which urges greater collaboration between DoD and VA to share 
exposure and related data for military operations in order to 
address the subsequent health concerns of disabled veterans, 
whatever the causes.
    DAV also supports H.R. 4006, the ``Rural, American Indian 
Veterans Health Care Improvement Act of 2009.'' Studies 
indicate this population reports high rates of unmet need, 
fragmentation of care and an overall lack of health care 
coordination.
    The intent of this bill appears beneficial to help resolve 
the unique health care issues of this population. The DAV has 
no adopted resolutions specific to the final three draft 
measures under consideration, but offer no objections to these 
draft bills.
    Mr. Chairman, that concludes my statement. I am happy to 
answer any questions.
    [The prepared statement of Ms. Ilem appears on p. 47.]
    Mr. Michaud. Thank you very much for your testimony, as 
well as the other three panelists.
    I guess I have just one question. You spoke about VA 
working more collaboratively with DoD to study breast cancer. 
It is my understanding that the VA currently has nine ongoing 
studies on breast cancer and I believe they have already 
completed three studies.
    Do you agree with the VA that they have to conduct broader 
studies rather than studying breast cancer in the way that is 
in the legislation? We will start with Ms. Williams.
    Ms. Williams. I think there needs to be definitely more 
study, especially with the servicemembers on active duty that 
are returning. I am not exactly sure about the studies that are 
ongoing in VA regarding--maybe my fellow VSO members are aware 
of that. But we would support the DoD conducting studies 
because of the data that we received from Walter Reed regarding 
the breast cancer incidents.
    Mr. Michaud. I don't know if any other----
    Mr. Ortner. Mr. Chairman, I think that the need for 
expansive studies, especially in the case of breast cancer is 
critical. I am not so sure, necessarily looking and saying, 
well, there are nine studies ongoing, therefore, enough is 
being done simply because of the wide variety of studies that 
can be done, specific instances of studies. For instance, there 
may be a number of studies facing just women with breast cancer 
and not the incidence of men because that is an unusual or 
becoming for usual, but an unusual case, so I still think there 
is need for that legislation.
    Mr. Hilleman. Mr. Chairman, our remarks would concur with 
both previous statements. I am not personally familiar with the 
number of studies or the studies' details, but this study being 
both broad and including DoD and VA seems like a logical thing 
to pursue.
    Ms. Ilem. I would ask if any of those studies include the 
data information that is in the bill you are considering with 
regard to toxic environmental exposures and troop locations in 
those areas or if it is just breast cancer incidents within the 
veteran community because I think that would be critical. I 
mean, we hear more and more about burn pits and these other 
possibly toxic exposures that veterans are facing returning. 
And so it would be proper to, I think include that.
    With your reference to VA making this broader and not just 
specific to one disease, it is noted in their testimony. I 
think, you know, we would like to see, surely VA tracking any 
sort of trends that should occur within the veteran population 
that may be related to these toxic exposures and the different 
environments that veterans are facing in these deployments. So 
that takes the greater collaboration of both agencies to be 
able to do that to avoid what happened in the Gulf War with 
regard to, you know, ongoing studies and the concern over 
health, subsequent health concerns. Thank you.
    Mr. Michaud. Thank you. Mr. Boozman.
    Mr. Boozman. Thank you, Mr. Chairman. First of all, I want 
to thank you all. We have had a number of Members offer 
suggestions as to how we can improve the VA situation, and as 
always, your all's testimony in perspective is such that what 
we all work toward is preventing unintended consequences of 
good ideas.
    But H.R. 84, trying to deal with a problem that we have 
been dealing with forever, the lengthy waiting times. I guess 
my question for the panel would be, we all know this is a 
problem. Is there a way, do you feel like we could amend H.R. 
84 in some way to make it such that waiting times are more 
appropriate? I know that some of you have expressed concern 
about the particular bill.
    What could we do in your mind to go ahead and make it such 
that we could whittle these times down even further?
    Ms. Ilem. I will take a stab at that. I think Ms. Brown-
Waite made some very important points in her remarks this 
morning. Obviously, she is very committed to trying to address 
this problem and resolve it. One thing that I think we would 
probably like to see would be to make sure that we get accurate 
waiting time information from VA, which has been addressed and 
she mentioned the Inspector General's report and their 
recommendations so that we really have an accurate view across 
the system, as well as where are there specific target areas 
that really are having some access issues.
    Additionally, I think we would want to have provisions in 
that bill that really get at what, you know, what are the real 
problems for this. We just don't see the benefit of sending 
people outside the system that may be more costly care. VA can 
do it in emergencies or if medically necessary and they can't 
get someone seen in a timely manner. They already have that 
authority and we would like to see VA take care of those 
patients so they have all the benefits of the system and find 
out where these waiting time issues are and if that needs to be 
addressed in terms of the advanced appropriation, better 
planning and that type of outcome versus just for having them 
go outside the system.
    Mr. Hilleman. If I might, Mr. Boozman, from a personal 
experience, it seems that hospitals develop solutions for 
bottlenecks in care. I seek treatment here in Washington, DC, 
and I have experienced after hours of appointments for MRIs and 
other bottlenecks within the system where appointments can't be 
made in within 30 days, but I have also had the adverse 
experience that in a 30-day referral, I couldn't get an 
appointment.
    There are some creative solutions that can happen locally, 
but I feel, and I would think that most of the organizations 
would have a similar approach that we can't solve problems 
unless we understand them first.
    So a comprehensive study would be something the VFW would 
definitely support.
    Mr. Ortner. Sir, like all the comments of my colleagues, 
unfortunately when we look at this, we think the idea of 
setting the 30-day standard and then sending someone off to 
contract care is too simple an answer. It seems like the easy 
answer and a simple way to do it.
    Our greatest concern has to do with a second and third 
order of facts of what that leads to. Does that then become the 
standard answer, hey, if we get backed up, we are going to go 
ahead and contract it out. But more importantly, I think, 
especially from PVA's standpoint, the concern about the 
continuity of care for our members. I know, personally, I don't 
like going to a different doctor. I go to my doctor. I drive a 
long distance to get my doctor because of that.
    My concern would be if we do have, if we do have this 
ability to contract it out, unless you are all of the sudden 
going to decide that individual is now going to be contracted 
to a different provider indefinitely, he is going to be jumped 
back and forth between the system and we think that is just too 
much of a risk to the veteran.
    Ms. Williams. The American Legion, we did state that we 
support this bill and that is because when we look at the 
overall legislation, we felt like this would give VA an 
opportunity to have a comprehensive view of the issue with 
timely access to care.
    So if it is enacted, our major concern is with timely 
access to care. So if they do enact it, we would like for VA to 
utilize this as a means to examine the long wait time for 
veterans to receive care.
    Mr. Boozman. Thank you. The other thing--can I do--I guess 
I worry a little bit also, yeah. I alluded to this with the 
situation that we have in New Orleans where the VISN becomes 
responsible rather than district-wide, so you might have a VISN 
where, and you correct me if I am wrong, but you might have a 
VISN where you have a problem and you don't who knows why that 
problem is, and then you might have a very efficient group 
within that VISN, too.
    But theoretically, the entire VISN would pay for that 
contracted care. Is that correct? I mean--is that, would that 
be correct back there? It wouldn't? So it would come out of the 
system versus the VISN? Okay, good. Very good.
    Thank you guys, again. I really do appreciate your 
perspective on these things. Thank you.
    Mr. Michaud. Mr. Perriello or Mr. Brown.
    Once again, I would like to thank you for your testimony 
today and I look forward to working with you as we move forward 
with these individual bills. Thank you.
    I would ask the third and final panel to come forward, Dr. 
Cross, who is accompanied by Mr. Hall, Mr. McVeigh and Ms. 
Vandenberg from the VA.
    Once again, I would like to thank you, Dr. Cross, for all 
the hard work you and the other panelists do to make sure that 
our veterans get the help that they are entitled to and deserve 
and your dedication to our veterans is to be commended. So, 
without any further ado, Dr. Cross.

  STATEMENT OF GERALD M. CROSS, M.D., FAAFP, DEPUTY CHIEF FOR 
 PATIENT CARE SERVICES AND CHIEF CONSULTANT FOR PRIMARY CARE, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
   AFFAIRS; ACCOMPANIED BY WALTER A. HALL, ASSISTANT GENERAL 
COUNSEL, OFFICE OF GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS 
   AFFAIRS; BRIAN MCVEIGH, CHIEF CONSULTANT, HUMAN RESOURCES 
MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
 VETERANS AFFAIRS; AND PATRICIA VANDENBERG, MHA, BS, ASSISTANT 
  DEPUTY UNDER SECRETARY FOR HEALTH FOR POLICY AND PLANNING, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

    Dr. Cross. And thank you, Mr. Chairman and the Committee 
for the great work that you do and your dedication as well.
    Good morning, Mr. Chairman and Members of the Subcommittee. 
It is a pleasure to appear before you again today to discuss 
legislation. I am accompanied by Walt Hall, Assistant General 
Counsel; Brian McVeigh, Chief Consultant, Human Resources 
Management; and Patricia Vandenberg, Assistant Deputy Under 
Secretary for Health for Policy and Planning.
    I would like to concentrate my remarks today on the three 
areas covered by this legislation, first, VA's human resource 
policies, including work with our union colleagues. Second, our 
efforts to improve care for rural veterans, and finally, our 
work to improve counseling and mental health access.
    We appreciate the many positive contributions, collective 
bargaining and labor management partnership make to VA's 
mission. VA and its labor partners signed a charter in 
September of 2009 to develop recommendations for the Secretary 
to improve knowledge, understanding and consistent use of the 
authorities and limitations in section 7422 of title 38.
    The workgroup consists of representatives from VA's five 
national unions and VA's lead representative is the new 
Assistant Secretary for Human Resources in Administration. We 
anticipate this workgroup will resolve the concerns that are 
the basis of H.R. 949. However, we strongly oppose H.R. 949. It 
would make patient care and clinical competency decisions 
subject to the review of non-clinical third parties, parties 
without health care expertise.
    We believe that the collaborative efforts of VA and its 
union partners in the workgroup can address the concerns about 
the interpretation and application of section 7422. Until such 
time as those efforts have been given an opportunity, we 
believe that legislative changes to section 7422 are premature.
    VA also does not support the draft bill that would require 
VA to reimburse all title 38 health professionals for up to 
$1,600 per year for their continuing medical education 
requirements. The bill would, of course, be costly, diverting 
resources from the veterans health care and we believe is 
unnecessary. VA has no objection to the draft bill that would 
create an exception to allow VA to employ mental health 
counselors who have not yet completed their licensure or 
certification requirements.
    We know that VA currently has a parallel statutory 
authority to appoint psychologists and clinical social workers 
who work under supervision for up to 2 years before they have 
completed their licensure or certification.
    Regarding our efforts to improve care and access for rural 
veterans, VA has initiated a number of programs that meet the 
intent of H.R. 2879 and H.R. 4006. We have established three 
Veterans Rural Resource Centers and a Veterans Rural Health 
Advisory Committee to improve care and services for veterans 
residing in geographically isolated areas. The centers are 
operational and are conducting important work, which my written 
statement describes in greater detail.
    VA also is developing pilot programs to implement 
innovative transportation services at various rural health care 
facilities and is supporting cooperation and resource sharing 
between the Indian Health Service and VA. Moreover, we are 
undertaking pilot programs at the direction of Congress in 
section 107 and 403 to Public Law 110-387, which will provide 
millions of dollars to support expanded fee-basis care in rural 
areas.
    VA believes it is more appropriate to evaluate the results 
of this pilot projects before beginning new initiatives so that 
we can ensure resources are best used to serve veterans.
    Furthermore, VA's enhancing assistance for family members. 
The Vet Center Program, for example, is taking steps to enhance 
access for veterans' families by hiring the additional staff 
necessary to place qualified family counselors in every Vet 
Center. And when it is necessary for their rehabilitation and 
treatment of the veteran, VA provides education and training 
prior to the veteran's discharge from care to ensure that 
family members can tend capably to the veteran's health care 
needs.
    The final area I would like to discuss includes our efforts 
to improve our counseling and mental health programs. 
Specifically, VA supports section 3 of H.R. 2698, which would 
direct VA to provide referrals, to assist individuals not 
otherwise eligible for VA services in obtaining mental health 
care and services outside VA.
    In advising such individuals of their rights to apply for 
review of their discharge or release, this would specifically 
help former servicemembers with problematic discharges.
    VA appreciates the concept of using scholarships to enhance 
succession planning, but section 2 of H.R. 2698 is unnecessary. 
Implementation of this provision would result in substantial 
costs to VA over a long period of time with very little short-
term benefit. It takes 2 to 7 years of education to qualify to 
become a VA behavioral health specialist. VA recommends 
reauthorization of the Health Profession Education Assistance 
Scholarship Program instead, as this program would be more 
effective and include more disciplines. Moreover, VA has had 
great success in hiring new counselors. In the past 3 years, VA 
has hired more than 5,800 additional mental health counselors.
    This concludes my prepared statement, Mr. Chairman. We 
would be, of course, pleased to respond to any questions that 
you have.
    [The prepared statement of Dr. Cross appears on p. 57.]
    Mr. Michaud. Thank you very much, Dr. Cross. I appreciate 
your testimony.
    What is your understanding of the current status of the 
Indian Health Service's electronic health care records, their 
capacity? Is it the same capacity as in the VA system?
    Dr. Cross. My understanding is that we are going for the 
broader solution, working with something called National Health 
Information Network (NHIN), which is our strategy to move 
forward, not just within VA and IHS or VA and DoD, but more 
broadly with our community partners as well. This is more of a 
national strategy going far beyond what we have looked at in 
the past. I think that we have testified on that to some degree 
before, but I think the strategy to engage with them is really 
part of that broader strategy.
    Mr. Michaud. Thank you. And what about with breast cancer? 
We heard some discussion about working with DoD and I know that 
there are nine ongoing VA studies and I think you have 
completed three. How comprehensive are those studies?
    Dr. Cross. First of all, we understand the importance and 
the sensitivity of this subject. We are absolutely committed to 
getting every bit of research done that would be beneficial to 
our veterans. And by the way, the research that we do helps not 
only our veterans but the Nation at large.
    We do have about nine studies underway, working through 
some remarkable issues that will, I think, produce dramatic 
outcomes, I hope, down in years to come where, particularly 
regarding the DNA component of this, genes and so forth, that 
we are working on.
    My understanding is that we have done some studies in the 
past on prevalence and I would be happy, you know, if the 
Committee prefers, to provide those for the record. But I don't 
want anything that I say to show any lack of concern or lack of 
intent to pursue this issue. We are very much committed to try 
and help be part of the solution for this problem.
    Mr. Michaud. And I appreciate it. I think sometimes Members 
of Congress and VSOs might not know all the work that the VA is 
doing in these different areas, so I would be interested. If 
you would submit that to the Committee, I would appreciate it 
very much.
    [The VA subsequently provided the following White Paper 
regarding studies done in the past by VA's Office of Research 
and Development (ORD) on breast cancer.]
            Short Descriptions of ORD Breast Cancer Studies
Cell-Cell Interactions During Breast Tumor Angiogenesis: Role of NRP-1

  Metastatic or spreading breast cancer requires a pathway to allow 
escape of the breast cancer cells from the breast into the general 
circulation and then potentially to all tissues. This proposal will 
delineate the mechanism whereby proteins made by the breast cancer 
effect changes in the vascular smooth muscle that allow the cancerous 
cells to escape from the breast. Understanding how these proteins 
effect changes in the blood vessels surrounding the cancer will provide 
potential targets for various therapy modalities, such as chemotherapy 
or using the immune system to block the action of these proteins.

The Roles of WISP-2/CCN5 Signaling in Breast Cancer Development

  This project will use non-invasive human breast cancer cells to 
identify the mechanism that leads to inhibition of apoptosis or 
programmed cell death. Once the components of the mechanism are 
identified then it will be possible to identify inhibitors of one of 
these components so that apoptosis or regulated cell death in the 
cancerous cells would be stimulated and thereby reducing the number or 
possibly even eliminating the cancerous cells.

The Role of CCN5 in Breast Cancer Progression

  Breast cancer cells transition from non-invasive (non-metastatic) 
cells into invasive or metastatic cells. A key element of the 
transition, which requires estrogen, will be further characterized in 
the hopes of developing another target for various therapeutic 
approaches.

Estrogen Receptor Regulates c-Jun Activity in Breast Cancer Cells

  Estrogen receptor is known to play a significant role in the 
development of breast cancer. The investigator has identified a 
protein, phosphorylated (the addition of a PO4 moiety from Adenosine 
triphosphate (ATP), the molecule generated from the breakdown of 
nutrients) c-jun, that becomes blocked from its normal action when 
estrogen receptor has been activated. When c-jun action is blocked, the 
cancerous cells multiply instead of dying (apoptosis), which results in 
the growth of the cancer. This study will determine the mechanism to 
unblock this protein, which would allow cancerous breast cells to 
undergo apoptosis or death instead of being stimulated to grow.

Estrogen Receptor, p38 MAPKs and Topo IIa in Breast Cancer

  There are various receptors on the outer membrane of breast cancer 
cells that are activated when they bind a receptor-specific activator 
or ligand. Many of the receptors in breast cancer cells are tyrosine 
kinases or enzymes that are responsible for phosphorylating (putting 
the terminal phosphate (PO4) from ATP onto a protein) specific 
tyrosines (an amino acid) in other proteins. These tyrosine 
phosphorylated proteins then mediate the transformation of a normal 
breast cell into a cancerous breast cell. There have been several 
clinically useful therapies based on inhibiting these receptors. 
However, as time passes the receptor is no longer inhibited by these 
treatments. This leads to renewed growth of the cancer. This proposal 
will test the idea that another receptor protein kinase can make the 
breast cancer cells more sensitive to the chemo/immuno-therapetic 
agents, which would restore their ability to inhibit the growth and 
spread of the cancerous cells.

STATs as Key Targets in Tumor Angiogenesis

  Growth and progression of breast cancer depends on the formation of 
new blood vessels (angiogenesis) to bring the blood nutrients and 
oxygen to the cancer. Cancer cells secrete several growth factors that 
recruit blood vessels from the surrounding tissue. Therefore, it is 
plausible that targeting blood vessel growth could be an effective 
cancer treatment approach. Recent clinical trials have shown that drugs 
designed to inhibit a vessel-inducing factor slow down tumor growth and 
prolong survival; unfortunately, blood vessels growth eventually resume 
that leads to resumed growth of the cancer. This proposal will focus on 
identifying inhibitors of several growth factors with the intent of 
using multiple inhibitors at one time to inhibit angiogenesis to the 
point that the tumor either dies or becomes much smaller because there 
is a lack of nutrients and oxygen needed for breast cancer to grow.

Targeting the COX-2 Pathway to Reduce Breast Cancer Mortality

  Cyclooxgenase 2 enzyme, commonly known as COX-2, is highly enriched 
in breast cancers and treatment this COX-2 inhibitors limit breast 
cancer growth and metastasis or spreading to other tissues. However, 
COX-2 inhibitors have recently been shown to have cardiac toxicities, 
which limit their use in patients with breast cancer. One of the major 
compounds generated by COX-2 is prostaglandin. Prostaglandin is a major 
regulatory agent and it mediates many physiological processes such as 
blood clotting. Prostaglandin mediates its numerous physiological 
effects through interacting with prostaglandin receptors. This proposal 
will identify which of these receptors activates breast cancer growth. 
Once identified, the next step will be to find inhibitors of this 
receptor, which should reduce the growth of breast cancer.

Targeting Breast Cancer Metastases: Role of Chemokine Heparanase

  The principal goal of this study is to investigate a possible genetic 
influence on the development of secondary lymphedema (LE) in breast 
cancer survivors. Lymphedema or swelling of the lymph nodes and 
lymphatic vessels in breast cancer survivors leads to swollen arms, 
discomfort and skin infections. This occurs because mastectomies can 
remove the normal pathway for the lymph generate in the arm to return 
to the general circulation. The question is of great importance, for if 
a genetic predisposition to secondary LE can be identified, therapy may 
be better tailored for patients or they can be made more aware of 
possible complications. Improved care of breast cancer survivors is of 
great significance.

Quality of Locoregional Breast Cancer Treatment for Breast Cancer in 
VHA

  The immediate objectives of this multi-year retrospective study are: 
1) To determine if the quality of surgical care provided for women with 
locoregional breast cancer in the VA is comparable to that provided in 
the private sector; 2) To identify factors within the VA system that 
are associated with quality of care (process and outcome measures) for 
locoregional breast cancer; and 3) To provide policy recommendations 
regarding how to improve the quality of treatment based on the results 
of this analysis. Ultimately, our long-term goal is to improve patient 
outcomes for women veterans with breast cancer.

Regulation of Breast Cancer Growth by MLK-3

  A protein kinase (MLK3), an enzyme that phosphorylates another 
protein, has been discovered to be highly active in breast tumors and 
is involved in the activation of another protein (Pin1), which has 
previously been implicated in breast cancer pathogenesis. The project 
will investigate the mechanism by which MLK3 regulates Pin1, and will 
examine the application of MLK inhibitors as potential therapeutic 
approach for breast cancer treatment.

CARP-1: A Potential Therapeutic Agent for Breast Cancer

  This study will further characterize how the cell cycle and apoptosis 
regulatory protein 1 (CARP-1) inhibits transformation of normal to 
cancerous breast cells. Elucidation of the mechanism of action of CARP-
1 will provide specific targets to be used in the design of 
chemotherapeutic agents. These agents will provide additional means to 
limit the growth of breast tumors.

Actively Targeted Nanoparticulate Paclitaxel to Treat Breast Cancer

  The proposed studies will develop nanoparticles containing 
Paclitaxel, a breast cancer chemotherapeutic agent. These nanoparticles 
will be specifically designed to enter only breast cancer cell. This 
will allow the delivery of higher doses of Paclitaxel without having 
harmful effects on normal cells throughout the body. Furthermore, this 
specificity will allow for much longer treatment times, which greatly 
increases the likelihood arresting the further growth of the cancer and 
maybe even killing all of the cancerous cells.

Identification of Breast Cancer Genes in Archival Pathology Specimens

  Normal breast epithelial growth and differentiation, benign 
proliferative growth and breast cancer are each under the complex 
control of various growth factor genes. This study will systematically 
investigate inherited genetic variation within these genes for their 
contribution to breast cancer risk among women with a history of benign 
breast disease. The combined genetic and pathological predictors of 
elevated breast cancer risk identified in this study will enable the 
identification of those women who would most benefit from more 
intensive screening, those who may be at increased risk associated with 
hormone replacement therapy or those who may benefit from prophylactic 
therapeutic agents to alter the function of the estrogen receptor.

    Mr. Michaud. You heard earlier testimony about what happens 
when a disaster strikes. Could you tell us exactly what happens 
when a disaster hits? How does that region get funding, if need 
be, from the Central Office to deal with it then and how do you 
cope with the disaster and how do you help veterans get care, 
if they do lose a hospital? How quickly can you gear up to take 
care of those needs?
    Dr. Cross. We don't have today, as a Department, formal 
comments on H.R. 1075, but I can certainly comment on what 
happened during Katrina and how we respond to that and those 
two elements that you talked about.
    First of all, in regard to funding, certainly we first look 
to the VISN for their support when we have hurricanes and so 
forth, but if there's a large disaster such as a Katrina, 
certainly the rest of the organization comes into play and the 
Central Office typically has maintained a reserve fund just for 
this kind of situation where there is a disaster of unusual 
proportions to come to the rescue with funding from Washington.
    In regard to New Orleans, I wanted to mention that we do 
have a program there working with one of our community 
partners, Tulane University, to provide hospital care, and we 
have been doing that for a long time. Our average daily census 
there is about 18 or 19 patients right now. And by the way, we 
have a floor and our staff go over there and take care of the 
patients as inpatients.
    In regard to the concept, there's something called hospital 
in a hospital and we used this as a solution, a partial 
solution after Katrina to help maintain continuity of care and 
also to have a familiar face and the same kind of technology 
systems that VA is already famous for to continue that care 
even in that setting. Certainly we are looking forward to our 
new hospital there as well.
    Mr. Michaud. Thank you. Mr. Brown.
    Mr. Brown of South Carolina. Dr. Cross, are you planning to 
replace the hospital in New Orleans in the location where it 
exists now?
    Dr. Cross. Sir, I will provide that to you for the record. 
I don't have that in my testimony today, but I understand great 
progress is being made and the funding worked out and I think 
everybody that I am aware of at my office is very optimistic 
about how this is going to move forward.
    Mr. Brown of South Carolina. I know you weren't here during 
that time. I know this is not part of the discussion, but it 
did come up because of the way the payments are going to be 
handled for lack of service; I went down with the Secretary at 
that time right after Katrina, and the hospital itself was in 
good sound condition, but what happened, was the water got into 
the basement and that is where most of the utilities, the air 
conditioning and so forth were. But it looked to me if that 
could have been pumped out and the air conditioning units 
repaired, that could have saved all that mold that accumulated. 
But a veteran asked a question, if it was going to be torn down 
and replaced by new construction.
    Dr. Cross. Yeah, it is a different site, but I would rather 
give you a written response on these.
    [The VA subsequently provided the following information:]

          The new hospital will not be in its existing location. VA has 
        selected a site in Mid-City New Orleans. The architect 
        submitted the design development package of the new medical 
        center in February 2010. As required by section 106 of the 
        National Historic Preservation Act, consulting parties met to 
        discuss the design. A detailed, site-specific environmental 
        assessment (SEA) in compliance with the National Environmental 
        Policy Act requirements was completed on March 31, 2010. The 
        Notice of Availability for the Finding of No Significant Impact 
        and the SEA were published on April 4, 2010. The New Orleans 
        City Council approved revocation of rights-of-way for the 
        streets within the site boundaries on April 22, 2010. VA 
        obtained ownership of the Pan-Am building on June 3, 2010. VA's 
        designers have completed the HazMat survey of the Pan-Am 
        building and are preparing abatement plans to incorporate into 
        construction documents for the building renovation.
          Negotiations continue among the City, State and VA to 
        expedite the acquisition process and mitigate further delays. A 
        groundbreaking ceremony was held June 25, 2010.

    Mr. Brown of South Carolina. Okay.
    Dr. Cross. That plan for the old facility. You know, there 
are other issues, as well, regarding that facility, the design, 
the changes that have taken place in medical care to better 
meet the needs of veterans currently in a more modern approach, 
you know, so much more now the VA highlights outpatient 
services and doing things like same-day surgery and those kind 
of things, more so than we did when that facility was built.
    Mr. Brown of South Carolina. And I guess if I could maybe 
even do a little special ad for my location in Charleston. We 
have been trying to do something to make some accommodations 
between the VA and the medical university there; and it is, you 
know, VA hospital is basically the same existing thing, and we 
at Charleston are certainly prone to hurricanes, we had Hugo 
back about 20 years ago if Hugo would hit in direct strike to 
Charleston, we would have been in real trouble; that is what we 
are trying to do now is to be proactive so we could have some 
cross sharing between the VA and the medical university just as 
a backup.
    I know down in New Orleans all those hospitals were in very 
low lying regions and I guess most of all the rest of those 
hospitals are going to probably be replaced, too. But my 
question in line with that is, I know that it sounds pretty 
simple to say if you can't provide service within 30 days, then 
we need to move into some kind of a private practice, but 
recognizing the opposite of doing that, all the records have to 
be transferred and a lot of times--I know just in my personal 
case where I go from one doctor to another doctor, they have to 
do a little bit of catch up procedures, too, to be sure that 
they have everything in--so it is not as easy to just implement 
it.
    But in light of that, who pays for it? Do you all have a 
national pot of money that would handle that or would that 
hospital be responsible for those charges or would the VISN be 
responsible?
    Dr. Cross. The local facility would bear some 
responsibility in terms of trying to practice efficiently in 
covering those expenses, including the fee-basis care but that 
is part of our overall appropriation for fee-basis care that we 
spend every year.
    Let me comment on what you said earlier, sir. From my 
understanding first of all, the 30 days, our true objective is 
to give the patients care when they need it, when they want it, 
and to not be so arbitrarily focused on a number of days. I 
think that is good medical care and that produces better 
satisfaction.
    And by the way, in regard to mental health care, we have a 
15-day standard for new patients, and so we have already moved 
beyond 30 days in that category because we understood the 
challenges facing our veterans.
    So for a new patient seeking mental health care, we do an 
evaluation within 24 hours, 7 days a week. That may be by 
phone, but we do some evaluation to check on them and see how 
acute their need is. And then we get them a comprehensive 
evaluation within that 15-day period.
    Mr. Brown of South Carolina. I tell you what. I want to 
compliment you for the VA hospital in Charleston. It certainly 
gives a great service to the veterans in our community.
    Dr. Cross. Thank you.
    Mr. Brown of South Carolina. I thank you all for being part 
of this discussion today.
    Dr. Cross. Thank you, sir.
    Mr. Michaud. I know the VA works with other agencies. For 
instance, on nursing homes, you work with CMS in other areas, 
we have asked you to work with the Department of Health and 
Human Services on federally qualified health care clinics and 
there are overlays where the care has recommended certain 
access points.
    My question is particularly in light of the new health care 
legislation that was passed this past Sunday, in dealing with 
other agencies, in this particular case Health and Human 
Services, how collaborative have they been and do you find that 
they are holding you back on issues that this Committee and 
other Committees might have asked the VA to look at? If you saw 
some of the bills we have before us today, they concern health 
access issues in rural areas. I think that is part of the slow 
process in getting access points up and running under the 
Capital Asset Realignment for Enhanced Services (CARES) 
process.
    So how much delay is there, or is working with other 
agencies not really a problem?
    Dr. Cross. No, sir, I don't think we have any problem at 
all really working with other agencies, you know, whether it be 
HHS or DoD. I have often commented that I am absolutely 
surprised at the degree of intense engagement and very 
collaborative engagement that we have with DoD. We see the same 
patients at different parts of their lives, and I think people 
would be very pleased if they could see all the meetings and 
all the collaboration. I know my counterparts on a first name 
basis. We meet together so frequently. We share committees 
together. We cochair committees together. We work through so 
many issues together.
    I think you should be well pleased that there is a great 
deal of work at my level and many other levels in a very 
collaborative framework with DoD, IHS and so forth. The head of 
IHS was in my office just a few months ago talking about what 
we can work on together and we have already started a project. 
It regards our Suicide Prevention Hotline, and we have arranged 
for the Indian Health Service staff to train my staff at the 
Suicide Prevention Hotline on cultural sensitivities dealing 
with Native American and American Indian veterans.
    I think that there were a few things that we were missing 
and just talking to her educating me about some terms that I 
may use or our staff may use, they have different meanings to 
them than it does to us. And so we have already started that 
program working with the National Suicide Prevention Hotline to 
make sure that we are very sensitive to their needs. That is an 
example of the kind of collaboration that we have been working 
on.
    Mr. Michaud. Once again, thank you very much. I really 
appreciate all the hard work and dedication that VA employees 
give to our veterans and look forward to working with you as we 
move forward with these pieces of legislation we have before us 
today and other issues before this Subcommittee, and ultimately 
full Committee. Once again, Dr. Cross, thank you, and the 
panels for coming here today. I really appreciate it.
    If there are no other questions, I will adjourn this 
hearing.
    [Whereupon, at 11:36 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. This is an 
important part of the legislative process that will encourage frank 
discussions and new ideas.
    We have a number of bills before us today. They cover a wide range 
of important issues dealing with access to VA health care; collective 
bargaining rights for VA employees; mental health care and counseling 
for individuals discharged or released from active duty; emotional and 
peer support for family members of the Armed Forces; breast cancer 
among members of the Armed Forces and veterans; and rural health 
including the unique needs of Native American veterans. We also have 
draft bills before us today on reimbursements for continuing education, 
mental health counselors, and bargaining rights and performance pay 
criteria.
    I look forward to hearing the views of our witnesses on this bill 
before us.

                                 
            Prepared Statement of Hon. Henry E. Brown, Jr.,
           Ranking Republican Member, Subcommittee on Health

    Thank you Mr. Chairman. I appreciate you holding this legislative 
hearing today and I look forward to working with you and the rest of 
our esteemed colleagues on these important legislative subjects.
    The ten bills being discussed this morning cover a wide array of 
veteran's issues and I look forward to learning more about them.
    Of particular interest to me is H.R. 1075, the RECOVER Act, 
introduced by Mr. Scalise. H.R. 1075 would provide medical services to 
veterans in a disaster area by allowing the VA to contract with one or 
more non-VA facilities. Making sure our veterans have access to the 
very finest care is always the top priority of this Committee, but--in 
times of real emergency--that priority takes on a whole new level of 
importance. Serving a district with facilities that are vulnerable to 
the sometimes destructive whims of nature--as I do in Charleston and 
along the coast of South Carolina--makes this a personal issue for me 
and I support Mr. Scalise in his efforts.
    I am also excited to hear more about H.R. 84, the Veterans Timely 
Access to Care Act, introduced by my friend Ms. Brown-Waite. Among 
other provisions, this bill would make the standard for access to care 
for a veteran seeking primary care from the VA 30 days from the date 
the veteran contacts the Department. Ms. Brown-Waite has long been 
committed to making sure America's veterans do not have to endure long 
waiting periods before they can access VA care and I applaud her 
efforts.
    To all of the witnesses appearing in front of us this morning--
thank you for your dedication to improving the lives of our veterans. 
Your work does not go unnoticed and I am eager to begin our discussion 
on the matters at hand.
    It is only by working together to advance meaningful and 
appropriate legislation that we can completely fulfill the promise we 
made to provide veterans with the ``best care anywhere.'' The men and 
women who served so bravely in uniform deserve nothing less.
    Again--thank you, Mr. Chairman. I yield back the balance of my 
time.

                                 
                 Prepared Statement of Hon. Bob Filner,
               Chairman, Committee on Veterans' Affairs,
     and a Representative in Congress from the State of California

    Chairman Michaud, thank you for the opportunity to testify before 
the Subcommittee on Health on H.R. 949, a bill that would improve the 
collective bargaining rights and procedures for reviews of adverse 
actions of certain VA employees.
    This bill is all about ensuring equity among the health care 
professionals employed at the Department of Veterans Affairs so that VA 
providers such as doctors, nurses, dentists, chiropractors, 
optometrists, and podiatrists who are hired under the ``pure title 38'' 
system have the same rights as their fellow VA health care 
professionals who are hired under different hiring systems.
    Without this bill, ``pure title 38'' providers do not have the 
right to challenge errors in pay computations and lack other key 
bargaining rights enjoyed by their colleagues at the VA.
    To address this problem, H.R. 949 would clarify that these ``pure 
title 38'' providers have equal rights to collective bargaining. This 
means that they would be able to challenge personnel actions through 
such methods as grievances, arbitrations, and labor-management 
negotiations.
    My bill would also require the VA to review the adverse personnel 
action and issue a final decision, no later than 60 days after the 
employee appeals the adverse personnel action.
    Finally, H.R. 949 would subject the VA's final decision on the 
employee appealed adverse personnel action to judicial review in the 
appropriate U.S. District Court or the U.S. Court of Appeals for the 
Federal Circuit.
    I recognize VA has concerns and I am looking forward to working 
with them and other stakeholders as we move forward on this piece of 
legislation.
    Thank you again for the opportunity to share my thoughts with you.

                                 
               Prepared Statement of Hon. Steve Scalise,
        a Representative in Congress from the State of Louisiana

    Thank you, Chairman Michaud, Ranking Member Brown, and 
distinguished Members of the Subcommittee.
    I appreciate the opportunity to testify before your Subcommittee on 
my bill, H.R. 1075. This bi-partisan legislation, with nineteen 
cosponsors, seeks to maintain vital health services to veterans in the 
event that a VA hospital is closed due to a federally declared 
disaster. Before I begin discussing my bill, I'd like to also thank you 
for your service on the Veterans' Affairs Committee, and for the work 
you do on behalf of our Nation's veterans.
    The welfare of our veterans and their families is of great 
importance to me, and I first filed this legislation during the 110th 
Congress when I served as a Member of the Veterans' Affairs Committee. 
Our Nation is grateful for the courage our veterans have displayed and 
the sacrifices they have made in order to protect America and the 
freedom we enjoy today. I believe, as you do, that it is our obligation 
to provide them the same honor and dedication that they provided us 
during their service.
    Hurricane Katrina flooded and closed the New Orleans VA Medical 
Center, leaving our veterans without the full services of their medical 
home. Unfortunately, nearly 5 years later, our VA hospital still 
remains closed. As a result, veterans throughout Southeast Louisiana 
face increased challenges and hardship to obtain the quality health 
care they deserve. The VA made a commitment to open a new hospital by 
late 2013, but with the current delays, I remain concerned about the 
status of veterans' health care in the interim, and want to make sure 
this doesn't happen to any of our Nation's veterans in the future.
    That is why I introduced H.R. 1075, the RECOVER Act. My bill would 
ensure that the VA must establish a contract with at least one non-VA 
facility to provide inpatient services in the event that a VA hospital 
will be closed for at least 6 months due to any federally declared 
disaster. Nothing in this bill would prevent a veteran from seeking 
care within the VA system if he so chooses. But last week, I spoke with 
a veteran who had to travel to another state for post operative care 
because the New Orleans hospital is still not open. Veterans still have 
to travel more than 350 miles for cardiac surgery and also have to 
travel to other states for mental health care as well. Several veterans 
with chronic conditions did not seek care after the storm because they 
did not know what their options were. This concerns me very much, and 
my bill seeks to eliminate these hardships. The RECOVER Act will also 
prevent families from having to travel hundreds of miles just to visit 
their loved ones who are undergoing treatment in the hospital. As the 
respected group Disabled American Veterans said when they expressed 
their support for this Act, ``Family support and care giving have been 
shown to accelerate recovery time and reduce cost and length of 
hospital stays.'' In the aftermath of a disaster, the last thing our 
veterans and their families should have to worry about is where to seek 
basic health care.
    I commend the Southeast Louisiana Veterans Health Care System for 
the initiative they have taken to provide care in light of the 
hospital's closure. The community outpatient clinics have been 
extremely valuable in delivering primary care and other services. We 
learned valuable lessons after Hurricane Katrina, and I want to make 
certain that no veteran has to travel long distances or experience long 
wait times to receive basic care in the event that their local VA 
hospital is closed due to a natural disaster, whether it be a 
hurricane, a tornado, earthquake, or any other natural disaster.
    My office is working with the Veterans' Service Organizations to 
address any issues they have as this bill moves through the legislative 
process. Let me also emphasize that this in no way undermines our 
strong commitment to the VA health care system. Our goals are the same: 
veterans and their families need to have options for receiving quality 
care close to home in the most convenient way possible, all while 
working to expedite the rebuilding of our VA hospital that was closed 
due to Hurricane Katrina. I continue working hard to cut through red 
tape and expedite the rebuilding of the New Orleans Medical Center that 
was devastated and closed by Hurricane Katrina's destruction. I look 
forward to working with you and Members of the Committee as we move 
forward.
    Again, I thank you for your dedication to our Nation's military 
veterans, and I appreciate this opportunity to testify before the 
Subcommittee.

                                 
             Prepared Statement of Hon. Gabrielle Giffords,
         a Representative in Congress from the State of Arizona

    Thank you, Mr. Chairman, and I want to thank Ranking Member Brown 
as well for the opportunity to testify today.
    This Committee has always been active in supporting the needs of 
America's veterans and I look forward to working with you on this 
endeavor.
    I also want to thank the Veterans Service Organization's in 
attendance today for their commitment to our men and women in uniform 
and for their lifetime of service.
    The two bills before you today that I have sponsored, H.R. 2698 and 
2699, will have a direct impact on improving the behavioral health of 
our Nation's heroes and their families.
    As a Member of the House Armed Services Committee who represents 
more than 25,000 servicemembers and dependants and nearly 96,000 
veterans and retirees in my Southern Arizona District, I have seen 
firsthand the trials and tribulations of our servicemembers returning 
from the frontlines.
    I know this issue is one that is close to both of your hearts, and 
I am hopeful that today's hearing signifies an important step in moving 
this vital legislation forward and passing it this Congress.
    There is no cause more honorable than service to our country. As 
our Nation's warriors bravely step into the breach, we must be prepared 
to care for them when they return home.
    In war, our soldiers, sailors, airmen and marines face unspeakable 
horrors--sometimes on a daily basis--and readjusting to everyday life 
is a long and complicated process. Every day, thousands of our Nation's 
bravest men AND women are suffering from different degrees of Post 
Traumatic Stress. In recent years, diagnosed cases of PTSD have 
increased by more than 50 percent for servicemembers returning from 
overseas deployments, and many experts believe that the actual number 
is much higher because a large majority of servicemembers never seek 
treatment.
    For an untold many diagnosed with the worst warning signs of PTSD, 
there are no simple fixes. We see each month the unfortunate and deeply 
saddening results as the Department of Defense releases its number of 
servicemember suicides. The trend is currently hovering slightly above 
the national average, more than double what is was 5 years ago.
    When I spoke with the Vice Chief of the Army, General Chiarelli, a 
year ago he agreed that even one suicide is unacceptably high, 
especially when there is so much more that we can be doing. Fellow 
Members, there is much more we can do and, while my legislation is not 
a silver bullet cure it is one round in the chamber.
    PTSD and other related behavioral health issues severely affect an 
individual's ability to perform everyday functions that we all take for 
granted. PTSD though, is treatable through a variety of methods 
including behavioral therapy and medication with a majority of 
servicemembers seeing an improvement after just one or two sessions 
with a behavioral therapist.
    Unfortunately, there are not enough behavioral health care 
providers within the military or VA to treat these servicemembers, 
their families or surviving spouses for the anguish they're suffering. 
What's worse still is that there aren't enough therapists to treat each 
other.
    Ultimately, our ailing heroes or the families they leave behind 
must wait to see a caregiver, often receive incomplete or inadequate 
care, or in some cases do not receive care at all leading to one of a 
few inevitable conclusions--depression, anger management problems, 
substance abuse or death.
    This is the first in many clear signs that the system is failing 
our men and women in uniform and badly needs to be fixed.
    H.R. 2698 establishes a scholarship-for-service program that 
provides educational benefits to those training in behavioral health 
care specialties critical to the operations of Vet Centers. These 
individuals would then pay back the investment by serving as a 
behavioral health care specialist at Vet Centers across the country.
    Because of the unpredictable nature and a lingering lack of 
understanding surrounding PTSD and its symptoms, many former 
servicemembers do not realize they are suffering until long after they 
have left military service. My bill will permit our Nation's Guardsmen 
and Reservists to access behavioral health care at Vet Centers even 
after they have been released from their Active Duty service 
requirement and provides for referrals to assist them to the maximum 
extent possible in obtaining behavioral health care and services from 
sources outside the Department.
    In such cases where a servicemember may have been discharged for 
actions connected to his or her PTSD, my bill would ensure that they 
are apprised of their rights to petition for a review of their 
discharge on those grounds, ending forever the practice of discharging 
those suffering from PTSD because of the nature of their disease.
    H.R. 2698 and H.R. 2699 also ensure that the Veterans 
Administration carry out a competitive grant program for nonprofit 
organizations that provide peer-to-peer emotional support services for 
servicemembers, veterans and survivors including members of the 
National Guard and Reserve who are often left out because of the 
changing nature of their service or the accessibility of care in local 
communities.
    But what additional counselors and additional opportunities cannot 
do is force a servicemember or veteran to get care. For too many, PTSD 
is still an inescapable sentence. Servicemembers and vets are bound on 
one side by their service and the other by the deep stigma that still 
surrounds behavioral health issues. Rumors persist within the rank and 
file that behavioral health disorders cause you to lose your clearance 
or that PTSD treatment will be reported up the chain of command, 
ruining an otherwise promising career. According to a report by the 
American Psychiatric Association, an estimated 60 percent of those 
surveyed feared reporting that they were suffering from behavioral 
health-related problems.
    The unfortunate fact is that 10 years ago we hardly acknowledged 
the existence of PTSD and had no logical measure of its effects. Five 
years ago, we began acknowledging it was a real problem. Today we have 
in place only a patchwork quilt of forms and meetings, training 
seminars and online courses that our servicemembers must complete along 
with dozens of other regular re-certifications and proficiency tests. 
What we are not doing is taking a comprehensive look at the problem and 
designing a smarter and more realistic solution.
    H.R. 2699 provides for just that by establishing a pilot program at 
three Posts across the country that each house high op-tempo mission 
sets--Fort Leonard Wood, home of our Military Police Corps and the NCO 
Academy; Fort Carson, home of the 10th Special Forces Group, 4th 
Infantry Division and 10th Combat Support Hospital; and Fort Huachuca, 
the home of our Nation's Center of Intelligence Excellence that trains 
and supports the best intelligence professionals in the world.
    By focusing on these three bases we can ensure that a new program 
focuses on the most stressed and most over-utilized units across the 
force and use real-life feedback from soldiers and their families on 
the best way to provide treatment and track their results.
    We cannot continue to accept that what is being done is the best we 
can do.
    I am committed to fixing the problems we know about and uncovering 
those we don't. I know that you Mr. Chairman and the Ranking Member and 
the others on this Committee share my passion and my commitment to 
those in service to our country and the families who serve in their own 
way as well.
    I look forward to receiving the feedback of the VA and from the 
Veterans Service Organizations in attendance today. And I look forward 
to working with the Committee to make these necessary changes into law.
    Thank you.

                                 

             Prepared Statement of Hon. Leonard L. Boswell,
          a Representative in Congress from the State of Iowa

    Chairman Michaud, Ranking Member Brown, and Members of the 
Committee, I would like to thank you for inviting me to speak before 
you today and for holding this hearing over many important pieces of 
veteran's health legislation.
    Women are currently the fastest-growing veteran population--
representing 8 percent of the population. As the demographics of the 
military continue to change, we find our VA system is struggling to 
serve the unique needs of this growing population. By 2020, 15 percent 
of veterans using the VA for health care will be women.
    What this means is that veterans' health care, which is now 
primarily tailored to men, needs to undergo significant changes--and 
fast.
    Particularly, one health concern that has been largely ignored is 
the prevalence of breast cancer in our servicewomen and women veterans. 
That is why I have introduced H.R. 3926, the Armed Forces Breast Cancer 
Research Act. This legislation would require the Secretary of Defense 
and the Secretary of Veteran Affairs to collaboratively study the 
incidence rate of breast cancer in servicemembers and veterans. This 
study would focus on the number of servicemembers who have deployed in 
support of Operation Iraqi Freedom and Operation Enduring Freedom, the 
demographic information of those servicemembers and veterans, an 
analysis of the clinical characteristics of breast cancer diagnosed, 
and possible exposures to cancer risk factors.
    The idea for this bill came about when a member of my staff, who is 
an Iraq veteran, went back to Iowa for a 5 year post-deployment 
reunion. One of the women at the reunion had returned home from serving 
her country and was diagnosed with breast cancer and had to undergo a 
double mastectomy, at age 25. Through the course of the night the 
servicemembers at the reunion were able to piece together about six 
women they were deployed with who had come back from their deployment 
in Iraq with breast cancer--all between the ages of 25 to 35 years old. 
Also, there were another half dozen women who returned with new lumps 
in their breasts that needed additional tests such as mammograms, 
ultrasounds, and/or biopsies. With 70 women deployed with the battalion 
(of 700), this incidence rate in young women seemed high and alarming 
to me.
    In recent years, the U.S. medical and research communities have 
stepped up their efforts on breast cancer detection, research, and 
treatment in the country's civilian population. However, women who 
serve or have served in our Nation's Armed Forces have largely been 
excluded from these studies, despite their exposure to cancer risk 
factors and access to medical care. A recent study of Department of 
Defense (DoD) and National Cancer Institute (NCI) compares the 
prevalence of certain types of cancer among active-duty military 
personnel with the general public. The study found that breast cancer 
among women is more common in the military than in the general 
population and that further studies are needed to confirm these 
findings and explore contributing factors.
    That is my goal for this legislation. To find out if our 
servicewomen do have a higher risk of breast cancer than the rest of 
the women in the country and why that might be. So that ultimately, we 
can determine if breast cancer is a service-connected disability--which 
I truly believe it is.
    At this moment in history it is particularly important to consider 
what we can do to better serve the brave individuals who fight for our 
security and liberty once they return home.
    I would again like to thank Members of this Committee for allowing 
me the time to speak and your diligence on this matter. I would be 
happy to answer any questions you might have.

                               __________
                      Veterans of Foreign Wars of the United States
                                                    Washington, DC.
                                                   October 26, 2009

The Honorable Leonard Boswell
United States House of Representatives
1427 Longworth House Office Building
Washington, DC 20515

Dear Representative Boswell:

    On behalf of the 2.2 million members of the Veterans of Foreign 
Wars of the United States and our Auxiliaries, I would like to offer 
our support for your proposed legislation, the Armed Forces Breast 
Cancer Research Act.
    Your important legislation would direct the Secretary of Defense 
and the Secretary of VA to work jointly in conducting a study on the 
incidence of breast cancer among our Nation's veterans. The valuable 
study would provide insight on breast cancer rates of servicemembers 
and document any harmful exposure the servicemembers were subjected to 
during their service. The Armed Forces Breast Cancer Research Act would 
provide crucial information on an important veteran issue that has 
otherwise been neglected.
    Representative Boswell, we thank you for proposing legislation that 
would greatly benefit our Nation's heroes. We need to do everything in 
our power to provide for these brave Americans who have sacrificed for 
their country. The VFW looks forward to working with you and your staff 
to ensure the passage of this legislation.
    Thank you for your continued support of America's veterans.

            Sincerely,

                                                   ERIC A. HILLEMAN
                             Director, National Legislative Service

                               __________

                           Iraq and Afghanistan Veterans of America
                                                    Washington, DC.
                                                   December 2, 2009

The Honorable Leonard Boswell
1427 Longworth House Office Building
Washington, DC 20515

Dear Congressman Boswell,

    Iraq and Afghanistan Veterans of America (IAVA) is honored to offer 
our full support for H.R. 3926, the ``Armed Forces Breast Cancer 
Research Act.'' The ``Armed Forces Breast Cancer Research Act'' will 
establish a collaborative effort between the Department of Defense and 
the Department of Veterans Affairs to study incidences of breast cancer 
among those who serve, their demographic information, possible 
exposures to carcinogenic material while serving our country and any 
treatments they have received.
    Civilian sector advances infesting and treatments for breast cancer 
have largely been determined without specific consideration of the men 
and women in our Armed Forces. However, in October 2009, there have 
been reports of 40 former Marines with breast cancer, who were 
potentially exposed to contaminated water at Camp Lejeune. As these 
reports evidence, there is a dire need for further research into the 
incidences of breast cancer among the unique population of troops and 
veterans.
    We are proud to offer our assistance and thank you for this vital 
legislation. If we can be of help, please feel free to contact Erin 
Mulhall, Deputy Policy Director for Research, at (202) 544-7692 or 
[email protected].
    We look forward to working with you.

            Sincerely,

                                                     Paul Rieckhoff
                                     Executive Director and Founder

                                 
             Prepared Statement of Hon. Ginny Brown-Waite,
         a Representative in Congress from the State of Florida

    Thank you, Mr. Chairman,
    I appreciate the opportunity to testify before the Subcommittee 
today.
    As of November 2009, there were nearly 8 million veterans enrolled 
in the VA health care system. With new veterans entering the system 
every day and approximately 174,000 Operation Enduring Freedom and 
Operation Iraqi Freedom patients receiving VA health care, it is clear 
that our duty to our Nation's veterans is as strong now as it has ever 
been.
    Today, there are 153 VA medical centers and 768 Community Based 
Outpatient Clinics (CBOC) available to serve the needs of these 
veterans.
    When a veteran calls to schedule an appointment in one of these 921 
facilities, they should be able to receive an appointment that is 
timely and appropriate to their medical needs.
    Unfortunately, for many veterans, this does not happen.
    The VA lauds itself for completing 99 percent of its primary care 
appointments within 30 days of the desired date. However, this means 
that nearly 32,000 patients still are waiting beyond 30 days for their 
primary care appointment.
    Additionally, there is a discernable difference between existing 
patients and new patients, as only 88.8 percent of new patients 
complete their appointments within 30 days of the desired date.
    Health care delayed is health care denied and our Nation's veterans 
deserve better.
    In September 2007, VA Office of the Inspector General found that 
the Veterans Health Administration's method of calculating the waiting 
times of new patients understates the actual waiting times. In this 
report, the Inspector General made five recommendations to reduce wait 
times at VHA facilities. To date, four of these five recommendations 
remain unresolved.
    When I first was elected to Congress, I inquired into the wait time 
numbers from Veterans Health Administration facilities in my District 
and across the country. The numbers the VA gave me both for VISN 8 and 
nationwide did not match with the stories I heard from my veterans. It 
was clear the VA was playing games with scheduling and canceling 
appointments. I fear these games are still being played today.
    For this reason, I introduced H.R. 84, the Veterans Timely Access 
to Health Care Act. This bill would make the standard for a veteran 
seeking primary care from the Department of Veterans Affairs 30 days 
from the date that the veteran contacts the Department.
    Veterans should not need to wait more than 30 days to receive an 
appointment from their primary care physician.
    The VA does provide a high level of care to all of the veterans who 
are enrolled in the system. This is why the majority of patients rate 
their level of overall satisfaction with their treatment as ``very 
good'' or ``excellent,'' regardless of whether they are receiving 
inpatient or outpatient services.
    I want to be clear: this bill is NOT a scheme to move the VA toward 
privatization. I simply want to ensure that veterans receive care in a 
reasonable amount of time.
    As Members of Congress, we have an obligation to ensure that 
veterans receive the best health care available to them. If veterans 
are having problems receiving care within 30 days of contacting the 
Department of Veterans Affairs, then Congress needs to allow them to 
look for an alternative. That is what this bill does.
    This hearing today is to determine whether the VA is meeting the 
goal of timely access to care.
    Our Nation's veterans did not wait 30 days to answer the call of 
duty.
    They answered their Nation's call and took up arms to protect our 
freedom.
    They deserve the same dedication and steadfastness from us.
    With over 116,000 veterans living in my District, I have the 
distinguished honor to meet with these true American heroes on a 
regular basis. I hear about the issues they have with the VA. Over and 
over again, I still hear about how difficult it is to schedule an 
appointment with a doctor in a timely matter.
    This is unacceptable and must be corrected. The Veterans Timely 
Access to Health Care Act is an important step in fixing this 
persistent problem.
    Congress recently allowed for advanced appropriations for the VA. 
This new funding structure should allow the VA to properly manage their 
funds and hire the staff necessary to meet the demand at VA facilities.
    However, when the VA still fails to meet the needs of our veterans 
seeking health care, this legislation provides an effective 
alternative.
    Congress and administrations must not turn the care of our Nation's 
veterans into a political issue.
    Instead, we must all work together to ensure that they receive the 
health care they risked so much to earn. We must continue those 
practices that already work and improve those that are failing. H.R. 84 
does just that.
    Thank you again, Mr. Chairman, and I yield back the balance of my 
time.

                                 
     Prepared Statement of Denise A. Williams, Assistant Director,
    Veterans Affairs and Rehabilitation Commission, American Legion

    Mr. Chairman and Members of the Subcommittee:
    Thank you for the opportunity to present The American Legion's 
views on the several pieces of legislation being considered by the 
Subcommittee.

H.R. 1075, RECOVER Act (Restoring Essential Care for Our Veterans for 
        Effective Recovery)
    This bill would expand access to hospital care for veterans in 
major disaster areas and for other purposes. In addition, it directs 
the Secretary of the Department of Veterans Affairs (VA) to enter into 
a contract with non-Department facilities located in the disaster areas 
to facilitate covered medical services to veterans, if their designated 
VA medical facility is unable to do so within 180 days due to the 
disaster.
    Timely and open access to quality health care for veterans is a 
major priority of The American Legion and this legislation is 
consistent with our efforts in this regard. The American Legion does, 
however, have some concerns. Although such contracts would certainly be 
helpful during a disaster in which VA medical facilities are not 
available, we do not want such an arrangement to become a disincentive 
for VA to quickly repair or replace damaged facilities. This bill also 
does not address length of the contracted care, long-term care or how 
quality of care will be assessed.

H.R. 84, Veterans Timely Access to Health Care Act
    This legislation would seek to establish standards of access to 
care for veterans seeking health care from VA. It also directs the 
Secretary to set standards for timeliness and to report how these 
standards were carried out.
    The American Legion supports this bill and believes that this 
endeavor will provide VA with a comprehensible overview of the 
challenges that veterans face in gaining timely access to care. This 
measure could prove to be a valuable asset in their undertaking to 
improve access to care, especially among veterans living in rural and 
highly rural geographic areas.

H.R. 4006, Rural, American Indian Veterans Health Care Improvement Act 
        of 2009
    This bill would require the VA Secretary to designate Indian Health 
Care Coordinators at 10 VA medical centers that serve communities with 
the greatest number of American Indian veterans. Additionally, a year 
after the bill has been enacted; the VA Secretary is directed to 
establish a Memorandum of Understanding with the Secretary of the 
Interior to authorize the electronic transfer of American Indian 
veterans' health records between the Indian Health Services (IHS) and 
the VA. The provisions of this bill also authorize the VA Secretary to 
transfer surplus medical and information technology equipment to IHS.
    The American Legion advocates timely access to quality health care 
to all veterans and is on record in strong support of VA's 
collaboration with other Federal health care providers to provide the 
best care, at the right time, in the most appropriate medical care 
setting. This legislation appears to address these goals to better 
serve veterans enrolled in the VA health care delivery system.

H.R. 3926, Armed Forces Breast Cancer Research Act
    This bill would direct the Secretaries of the Departments of 
Defense (DoD) and VA to jointly conduct a study on the incidence of 
breast cancer among members of the Armed Forces and veterans. This 
study would determine the number of servicemembers and veterans 
diagnosed with breast cancer; their demographic information; and any 
possible exposure to hazardous elements or chemical or biological 
agents.
    The American Legion fully supports this timely and important 
legislation given the recent breast cancer incidences among male 
veterans that were stationed at Camp Lejeune. Moreover, according to 
the Clinical Breast Care Project at Walter Reed Army Medical Center, 
there have been over 2,000 cases of breast cancer diagnosed in both 
male and female active-duty servicemembers within the last decade. The 
Center further stated that breast cancer is the single greatest cause 
of cancer deaths among women under 40 and is a significant cause of 
mortality for women in the Armed Forces. The American Legion would also 
encourage inclusion of the Reserve component in this study.

H.R. 949, Improving the Collective Bargaining Rights of Certain VA 
        Employees

    This legislation would seek to amend section 7422 of title 38, 
United States Code (USC), which would improve the collective bargaining 
rights and procedures for review of adverse actions of certain VA 
employees.
    Although The American Legion strongly supports the recruitment and 
retention of quality VA employees, it has no official position on this 
legislation.

Proposed Legislation to Amend Title 38, USC, Concerning Performance Pay 
        and Collective Bargaining

    This legislation would seek to amend section 7431 and section 7422 
of title 38, USC, which would make certain improvements in the laws 
relating to the performance pay and collective bargaining right for 
certain VA employees.
    Although The American Legion strongly supports the recruitment and 
retention of quality VA employees, it has no official position on this 
legislation.

Proposed Legislation to Amend Title 38, USC, Concerning Continuing 
        Professional Education

    This bill would seek to amend title 38, USC, to improve the 
continuing professional education reimbursement provided to health 
professionals employed by VA. This proposal would not only maintain 
VA's presence in the competitive medical professional market, but also 
help decrease the attrition rate among VA medical centers' medical 
professionals.
    The American Legion supports this draft proposal because it will 
serve to provide professional education reimbursement for eligible 
health professional. The expansion of this benefit may also diminish 
the attrition rate of medical professionals within VA medical 
facilities because it will be an added benefit to more staff in various 
disciplines.

Proposed Legislation to Amend Title 38, USC, Concerning Mental Health 
        Counselors

    This proposal would seek to amend title 38, USC, to authorize the 
VA Secretary to waive certain requirements relating to mental health 
counselors.
    The American Legion believes VA should be staffed with the best 
qualified professionals to ensure this nation's veterans receive timely 
access to quality health care, especially mental health services. With 
servicemembers returning from Iraq and Afghanistan with complex and 
overlapping illnesses and injuries, it is imperative VA maintains its 
charge to ensure its medical professionals are properly trained and 
fully qualified to provide quality care.
    According to the National Institute of Health, injuries and 
illnesses such as mild Traumatic Brain Injury (TBI) and Posttraumatic 
Stress Disorder (PTSD) respectively, have several symptoms in common. 
Among these symptoms are irritability, concentration deficits, amnesia 
for the causal event, reduced cognitive processing ability and sleeping 
disturbances. Clearly, this situation adds to the difficulty in 
diagnosing PTSD in patients with TBI. The American Legion contends that 
due to the complexity of these illnesses and injuries, such as TBI and 
PTSD, the most qualified mental health professionals are required. 
Therefore, The American Legion is opposed to waiving current 
requirements relating to mental health counselors.

H.R. 2698, Veterans and Survivors Behavioral Health Awareness Act

    This bill would seek to improve and enhance the mental health care 
benefits available to veterans. The legislation would also enhance 
counseling and other benefits available to survivors of veterans, and 
for other purposes.
    The American Legion fully supports this legislation. VA's Vet 
Centers have served as one of the main catalysts that have assisted 
with successfully transitioning servicemembers and veterans to VA. 
Section 3 of this bill would seek to restore the authority of Vets 
Centers to provide referral and other assistance upon request to 
veterans currently not authorized counseling. This provision would 
allow Vet Centers to cast a broader net in further minimizing veterans 
who would otherwise continue to face transition challenges.
H.R. 2699, Armed Forces Behavioral Health Awareness Act
    This bill would seek to improve the mental health care benefits 
available to servicemembers, to enhance counseling available to their 
family members, and for other purposes.
    While The American Legion agrees with the intent of this bill, we 
disagree with the restrictive nature of section 4, which would seek to 
carry out a pilot program, for servicemembers of the Army only, to 
enhance awareness of PTSD. This pilot program should be open to members 
of all five branches of the Armed Services with a presence in Iraq or 
Afghanistan. In addition, the locations should be expanded to include 
venues near all of the respective servicemembers.
    The American Legion believes the success of the Armed Forces 
Behavioral Health Awareness Act, with the amendment of section 4, would 
assist with timely intervention to help minimize issues plaguing 
veterans and their families that possibly lead to substance abuse, 
suicide, and homelessness.
H.R. 2879, Rural Veterans Health Care Improvement Act of 2009
    This legislation would seek to amend title 38, USC, to improve 
health care for veterans who live in rural and highly rural geographic 
areas, and for other purposes.
    VA's Office of Rural Health held their inaugural meeting in August 
2008. During that time, VA established Rural Health Centers located in 
three regions of the country:

      Eastern Region RHRC: White River, Vermont
      Central Region RHRC: Iowa City, Iowa
      Western Region RHRC: Salt Lake City, Utah

    These three regions also partner with various VA medical centers 
and universities. Section 3 of this bill proposes Centers of Excellence 
for Rural Health Research, Education, and Clinical Activities. The 
American Legion believes there should be interaction between the 
abovementioned Rural Health Centers to prevent redundancy. Due to the 
vastness of rural areas, Rural Health Centers should be increased to 
accommodate various issues such as lack of access to medical 
facilities, lack of medical professionals, women veteran issues, and 
homelessness.
    This bill would also seek to increase transportation options for 
rural veterans. The American Legion believes this is imperative and 
will increase veterans' options of receiving timely access to quality 
health care. The American Legion also believes that veterans should not 
be penalized due to the geographical location in which they choose to 
reside.
    Mr. Chairman, once again The American Legion appreciates the 
opportunity to address these issues and looks forward to working with 
you, your colleagues and the staff in advancing legislation that will 
make a positive difference in the lives of servicemembers, veterans and 
their families.
    That concludes this written statement and I welcome any questions 
you or your colleagues may have concerning The American Legion's views, 
comments and recommendations.

                                 
                 Prepared Statement of Blake C. Ortner,
  Senior Associate Legislative Director, Paralyzed Veterans of America

    Chairman Michaud and Members of the Subcommittee, on behalf of 
Paralyzed Veterans of America (PVA), I would like to thank you for the 
opportunity to present PVA's position on the legislation pending before 
the Subcommittee, as well as the three draft bills you are preparing.
       H.R. 84, the ``Veterans Timely Access to Health Care Act''
    H.R. 84, the ``Veterans Timely Access to Health Care Act,'' would 
establish standards of access to care within the VA health system. PVA 
has testified on similar legislation in the past and is unable to 
support H.R. 84.
    Under the provisions of this legislation, the Department of 
Veterans Affairs (VA) will be required to provide a primary care 
appointment to veterans seeking health care within 30 days of a request 
for an appointment. If a VA facility is unable to meet the 30-day 
standard for a veteran, then the VA must make an appointment for that 
veteran with a non-VA provider, thereby contracting out the health care 
service. The legislation also requires the Secretary of the VA to 
report to Congress each quarter of a fiscal year on the efforts of the 
VA health system to meet this 30-day access standard.
    Access is indeed a critical concern of PVA. The number of veterans 
enrolled in the VA is continuing to increase. This is particularly true 
as more and more Operation Enduring Freedom/Operation Iraqi Freedom 
(OEF/OIF) veterans continue to take advantage of the services in VA. 
Likewise, the effort of the administration to expand Priority Group 8 
enrollments is increasing the workload.
    Unfortunately, funding for VA health care in the past has had 
difficulty keeping pace with the growing demand. Even with the passage 
of Advance Appropriations and record budgets in recent years, funding 
is not guaranteed to be sustained at those levels and PVA is concerned 
that contracting health care services to private facilities when access 
standards are not met is not an appropriate enforcement mechanism for 
ensuring access to care. In fact, it may actually serve as a 
disincentive to achieve timely access for veterans seeking care. 
Contracting out to private providers will leave the VA with the 
difficult task of ensuring that veterans seeking treatment at non-VA 
facilities are receiving quality health care.
    PVA is also concerned about the continuity of care. If veterans are 
shifted between the VA and non-VA facilities each time the imposed 
standard is not met, how will this affect the quality of the health 
care these veterans receive? This is neither an effective nor efficient 
way to supply health care and in the long run may be detrimental to the 
veteran. We do think that access standards are important, but we 
believe that the answer to providing timely care is in providing 
sufficient funding in the first place in order to negate the impetus 
driving health care rationing. For these reasons, PVA cannot support 
H.R. 84.
    H.R. 949 to Improve Collective Bargaining Rights and Procedures
    PVA supports H.R. 949 introduced by Chairman Filner that will more 
quickly resolve adverse actions and set deadlines for final decisions.

                     H.R. 1075, the ``RECOVER Act 
  (Restoring Essential Care for Our Veterans for Effective Recovery)''

    PVA strongly supports H.R. 1075, the ``RECOVER Act (Restoring 
Essential Care for Our Veterans for Effective Recovery).'' During 
periods of major disasters, medical care is as critical as food or 
water to protecting the lives and health of those in the affected 
disaster area. Ensuring veterans have uninterrupted access to health 
care during these periods is critical to their well-being. The ability 
of the Secretary of VA to enter into contracts for in-patient care with 
non-Department facilities for those veterans who otherwise would 
normally be provided care by Department medical facilities only makes 
sense. PVA would only caution that this arrangement should not 
inadvertently lead to delays in repairing or replacing VA facilities 
that may have been damaged during the disaster. VA facilities still 
provide a unique form and quality of care that is seldom replicated in 
non-VA facilities, particularly for those veterans with special health 
needs such as spinal cord injury, blindness and other catastrophically 
disabled veterans. Likewise, this contracting authority should not 
become the default health care policy for meeting the needs of veterans 
in a disaster area.

  H.R. 2698, the ``Veterans and Survivors Behavioral Health Awareness 
  Act'' and H.R. 2699, the ``Armed Forces Behavioral Health Awareness 
                                 Act''

    PVA supports H.R. 2698, the ``Veterans and Survivors Behavioral 
Health Awareness Act'' and H.R. 2699, the ``Armed Forces Behavioral 
Health Awareness Act.'' The scholarships and other provisions of H.R. 
2698 should increase the number of behavioral health care specialists. 
Additionally, we applaud provisions requiring those receiving the 
scholarship to serve in Vet Centers. As the increasing numbers of OEF/
OIF veterans continues to grow, the need for behavioral specialists on 
Vet Center's staff will also grow. H.R. 2698 may help generate those 
additional individuals to meet this need. While the scholarships are 
not targeted or reserved for veterans, PVA would encourage VA to market 
the scholarship to veterans who will be best able to relate to veterans 
visiting the Vet Centers.
    PVA also welcomes provisions of both H.R. 2698 and H.R. 2699 which 
award grants to non-profit organizations to provide emotional support 
to survivors of members of the Armed Forces and veterans in the case of 
H.R. 2698 and to members of the Reserves and all family members in the 
case of H.R. 2699. This is in keeping with the best traditions of VA in 
providing for the widow and orphans of our veterans and all family 
members and members of the Reserves who are facing the significant 
challenges of multiple OEF/OIF deployments.
    Regarding sec. 3 of H.R. 2698 and sec. 2 of H.R. 2699, PVA supports 
these provisions of the legislation, but both sections are reflected in 
the recent negotiated changes in S. 1963 and as currently amended will 
address the specified referral and readjustment counseling issues 
making these portions of the legislation no longer necessary should the 
amended legislation pass.

 H.R. 2879, the ``Rural Veterans Health Care Improvement Act of 2009'' 
                                  and
      H.R. 4006, the ``Rural, American Indian Veterans Health Care
                       Improvement Act of 2009''

    PVA supports H.R. 2879, the ``Rural Veterans Health Care 
Improvement Act of 2009'' and H.R. 4006, the ``Rural, American Indian 
Veterans Health Care Improvement Act of 2009.'' PVA recognizes that 
there is no easy solution to meeting the needs of veterans who live in 
rural areas and that Native Americans often face even tougher 
challenges. These rural veterans were not originally the target 
population of men and women that the VA expected to treat. However, the 
VA decision to expand to an outpatient network through community-based 
outpatient clinics reflected the growing demand on the VA system from 
veterans outside of typical urban or suburban settings. The need to 
determine methods to provide for these more dispersed rural veterans is 
a challenge. Establishing Centers of Excellence for rural health 
research, education and clinical activities may be a way to develop 
better ideas for rural veteran care and help shed light on how best to 
provide services in rural areas. Together with the demonstration 
projects outlined in section 5, a path may be identified to provide a 
greater level of health care for rural veterans.
    However, while these paths may show promise, they should still all 
fit within policies that promote the use of VA facilities and should 
not be used as a method or course to eliminate VA facilities in rural 
areas. While all these ideas are welcome, the greatest need still is 
for qualified health care providers to be located in rural settings. 
Only significant incentives and opportunities for these professionals 
will bring them to these often remote areas. In fact, the expansion of 
VA facilities may be the best way to care for special needs veterans 
that seldom have the types of critical care services that they need in 
rural areas. We must be sure that veterans most in need of specialized 
care, provided best by VA, are not sacrificed to efficiencies 
discovered through these programs.
    PVA also applauds the provisions of H.R. 2879 on travel 
reimbursement and transportation grants. Mobility, in particular for 
those with disabilities, is often the greatest challenge to care in a 
rural environment. Providing greater transportation benefits will allow 
veterans a better chance of receiving health care without a 
disproportionate cost often associated with the long distances traveled 
in rural areas. Both reimbursement and transportation grants are 
included in the recent negotiated changes in S. 1963 as currently 
amended address these issues. We believe this portion of the 
legislation would no longer be necessary should the amended legislation 
pass.
    PVA also supports the provisions of H.R. 2879 for helping our 
Native American veterans through provisions for a program of 
readjustment and mental health care services to veterans who have 
served in OEF/OIF. PVA also supports the provisions of H.R. 4006 and 
H.R. 2879 which helps our Native American veterans by establishing 
Indian Veterans Health Care Coordinators. Improving outreach to this 
underserved population as well as expanding access and participation by 
VA, the Indian Health Service and tribal members in the Department of 
Veterans Affairs Tribal Veterans Representative program may help to 
bring a larger number of Native American veterans into the health care 
system. Together with the integration of electronic health records in 
the Indian Health Service and the authority to transfer surplus VA 
medical and information technology equipment, Native American veterans 
will have better access and a higher quality of health care.
       H.R. 3926, the ``Armed Forces Breast Cancer Research Act''
    PVA strongly supports H.R. 3926, the ``Armed Forces Breast Cancer 
Research Act.'' Recent U.S. military conflicts, as happened with 
Operations Desert Storm/Desert Shield, have demonstrated that members 
of the military deployed to foreign areas often are exposed to agents, 
chemicals and environments detrimental to their health. In many cases, 
these exposures may have long-term health effects not identified during 
a post deployment medical examine. With the growing number of women 
that comprise members of the Armed Forces, and their increasing 
involvement in forward operating areas and combat activities, it only 
makes sense to examine the potential increased risk of breast cancer 
among this population.

  Draft Legislation to ``Improve Continuing Professional Education,''
 ``Waive Certain Requirements Relating to Mental Health Counselors,'' 
                                  and
    ``Make Improvement to Performance Pay and Collective Bargaining 
                                Rights''

    PVA supports the draft legislation to raise the reimbursement rate 
for health professionals from $1,000 to $1,600. In addition, PVA 
cautiously supports the legislation to waive certain requirements 
relating to mental health counselors, but want to ensure that this is 
done only in the circumstances that will benefit VA health care and in 
no way be detrimental to veterans served by a counselor whose license 
or certification requirement has been waived.
    Regarding collective bargaining, PVA generally supports the 
provisions of the draft legislation that would improve the collective 
bargaining rights and procedures for certain health care professionals 
in the VA. These changes may be a positive step in addressing the 
recruitment and retention challenges the VA faces to hire key health 
care professionals, particularly registered nurses (RN), physicians, 
physician assistants, and other selected specialists.
    As we understand current practice, certain specific positions 
(including those mentioned previously) do not have particular rights to 
grieve or arbitrate over basic workplace disputes. This includes 
weekend pay, floating nurse assignments, mandatory nurse overtime, 
mandatory physician weekend and evening duty, access to survey data for 
setting nurse locality pay and physicians' market pay, exclusion from 
groups setting physicians' market pay, and similar concerns. This would 
seem to allow VA managers to undermine Congressional intent from law 
passed in recent years to ensure that nurse and physician pay are 
competitive with the private sector and to ensure nurse work schedules 
are competitive with local markets.
    Interestingly, given the VA's interpretation of current laws, these 
specific health care professionals are not afforded the same rights as 
employees who they work side-by-side with everyday. For instance, 
Licensed Practicing Nurses (LPN) and Nursing Assistants (NA) can 
challenge pay and scheduling policies, while RN's cannot. This simply 
makes no sense to us.
    VA must work with their employees to achieve a less hostile work 
relationship, but any changes or modifications on either side of the 
issue must first address the care of veterans. Furthermore, this care 
should not be used as a rallying cry on either side as an argument for 
their position. Veterans deserve better.
    PVA appreciates the opportunity to comment on the bills being 
considered by the Subcommittee. I would be happy to answer any 
questions that you might have. Thank you.

                                 
           Prepared Statement of Eric A. Hilleman, Director,
 National Legislative Service, Veterans of Foreign Wars of the United 
                                 States

    MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
    On behalf of the 2.1 million men and women of the Veterans of 
Foreign Wars of the U.S. and our Auxiliaries, I want 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.

Draft Bill for Continuing Education of VHA Staff
    The VFW supports this bill, ``to improve the continuing 
professional education reimbursement provided to health professionals 
employed by the Department of Veterans Affairs.'' Currently, only full-
time board certified physicians and dentists are eligible for $1,000 
annually for continuing professional education. This bill would 
increase the annual continuing education reimbursement from $1,000 to 
$1,600 annually, and bar any potential duplicate compensation from 
medical centers. Further, it would expand the eligible professions from 
physicians and dentists to also include podiatrists, chiropractors, 
optometrists, registered nurses, physician assistants, and expanded-
function dental auxiliaries. We urge further expansion of this 
legislation to include education reimbursement for other health care 
professionals such as mental health.
    The VA has built a reputation for being an innovator in research 
and a teaching institution. We are encouraged to see emphasis placed on 
continuing education for medical professionals. Ongoing education of 
VHA staff will help to keep VA a leader in providing high quality 
medical care and attract staff that are inclined toward constant 
improvement.

Draft Bill to Improve Performance Pay and Bargaining Rights
    This draft legislation would further clarify performance pay 
awarded to physicians and dentists. Existing law does not specify that 
performance pay can only be awarded based on an individual performance. 
This has led to performance rewards ambiguity. The VFW supports this 
bill.

Draft Bill, Waving Requirements for Mental Health Counselors
    The VFW opposes this legislation to allow the Secretary to wave 
licensure or certification requirements. The VA may be facing shortages 
of mental health professionals, but we believe making exceptions in 
lieu of valid state-issued certifications undermines the quality of 
care and the confidence that veterans have in speaking with VA mental 
health professionals. State licensure and certification, demonstrates 
that an individual meets the state requirements in the areas of 
prerequisite education, and knowledge, and is culpable under the law 
for malpractice or abuse of the unique trust placed in their position.

H.R. 84, the Veterans Timely Access to Health Care Act
    The VFW supports the intent of the ``Veterans Timely Access to 
Health Care Act,'' but we cannot support this bill. This legislation 
would require the VA Secretary to contract care for any veteran who 
would have to wait 30 days or more for primary care. The VFW has 
supported guaranteed access standards for VA Health Care for a number 
of years--but we remained concerned about quality and cost of contract 
care.
    The VFW shares the desire to see all veterans have timely access to 
high-quality VA health care, which has been and continues to be our 
highest legislative priority. We feel, however, that this legislation 
would create more problems than it would fix. We must be mindful of the 
unintended consequences of the legislation.
    With the advent of advanced appropriations, VA now has the capacity 
to ensure that it can properly plan for and manage these dollars 
efficiently. Additionally, on-time funding should allow VA to recruit, 
hire and train doctors, nurses and other health care providers, 
ensuring that VA has sufficient staff to keep up with demand. Congress 
has made great strides in improving the funding stream for veterans' 
health care--for which the VFW applauds your efforts--but a greater 
attention is needed to ensure those health care dollars are spent 
appropriately at each medical facility.
    We strongly support the reporting requirements of H.R. 84. The 
reporting mechanisms on wait times would help gain more accurate 
insight into hard numbers, which are always more informative than 
anecdotal statistics. Better numbers would allow us to understand the 
problem as well as see which areas are having difficulties.

H.R. 949
    This bill addresses VA employee's collective bargaining rights. 
Specifically, it repeals specified exceptions to rights of certain 
Department of Veterans Affairs (VA) employees to engage in collective 
bargaining. There by, allowing increased negotiation between VA 
employees and the VA Secretary on items such as professional conduct, 
competence and determination of employee compensation. It further 
requires a VA final decision with respect to the review of an adverse 
personnel action against an employee to be issued no later than 60 days 
after such action has been appealed. Subjects such decision to judicial 
review in the appropriate U.S. District Court or, if the decision is 
made by a labor arbitrator, in the U.S. Court of Appeals for the 
Federal Circuit. The VFW has no position on this legislation.

H.R. 1075
    This bill would require the VA Secretary to seek outside contacts 
in the event a VA hospital is closed for greater than 180 days due to a 
national disaster. Currently, when VA hospitals are closed, veterans 
must travel long distances to other VA facilities, which may be 
impractical or impossible following a disaster. This bill would ensure 
that the VA secures alterative arrangements for local medical care, to 
include non-emergency care and inpatient medical care services as 
required.
    The VFW supports this legislation. However, we feel 180 days is far 
too long for a veteran to wait for servicers. We urge the Veterans 
Affairs Committee to hold hearings evaluating the VA's current disaster 
contracting provisions. Allowing a veteran to wait 180 days for medical 
care is unacceptable. Contracts to provide health care must be in place 
before a VA hospital shutters its doors due to natural disaster. The 
VFW believes plans need to be implemented immediately in the event of a 
disaster.

H.R. 2698, the Veterans and Survivors Behavioral Health Awareness Act
    VFW is pleased to support this critical legislation to improve 
mental health care services for veterans and members of the Armed 
Forces and their survivors. This bill recognizes that many of today's 
war wounds are invisible wounds--which often take months to appear, 
making the transition our service men and women face more difficult. We 
believe that this bill is a good first step in making positive changes 
for those suffering the invisible wounds of war.
    Section 2 of the bill concerns Vet Centers. The VFW is a strong 
supporter of Vet Centers and their approach to providing mental health 
care to veterans. VA has done a good job expanding their reach, but 
they are victims of their own success. Many Vet Centers are struggling 
with difficult workloads as increasing numbers of veterans turn to them 
for the unique services they provide. Provisions provided in section 2 
would give some relief by offering scholarship programs for individuals 
seeking education and training in health care specialties needed by the 
Vet Centers. Finding qualified mental health professionals is a 
challenge for VA, and the more incentives they can provide potential 
employees, the more likely that these men and women will turn to VA as 
their employer of choice.
    Section 3 would require VA to help seek outside counseling services 
for veterans who are otherwise not authorized to receive care through 
VA. Many discharged OEF/OIF veterans who are beyond the 5-year dead 
line of access to VA do not have access to counseling, so this is 
clearly the right thing to do.
    Section 4 would allow VA to provide grants to nonprofit 
organizations that provide support for survivors of deceased 
servicemembers and veterans. Family members may not know where to go to 
seek help, and we believe that VA can help point them in the right 
direction.

H.R. 2699, the Armed Forces Behavioral Health Awareness Act
    This legislation would offer OEF/OIF veterans counseling services 
at Vet Centers before they separate from the military. VFW supports all 
the provisions of this bill.
    Section 2 expands mental health services and counseling to active 
duty forces and those in the Reserve Components. VFW believes this 
change is important for two reasons. First, military mental health 
services come with a stigma. That has been shown repeatedly to be the 
greatest impediment to men and women seeking care. By allowing 
servicemembers to seek care without fear of reprisal or reporting 
relieves an emotional burden that can and would otherwise have a 
serious impact on their career. The second reason is that the military 
does not have a sufficient number of mental health care providers. 
While this legislation does not absolve the military of their 
responsibility to properly care for these men and women while in 
service, it helps fill in the gaps in care that are often not there 
when our servicemembers need it.
    Section 3 would require DoD to provide grants to nonprofit 
organizations that provide support for survivors of deceased 
servicemembers and veterans. This provision is similar to the provision 
offered in H.R. 2698. It allows DoD to expand its counseling base and 
go beyond the limited services provided by the military's casualty 
assistance officers, which can help ease the burden on these families 
at a most difficult time in their lives.
    Section 4 would require the Secretary of the Army to carry out a 
pilot program in three locations to improve PTSD awareness among 
members. The alarming rate of veterans and those on active duty 
suffering from mental stress has been well-documented. Providing an 
environment to study the neurophysiological and psychological effects 
associated with the stress and trauma of combat is critical to today's 
Armed Forces. With repeated deployments affecting servicemembers and 
their families, this pilot program would begin to address some of the 
key factors in identifying and addressing PTSD, as well as helping 
those involved reintegrate back into civilian life.

H.R. 2879, the Rural Veterans Health Care Improvement Act of 2009
    VFW supports this comprehensive bill aimed at improving care to 
veterans living in rural areas across the country. We applaud the 
provisions in the bill that would increase the travel reimbursement 
rate to 41.5 cents a mile when they travel to VA facilities for 
treatment, as well as language authorizing VA to establish a grant 
program to provide innovative transportation options to veterans in 
rural areas. The $50,000 grant to state veterans' service agencies and 
veterans' service organizations goes a long way toward helping rural 
veterans--oftentimes, getting to and from appointments is the largest 
hurdle to care.
    The bill would also allow the VA Secretary to carry out 
demonstration projects to examine the feasibility and advisability of 
alternatives for expanding care to veterans in rural areas. The VA 
would establish partnerships with the Department of Health and Human 
Services, Centers for Medicare and Medicaid Services, Indian Health 
Services, and other programs to examine the best way to extend care to 
these veterans. The VFW believes that VA should explore all avenues of 
telemedicine for care of veterans in rural areas.
    It would increase care to OEF/OIF veterans and their families by 
allowing VA to establish programs to provide peer outreach and support 
services. VA would be authorized to contract with community mental 
health centers and/or other qualified entities offering readjustment 
services in areas where those services are not adequately provided. 
Further, it would establish training goals with nonprofit mental health 
organizations by utilizing other veterans in providing peer outreach 
and peer support in their communities. Offering readjustment services 
and counseling where the servicemembers and families live is something 
the VFW believes is critical to the well-being of our servicemembers 
and their families.
    The Rural Health Care and Improvement Act would allow the VA 
Secretary to establish centers of excellence for rural health research, 
education and clinical activities. These centers would research the 
availability of health services in rural areas and develop specific 
models for furnishing those services to veterans in rural areas.
    Section 7 of the bill--Indian Veterans Health Care Coordinators, 
would direct VA to employ an Indian Health Care Coordinator at 10 VA 
medical centers that serve communities with large Indian populations. 
This provision is the same as language found in H.R. 4006, which we 
will comment on in that section of our testimony.
    Last, H.R. 2879 would require the VA Secretary to submit an annual 
report to Congress on the implementation of the provisions of this bill 
and any amendments. VFW looks forward to the enactment of this bill to 
improve the quality and access to care for veterans in rural areas.

H.R. 3926, the Armed Forces Breast Cancer Research Act
    The VFW strongly supports a joint study between VA and DoD into the 
occurrence of breast cancer among members of the Armed Forces. Breast 
cancer remains the second leading cause of death among women, and the 
rate of incidence for men have remain steady according to the American 
Cancer Society. This bill would for require VA and DoD to provide 
information on the number of servicemembers and veterans--male and 
female--who have been diagnosed with breast cancer, the treatment they 
have received and demographic information about their age and service. 
The report, which would be provided to Congress in 18 months, would 
also address whether Defense and VA officials see any service-related 
breast cancer risk or patterns. VFW encourages immediate passage of 
this bill and looks forward to reviewing the report to ensure those 
veterans affected receive the proper medical services they earned.

H.R. 4006, Rural, American Indian Veterans Health Care Improvement Act 
        of 2009
    VFW supports this bill which would improve care to American Indian 
veterans. H.R. 4006 would create an ``Indian Veterans Health Care 
Coordinator'' for 10 VA medical centers that serve the greatest number 
of Indian veterans per capita. This coordinator would improve outreach 
to tribal communities, coordinate the medical needs of Indian 
reservations, and expand the access and participation of VA in the 
Department of Veterans Affairs Tribal Veterans Representative program.
    The bill would also require the VA and Department of the Interior 
to enter into a Memorandum of Understanding to ensure the electronic 
transfer of health records of Indian veterans between Indian Health 
Service (HIS) and VA facilities. VA would also be authorized to 
transfer to HIS any surplus medical and information technology 
equipment.
    This bill would also require VA and the Department of Health and 
Human Services to report jointly to Congress on the advisability of the 
joint VHA-IHS establishment and operation of health clinics to serve 
eligible populations on Indian reservations.

                                 
                   Prepared Statement of Joy J. Ilem,
    Deputy National Legislative Director, Disabled American Veterans

    Mr. Chairman, Ranking Member Brown, and 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 the 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. 84--Veterans Timely Access to Health Care Act

    The stated goal of this bill is to provide timely access to VA 
health care. To accomplish this objective, a 30-day standard would be 
established as the maximum time that a veteran would be required to 
wait to receive a VA primary care appointment. The bill would also 
direct VA to establish a standard for the maximum length of time that a 
veteran would be required to wait to actually see a provider on the day 
of a scheduled appointment. Under the bill, if the Secretary found that 
any particular VA geographic service area failed to substantially 
comply with the timeliness standards, facilities in that area would be 
required to contract for the care of a veteran in each instance it was 
unable to meet those standards. The contracting requirement would be 
mandatory for veterans who are classified within enrollment Priority 
Groups 1 through 7 and discretionary for those within Priority Group 8.
    The bill would require the Secretary to carry out a one-time 
examination of waiting time data for the entire VA health care system, 
stratified by geographic service area. The Secretary would be required 
to issue a determination regarding compliance with the standard in each 
geographic service area. If the compliance rate for any area were below 
90 percent, facilities located in that area would be subjected to the 
requirement to contract for care whenever they were unable to meet 
those standards. Facilities with a compliance rate of 90 percent or 
more would be prohibited from contracting out such services.
    Under the bill, VA would be required to submit two reports to the 
Committees on Veterans' Affairs. The first would be an annual report 
providing an assessment of its performance in meeting the timeliness 
standards. The second report would be made quarterly, and would include 
detailed waiting-time data for each geographic service area. The bill 
would require quarterly reports to include the number of veterans in 
each geographic service area waiting for care, distinguished by primary 
care and specialty care, and segregated periodically by those waiting 
from under 30 days to those waiting over a year, plus those who cannot 
be scheduled at all. The quarterly reporting requirement would continue 
through December 2010.
    The bill provides that payments under these contracts could not 
exceed the reimbursement rates under Medicare, and the non-VA 
facilities or providers would be prohibited from billing veterans 
affected by this process for the difference between the billed amounts 
and the amounts of VA payments.
    Mr. Chairman, we note similar bills, H.R. 3094 from the 108th 
Congress and H.R 92 from the 110th Congress, were considered by this 
Subcommittee in prior legislative hearings. The historical context 
during which the first bill was introduced is best described by then-VA 
Secretary Anthony J. Principi's reference to a ``perfect storm'' 
related to significantly increased demand for care and insufficient 
resources to meet timely access for that demand, resulting in a backlog 
or waiting list for access to VA medical services. Between October 1, 
2001 and September 2002, VA enrolled an additional 830,237 veterans. 
With years of insufficient funding and an overwhelming demand for VA 
medical care, a July 2002 survey conducted by the Veterans Health 
Administration (VHA) revealed over 310,000 veterans waiting for medical 
appointments, half of whom were reported to be waiting 6 months or more 
for care and the other half having no scheduled appointments at all. In 
January 2003, over 200,000 were waiting 6 months or longer. At that 
time, exercising its annual enrollment decision authority as required 
by Public Law 104-262, VA suspended the enrollment of new Priority 
Group 8 veterans.
    While DAV and many others opposed this decision on the record, we 
understood the reasons for it--clearly, VA was struggling from severe 
underfunding across its health care programs. The run-up to that 
decision also fueled our determination at DAV to seek a legislative 
remedy for VA's flawed health care budget formulation and discretionary 
appropriations processes.
    On September 30, 2003, your Subcommittee held a legislative hearing 
on H.R. 3094 (a similar version of the current bill), at a time when 
about 130,000 veterans were still waiting 6 months or longer for access 
to VA care. DAV testified at that hearing that veterans must have 
access to timely health care and that VA must be held accountable for 
meeting its own access standards. However, we were deeply concerned 
that this bill to contract care in order to meet its proffered access 
standards would ultimately shift medical services and veteran patients 
from VA to private providers. The effect of contracting out care to 
non-Department facilities and providers would encourage VA to refer 
patients, and the dollars that would underwrite their care outside a 
unique governmental system of care specifically created for veterans to 
meet their specialized health needs. We testified at that time that if 
given sufficient, timely and predictable funding, VA should be held 
accountable for meeting all its demands, and that only as a last resort 
would we support the broad contracting out of their medical care.
    On April 26, 2007, DAV's testimony on H.R. 92 (another similar bill 
to this one) recounted our position on H.R. 3094 from the 108th 
Congress and included the need for consideration in the bill to 
reinforce that VA must have a comprehensive, systemic process for 
contracting care to ensure:

      care is safely delivered by certified, licensed, 
credentialed providers;
      continuity of care is sufficiently monitored, and that 
patients are properly directed back to the VA health care system 
following private care;
      veterans' medical records accurately reflect the care 
provided and the associated pharmaceutical, laboratory, radiology and 
other key information relevant to the episode(s) of care; and
      the care received is consistent with a continuum of VA 
care.

    Therefore, we recommend the Subcommittee consider amending H.R. 84 
to first implement the data requirements and reports required in the 
current measure prior to further considering approving provisions in 
the bill to automatically contract for care if the stated access 
standards would not be met. Over the past several years we believe VA 
has made tremendous effort to significantly reduce waiting times,\1\ 
and thanks to the work of the Members of this Subcommittee VA now has 
the opportunity to receive timely, sufficient, and predictable funding 
for VA medical care through advance appropriations (Public Law 111-81).
---------------------------------------------------------------------------
    \1\ Fiscal Year 2009 Performance and Accountability Report, 
Department of Veterans Affairs, Office of Management. Washington, D.C. 
www.va.gov/budget/report.
---------------------------------------------------------------------------
    In addition, DAV remains concerned about two weaknesses affecting 
the impact of H.R. 84, if enacted. Despite our recommendations in The 
Independent Budget (IB) over several years, VA has yet to establish a 
comprehensive, systemic program of contract care coordination to ensure 
that the services veterans receive in the private sector, paid for by 
VA, do not represent a diminished quality of care that they would have 
received otherwise from the VA.\2\ Our second concern questions the 
validity of the reportable data for waiting times. DAV has raised this 
unresolved issue in concurrence with a report by the VA Office of 
Inspector General.\3\ Finally, we note the bill does not seek to 
identify the underlying cause(s) for delays in access to care, an issue 
that is critical to VA's developing an effective solution.
---------------------------------------------------------------------------
    \2\ The Independent Budget, Fiscal Year 2011; Contract Care 
Coordination, Non-VA Purchased Care; & Timely Access to VA Health Care. 
www.independentbudget.org/.
    \3\ Department of Veterans Affairs, Office of Inspector General; 
Semiannual Report to Congress, October 1, 2008-March 31, 2009; pg. 10. 
http://www4.va.gov/oig/pubs/VAOIG-SAR-2009-1.pdf.
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 H.R. 949--To Improve the Collective Bargaining Rights and Procedures 
                                  for
  Review of Adverse Actions of Certain Employees of the Department of
                Veterans Affairs, and for Other Purposes

    This bill would repeal specified exceptions to rights of certain VA 
health professional employees to engage in collective bargaining over 
conditions of employment. It would also require reviews of adverse 
personnel actions of VA employees be completed within 60 days after 
such actions have been appealed, and would permit judicial review of 
these final decisions by the appropriate U.S. District Court or, if a 
decision were made by a labor arbitrator, review would occur within the 
jurisdiction of the U.S. Court of Appeals for the Federal Circuit in a 
manner similar to processes of the Merit Systems Protection Board in 
reviewing decisions related to Federal employees under title 5, United 
States Code.
    Mr. Chairman, this bill would restore bargaining rights for 
clinical care employees of the VHA that have been eroded over the past 
several years. A similar version of this bill was introduced in both 
Chambers in the 110th Congress but did not advance.
    DAV did not receive an adopted resolution from our membership on 
the specific VA labor-management dispute that prompted Chairman 
Filner's introduction of this bill. However, as a partner organization 
of the IB, DAV endorses its recommendations dealing with the need for 
VA to improve its human resources management systems and programs to 
make VA a better workplace for the care of sick and disabled veterans. 
Also, we believe VA-recognized labor organizations that represent 
employees in bargaining units within the VA health care and benefits 
systems have an innate right to information and reasonable 
participation that result in making VA a workplace of choice (a stated 
longstanding VA strategic goal), and particularly to fully represent VA 
employees on issues impacting their working conditions, ultimately 
protecting the quality of care for veterans.
    Congress passed section 7422, title 38, United States Code (USC), 
in 1991, in order to grant specific bargaining rights to labor in VA 
professional units, and to promote effective interactions and 
negotiation between VA management and its labor force representatives 
concerned about the status and working conditions of VA physicians, 
nurses and other direct caregivers appointed under title 38, USC. In 
providing this authority, Congress granted to VA employees and their 
recognized representatives a right that already existed for all other 
Federal employees appointed under title 5, USC. Nevertheless, Federal 
labor organizations continue to report that VA has severely restricted 
the recognized Federal bargaining unit representatives from 
participating in, or even being informed about, human resources 
management decisions and policies that directly impact conditions of 
employment of the VA professional staffs within these bargaining units. 
We are advised by labor organizations that when management actions are 
challenged, VA officials (many at the local level) have used 
subsections (b), (c) and (d) of section 7422--subsections that this 
bill would repeal--as a statutory shield to obstruct any labor 
involvement to correct or ameliorate the negative impact of VA's 
management decisions, even when management is allegedly not complying 
with clear statutory mandates (e.g., locality pay surveys and 
alternative work schedules for nurses, physician market pay 
compensation panels, etc.).
    Facing VA's refusal to bargain or to discuss the fairness of these 
policies, the only recourse available to labor organizations is to seek 
redress in the Federal court system. However, recent case law has 
severely weakened the rights of title 38 appointees to obtain judicial 
review of arbitration decisions. Title 38 employees also have fewer due 
process rights than their title 5 counterparts in administrative 
appeals hearings.
    It appears to DAV that the often contentious local environment 
consequent to these disagreements could diminish the VA as a preferred 
workplace for many of its health care professionals. As a result, 
veterans who depend on VA and who receive care from VA's physicians, 
nurses and others in the professional ranks can be negatively affected 
by that environment.
    We believe this bill, that if enacted would rescind VA's claimed 
authority to refuse to bargain on matters within the purview of section 
7422, through striking of subsections (b), (c) and (d), would clarify 
other critical appeal and judicial rights of title 38 appointees, and 
would return VA and labor to a more balanced bargaining relationship on 
issues of importance to VA's professional workforce. In past hearings 
before this Committee, VA clearly has indicated vigorous disagreement 
with the intent of the bill, but to date has not offered to compromise 
its position in refusing to bargain across a wide group of issues that 
are defined by VA as ``direct patient care.'' Given the continuing 
stalemate, our only recourse is to support the intent of the bill in 
the spirit of the recommendations we have made in the IB, yet continue 
to urge both VA and Federal labor organizations to seek and find a 
basis for compromise on these matters.

                         H.R. 1075--RECOVER Act
   (Restoring Essential Care for Our Veterans for Effective Recovery)

    In the event of a declared major disaster, on or after August 29, 
2005, where a VA medical facility is unable to provide covered health 
care services for at least 180 days due to the disaster, this measure 
would direct VA to contract with one or more non-VA facilities in that 
area to provide such services to veterans who reside within 150 miles 
of the affected VA facility(s). The requirement would not be applicable 
to VA facilities that were closed, or were intended to be closed as 
part of the Capital Asset Realignment for Enhanced Services (CARES) 
process.
    Nearly 4 years after Hurricane Katrina, the House Veterans' Affairs 
Committee conducted a field hearing on July 9, 2009, in New Orleans, 
Louisiana, to explore the challenges faced by the VA and other local 
health care facilities to provide high quality safe health care to area 
veterans and citizens. Believing geographic and timely access to care 
is particularly important to disabled veterans in need of medical 
attention, DAV testified that our Nation owes it to our veterans to 
properly care for them now--and not keep them waiting.
    Prior to and during the disaster, VA did an admirable job of 
ensuring veteran patients were expeditiously evacuated, relocated and 
kept safe, and that local veterans' medical records were available to 
other VA medical facilities to meet immediate needs for medications and 
specialized care. However, over the last 4-plus years, VA has struggled 
to re-establish comprehensive care services in the area following the 
devastating effects of Hurricane Katrina, and ensuring the immediate 
health care needs of our veterans are met without undue hardship. The 
network of community-based outpatient clinics and deployment of mobile 
clinics have created capacity to meet veterans' basic outpatient 
primary care needs; however, reports from many affected veterans 
indicated that if hospitalization or inpatient treatment in a tertiary 
care facility were necessary, they must still travel great distances to 
the nearest VA health care facilities that can provide their needed 
care. For some elderly, ill, brittle and disabled veterans this creates 
a travel hardship. In addition, family members are often unable to 
accompany veterans due to travel restrictions, given the cost of travel 
without financial assistance for subsistence or lodging. Of note, 
research has proven that family support during hospitalizations and 
recovery, or during difficult or stressful medical procedures can 
assist with accelerating recovery time and lowering length of stay, 
both resulting in cost savings for the VA.
    This Subcommittee is aware of DAV's position regarding contracting 
care, specifically that it be utilized judiciously by VA. Current law 
places limits on VA's ability to contract for private health care 
services in instances where VA facilities are incapable of providing 
necessary care to a veteran; when VA facilities are geographically 
inaccessible to a veteran for necessary care; when medical emergency 
prevents a veteran from receiving care in a VA facility; to complete an 
episode of VA care; and for certain specialty examinations to assist VA 
in adjudicating disability claims. VA also has the authority to 
contract to obtain the services of scarce medical specialists in VA 
facilities.
    Hurricane Katrina impacted all of the major medical facilities in 
the immediate city area affected and we understand most are still not 
operational. However, in retrospect, it seems possible that VA could 
have established more contracts with other medical facilities just 
outside the affected city area. DAV is concerned that VA sparingly used 
existing authority in the instance of this major disaster, to contract 
with local non-VA facilities in the region to provide inpatient care 
but rather required veterans who were sick and in need of inpatient 
care to make long trips to the nearest VA facility in many cases.\4\ We 
do not believe such actions are in the best interest of sick and 
disabled veterans who rely on VA, nor are they an acceptable standard 
in this instance, given the length of time it has taken to reestablish 
and rebuild new VA facilities in that location. We hope, in considering 
this bill, the Subcommittee will note that within mere weeks of the 
disaster, Congress provided billions of dollars to restore the Gulf 
Coast region. Those funds and mandates failed to include mandates for 
replacement of the destroyed VA medical centers in New Orleans and 
Gulfport. While Congress eventually acted to authorize the funds and 
projects to replace these facilities destroyed by the storm, nearly 5 
years after Katrina, sick and disabled veterans still await the opening 
of the replacement facilities.
---------------------------------------------------------------------------
    \4\ Travel times and distances from the New Orleans VAMC to: Biloxi 
VAMC--1.5 hours/85 miles; Sonny Montgomery (Jackson) VAMC--3 hours/189 
miles; Alexandria VAMC--3.5 hours/199 miles; the Michael E. DeBakey 
(Houston) VAMC--6 hours/352 miles; Overton Brooks (Shreveport) VAMC--
5.5 hours/319 miles.
---------------------------------------------------------------------------
    The delegates to our most recent National Convention passed DAV 
Resolution No. 037, calling on VA to ensure timely access to quality 
health care and medical services. We therefore support the purposes of 
this bill as a contingency, but point out concerns that we recommend be 
addressed before final passage. The operational loss of a VA medical 
facility due to a major disaster and subsequent contracting with non-VA 
facilities as proposed by this measure should not become a foundation 
for delay of replacement facilities, or repair of the affected VA 
facility. Also, the bill should reflect Congressional intent that upon 
the completion of replacement or repair of an affected VA facility, 
veterans who have received care under a contract arrangement with a 
non-VA facility will return to the repaired or replaced VA facilities 
for their continuing health care needs. Accordingly, we recommend 
improvements outlined in DAV Resolution No. 232 (on the need for better 
coordination of VA contract care programs), to include ensuring that 
service-connected disabled veterans would not be financially encumbered 
in receiving non-VA care at VA's expense; and that VA would establish a 
systemic, comprehensive contract care coordination program for these 
patients.

   H.R. 2698--Veterans and Survivors Behavioral Health Awareness Act

    The intent of this measure would improve and enhance the mental 
health care benefits available to veterans as well as to enhance 
counseling and other benefits to survivors of veterans.
    Section 2 of this bill would direct the VA Secretary to provide 
scholarships to individuals pursuing education or training leading to 
licensure or other certified proficiency in behavioral health care 
specialties that are critical to the operations of Vet Centers for 
readjustment counseling and related mental health services for 
veterans. These scholarships would assist in recruitment and in 
retaining individuals within such specialties. In order to accept 
scholarships, the recipients would agree to continue to serve in such a 
capacity for defined periods the Secretary specified in agreements--
including repayment of the scholarships if encumbered individuals 
subject to these scholarships failed to fulfill the service 
requirements of the aforementioned agreements. The VA Secretary would 
determine the amount of the scholarships and amounts under the program 
would be derived amounts available to the Secretary for readjustment 
benefits--but would not exceed $2 million in any fiscal year (FY).
    Section 3 of this bill would stipulate that upon receipt of a 
request for counseling from an individual discharged or released from 
active service, but who would not be otherwise eligible for such 
counseling, the Secretary would be required to (1) provide referrals to 
assist the individuals in obtaining mental health care and services 
outside the VA to extent practicable; and (2) if pertinent, would 
advise such individuals of their rights to apply for review of their 
military discharge documentation.
    Section 4 would direct the Secretary to award grants to nonprofit 
organizations that provide emotional support services for survivors of 
deceased members of the Armed Forces (including National Guard and 
Reserves) and deceased veterans through peers of such survivors. The 
Secretary would establish the criteria for nonprofit organizations' 
eligibility through an application process to be specified by the 
Secretary as well as the amounts for such awards.
    While the DAV has no specific resolution pertaining to section 2 of 
the measure, related to scholarships, we have two national resolutions 
that apply to the main intent of this section of the bill. The first is 
DAV's resolution number 101, which calls for adequately funding and 
sustaining the successful readjustment counseling services of the VA 
and its highly effective Vet Center programs. The second DAV resolution 
is number 243, which strongly supports program improvement and enhanced 
resources for VA mental health programs to achieve readjustment of new 
war disabled veterans and continued effective mental health care for 
all enrolled veterans needing such services.
    In addition, the FY 2011 IB contains a section on human resources 
challenges facing VA. We remain concerned about the current status of 
human resources challenges faced in the VA and the need to consider 
creative and alternative programs to ensure veterans have access to the 
best medical and mental health services for rehabilitation of their 
service-related injuries. We have recommended that Congress and VA 
continue to work to strengthen and energize VA's human resources 
management programs to recruit, train, and retain qualified VA 
employees and to identify new tools to enable VA to gain equality with 
other employers in attracting a new generation workforce for veterans.
    Therefore, since the intent of the section is to recruit and retain 
mental health care providers at VA's Vet Centers, we support enactment 
of this section of the bill.
    DAV has no objection to the provisions in section 3 of H.R. 2698 
related to referrals to assist individuals, who are not otherwise 
eligible for Vet Center counseling services, in obtaining mental health 
care and services outside the VA or to advise such individuals of their 
rights to apply for review of their military discharge determinations.
    The DAV does not have a specific resolution related to section 4 of 
the bill that pertains to Federal funding through a grant program for 
nonprofits to provide emotional support through peer groups to 
survivors of deceased servicemembers and veterans. We do support the 
peer-to-peer initiatives that have been employed in the VA's Vet Center 
program. However, DAV would not be able to participate in the program 
that would be authorized in this section of the bill because, as a 
matter of principle, DAV does not accept federally appropriated grants 
to provide services to disabled veterans.

        H.R. 2699--Armed Forces Behavioral Health Awareness Act

    The purpose of this measure would be to improve the mental health 
care benefits available to members of the Armed Forces, including 
Reserve components, and to enhance counseling available to 
servicemembers' family members.
    Section 2 of this measure would make any servicemember of the Armed 
Forces who deploys in support of Operations Enduring Freedom or Iraqi 
Freedom (OEF/OIF) eligible for readjustment counseling and related 
mental health services through VA Vet Centers, regardless of the 
member's duty status.
    Section 3 would require that the Secretary of Defense award grants 
to nonprofit organizations that provide emotional support services for 
family members of members of the Armed Forces, including members of the 
Reserve components. The amount of each grant and duration of the 
program would be determined by the Secretary based on the scope of the 
proposed program. Such funding would be derived from the amounts 
authorized to be appropriated to the Department of Defense (DoD) for 
military personnel.
    Section 4 would require the Secretary of the Army to carry out a 3 
year pilot program to enhance awareness and understanding of post 
traumatic stress disorder (PTSD) among members of the Army at three 
military base locations: Fort Huachuca, Arizona, Fort Carson, Colorado, 
and Fort Leonard Wood, Missouri, and for the family members of 
servicemembers covered under the bill in order to assist the families 
in recognizing and addressing PTSD. No later than 2 years after the 
date of enactment, the DoD Secretary would be required to submit a 
report to Congress assessing the effectiveness of the pilot program.
    DAV takes no position on provisions in H.R. 2699 related to 
enhancement of post-deployment mental health services for active duty 
servicemembers, Reserve components or their family members. These 
matters are under the jurisdiction of the Committees on Armed Services. 
We do provide the following comments on section 2 of the bill related 
to expansion of eligibility of readjustment counseling services at Vet 
Centers under section 1712 A of title 38, United States Code.
    DAV's resolution number 243 strongly supports program improvement 
and enhanced resources for VA mental health programs to achieve 
readjustment of new war disabled veterans and continued effective 
mental health care for all enrolled veterans needing services. Although 
we do not have a resolution specific to expanding eligibility for Vet 
Center services to active duty status servicemembers, we have supported 
seamless transition for servicemembers and veterans and improved 
collaboration between the two Departments to achieve this goal. 
Therefore, we have no objection to such expansion, since it would 
likely be most beneficial for certain servicemembers to obtain early 
interventions of any deployment-related mental health concerns to avoid 
more complicated health challenges and costly treatment interventions 
at a later date. We note similar provisions are included in Title IV of 
the proposed negotiated agreement on an omnibus VA health care bill, 
the vehicle for which will be S. 1963, the Caregivers and Veterans 
Omnibus Health Services Act of 2010.
    Should the Subcommittee plan to report this measure to the full 
Committee, we ask you to consider amending section 2 of the bill to 
include provisions to authorize either a cost sharing agreement with 
DoD, as envisioned in Public Law 97-174, to cover the VA's costs of 
servicemembers' care based on data verifying the number of 
servicemembers who access such counseling, or to authorize additional 
VA resources in the bill specifically for this care of the active 
force, as well as the cost of the additional staff needed to provide 
such services. Additionally, consideration should be given to include 
provisions to provide proper outreach to active servicemembers about 
this exceptional service and assured confidentiality when accessing 
such care at a VA Vet Center, to ensure the intended purpose of the 
program is achieved.

     H.R. 2879--Rural Veterans Health Care Improvement Act of 2009

    Section 2 of this bill would amend section 111, title 38, USC, to 
insert a fixed rate of 41.5 cents per mile in reimbursement for the 
purposes of VA's travel beneficiary program. Reimbursement at this rate 
may exceed the cost of travel by public transportation regardless of 
medical necessity. A report is required no later than 14 months after 
enactment of the Act.
    Section 3 of this bill would require VA to establish at least one 
and no more than five centers of excellence for rural health research, 
education, and clinical activities.
    Section 4 would require the Secretary to establish a transportation 
grant program to veterans service organizations to allow for other 
transportation options to assist veterans residing in highly rural 
areas to travel to VA facilities.
    Section 5 would require the VA's Office of Rural Health to conduct 
demonstration projects with the goal of expanding care in rural areas.
    Section 6 of the bill would require the VA to establish a contract 
care program through community mental health centers and other 
``qualified entities'' for the provision of certain readjustment, 
mental health, peer counseling and similar services to OEF/OIF veterans 
and their dependents in rural and remote regions. The program would be 
restricted to areas determined by the Secretary to be inadequately 
served by direct VA services.
    Section 7 of the bill would establish a Native American health care 
coordination function in the 10 VA medical centers that serve the 
greatest number of Native Americans per capita, with specification of 
the duties associated with the new function. Also, the bill would 
require the Secretary and the Secretary of the Interior to execute a 
memorandum of understanding that would ensure the health records of 
Indian veterans may be transferred electronically between the Indian 
Health Service (IHS) and the VHA.
    Section 8 would require an annual report to Congress as a part of 
the President's budget on a variety of matters concerned with rural 
veterans.
    The DAV appreciates the intent of this measure to improve health 
care for veterans residing in rural and remote areas. With some concern 
outlined below, we support enactment of this bill as consistent with 
DAV resolution numbers 240 (related to VA's beneficiary travel 
reimbursement policy) and 247 (related to improved health care services 
and access for veterans living in rural areas), adopted by our 
membership at DAV's 2009 National Convention.
    As this Subcommittee is aware, the conference report accompanying 
the Consolidated Appropriations Act of 2008 (Public Law 110-161), 
specified that $125 million of the funds provided for veterans medical 
services should be used to increase the travel reimbursement rate. The 
Consolidated Security, Disaster Assistance, and Continuing 
Appropriations Act of 2009 (Public Law 110-329), provided an additional 
$133 million to increase the beneficiary travel reimbursement mileage 
rate to 41.5 cents per mile, while freezing the deductible at current 
levels. Subsequently, the Veterans' Mental Health and Other Care 
Improvements Act of 2008 reduced the mileage deductible to $3 for each 
one-way trip; $6 per round trip; with a calendar month cap of $18 as 
specified in title 38, United States Code, Subsection 111(c)(1) and (2) 
for travel expenses incurred on or after January 9, 2009.
    DAV supported the increase in mileage reimbursement afforded under 
Public Law 110-329. However, by prescribing in law the current travel 
reimbursement rate of 41.5 cents per mile without any mechanism for 
annual adjustment may lead to the situation that occurred prior to 
enactment of Public Law 110-161 to break the long period where the 
beneficiary travel mileage reimbursement rate had not been changed in 
over 30 years.
    Additionally, in eliminating title 38, USC, Subsection 111(g), we 
are concerned this bill does not replace the required report from VA 
containing full justification (including the ramifications of diverting 
funds not provided for in appropriations, such as those in Public Laws 
110-161 and 110-329, from direct medical care for the purpose of 
increasing mileage) when exercising its authority to increase or 
decrease the rates of allowances or reimbursements. We refer the 
Subcommittee to section 305 of the recently reached proposed negotiated 
agreement on an omnibus VA health care bill, the vehicle for which will 
be S. 1963, the Caregivers and Veterans Omnibus Health Services Act of 
2010. In amending title 38, USC, Subsection 111(g), S. 1963 provides 
certain flexibility to the Secretary as it relates to investigating and 
determining the actual cost of travel for establishing VA mileage 
reimbursement rates.
    Finally, should Congress decide to strike Subsection (g) of title 
38, USC, Subsection 111, as is proposed by this measure, we recommend a 
technical correction be made to Subsection 111(b)(1) because it 
references Subsection (g)(2)(A).

           H.R. 3926--Armed Forces Breast Cancer Research Act

    This Act would direct the Secretaries of DoD and VA to jointly 
conduct a study on the incidence of breast cancer among members of the 
Armed Forces, including National Guard and Reserve components, and 
veterans and report those study results to Congress.
    H.R. 3926 would also require demographic information on study 
participants including information on possible exposure to hazardous 
elements or chemical or biological agents (including vaccines), 
locations in which the servicemembers or veterans were deployed, and 
analysis of breast cancer treatments received by Armed Forces members 
and veterans.
    DAV Resolution No. 252 urges greater collaboration between DoD and 
VA to share necessary deployment, health and exposure data from 
military operations and deployments, in order to timely and adequately 
address the subsequent health concerns of disabled veterans, whatever 
the causes of those disabilities. Additionally, this resolution urges 
Congress to provide adequate funding for research to identify all 
disabling conditions and effective treatment for such disabilities that 
may have been caused by exposure to environmental hazards and man-made 
toxins while serving in the Armed Forces of the United States.
    DAV is committed to ensuring veterans disabled by exposure to 
environmental hazards and toxins receive effective high quality health 
care and that the biomedical research and development programs of the 
Department are fully addressing their needs. For these reasons we are 
pleased to support H.R. 3926, the Armed Forces Breast Cancer Research 
Act, and urge its passage.

H.R. 4006--Rural, American Indian Veterans Health Care Improvement Act 
                                of 2009

    The Rural, American Indian Veterans Health Care Improvement Act of 
2009 directs the Secretary of VA to assign an Indian Veterans Health 
Care Coordinator for each of the ten VA facilities that serve 
communities with the greatest per capita number of Indian veterans. The 
Indian Veterans Health Care Coordinator would be tasked with: (1) 
improving outreach to tribal communities; (2) coordinating the medical 
needs of Indian veterans on Indian reservations with the VHA and the 
IHS; and (3) acting as an ombudsman for Indian veterans enrolled in the 
VHA health care system.
    The bill would require the VA and the Department of the Interior to 
enter into a memorandum of understanding to ensure the electronic 
transfer of health records of Indian veterans between IHS and VA 
facilities. Moreover, VA would be authorized to transfer to IHS any 
surplus medical and information technology equipment.
    This measure would also require VA and the Department of Health and 
Human Services (HHS) to report jointly to Congress on the advisability 
of the joint VHA-IHS establishment and operation of health clinics to 
serve populations of Indian reservations, including Indian veterans.
    Since 2003, the IHS and the VHA have collaborated using a 
memorandum of understanding (MOU) to promote greater cooperation and 
resource sharing to improve the health of American Indian/Alaska Native 
(AI/AN) veterans. The MOU encourages VA and IHS programs to collaborate 
and improve beneficiaries' access to health care services, improve 
communications between IHS and VHA and to create opportunities to 
develop strategies for sharing information, services, and information 
technology. In some areas, this coordination between IHS and VHA has 
improved while in other areas, such coordination needs improvement.
    A recent study examined AI/AN veterans' utilization of the IHS and 
VA health services. Based on the study's survey, 25 percent of AI/AN 
veterans receive care through both IHS and VA, while over 25 percent of 
AI/AN veterans accessed care through VA only and nearly 50 percent of 
AI/AN veterans accessed care through IHS only.\5\ Those AI/AN veterans 
who used both VA and IHS for medical care actively matched health care 
resources to their medical needs, generally use IHS for primary care 
and VA for specialty care, thus using VA as a form of supplemental 
coverage. The report also indicates that AI/AN veterans report a high 
rate of unmet health care needs and experience a lack of coordination 
of health care.
---------------------------------------------------------------------------
    \5\ B.J. Kramer, M. Wang, et al; Veterans Health Administration and 
Indian Health Service--Healthcare Utilization by Indian Health Service 
Enrollees, Medical Care, Vol. 47, No. 6. June 2009.
---------------------------------------------------------------------------
    Another study concluded fostering closer alignment between VHA and 
IHS would reduce care fragmentation and improve accountability for 
patient care.\6\ This study found coordination between VA and IHS 
providers occurred on an ad hoc basis. Although both VA and IHS could 
share information through medical releases, veterans were dissatisfied 
with the burdensome process when it was made available as an option. 
Since medical information was not routinely shared, treating chronic 
health conditions was challenging, especially when providers were 
unaware of their counterpart's recommendations of treatments, including 
medications and dosage. Appropriate referrals to VHA from the IHS would 
be a significant step toward resource sharing that would benefit both 
organizations financially. By displaying leadership in coordination of 
care, VHA and IHS can demonstrate how to overcome technical, policy and 
administrative challenges in implementing the Institute of Medicine 
recommendations to enhance quality through data sharing and care 
coordination.\7\
---------------------------------------------------------------------------
    \6\ B.J. Kramer, R.L. Vivrette, MA, et al; Dual Use of Veterans 
Health Administration and Indian Health Service: Healthcare Provider 
and Patient Perspectives, Gen Intern Med. 24(6): 758-764. Published 
online April 18, 2009.
    \7\ Institute of Medicine, Committee on Enhancing Healthcare 
Quality Programs. Leadership by Example: Coordinating Government Roles 
in Improving Health Care Quality; National Academy Press. 2002.
---------------------------------------------------------------------------
    As with section 7 of H.R. 2879, the Rural Veterans Health Care 
Improvement Act of 2009, DAV supports this measure based on DAV 
Resolution No. 247 (supporting improved access to rural health care 
services for veterans residing in those areas), adopted by our 
membership at DAV's 2009 National Convention. We are aware that better 
collaboration between VA and IHS is critical, particularly in the 
behavioral health understanding and accommodation of the cultural needs 
of American Indian, Alaska Native and Pacific Islander veterans--and 
that culturally traditional treatments should be considered as an 
option for tribal veterans.

       Draft Bill--To Amend Title 38, United States Code, To Make
    Certain Improvements in the Laws Relating to Performance Pay and
       Collective Bargaining Rights for Certain Employees of the
                     Department of Veterans Affairs

    This measure would amend section 7431(d)(2) of title 38 by 
inserting ``individual'' after ``dentist's'' and by inserting ``in 
accordance with regulations'' after ``objectives,'' in addition to 
editing section 7422 by inserting ``rates'' after ``employee 
compensation.'' Further, ``patient care'' would be inserted in 
subsection (c)(1) after ``not including procedures or appropriate 
arrangements as such terms are used in section 7106(b) of title 5l and 
in subsection (d) by inserting ``rates'' after ``employee 
compensation.''
    Section 1 of this bill would clarify Congressional intent in 
establishing performance pay elements for VA physicians and dentists in 
Public Law 108-445, the VA Health Care Personnel Enhancement Act of 
2004, by sharpening its intent to measure performance of individual 
physicians and dentists, rather than groups of these key VA 
professionals in establishing performance pay. The bill would also 
require the Secretary to establish by published regulation (presumably 
in the Federal Register) in advance the performance objectives that VA 
would use to justify awarding performance-based salary increments, or 
performance bonuses, to VA physicians and dentists who chose to 
function under those performance objectives. Under the bill, such 
regulations would be required to be published within 60 days post-
enactment of this bill.
    The DAV has no adopted resolution on these particular matters, but 
we again refer the Subcommittee to the FY 2011 IB discussion on the 
need for VA to improve human resources programs. Publishing performance 
objectives for VA physicians and dentists in the Federal Register in 
advance of their use would be a novel but probably effective way to 
guarantee VA would be required to consider their views before adopting 
new procedures that impacted their conditions of employment. We believe 
this bill's enactment would be consistent with our views in the IB. 
Thus, we would have no objection to passage of this section.
    Section 2 of the bill would make a series of amendments to section 
7422 of title 38, USC, in subsections (b), (c) and (d), to narrow the 
definition of exclusions from collective bargaining dealing with the 
interests of certain health professional employees of the Department. 
Again, DAV refers the Subcommittee to our human resources discussion in 
the IB for FY 2011. These changes would afford recognized employee 
units more ability to bargain with VA on policies that would make VA a 
preferred workplace for clinical professional staffs. DAV would offer 
no objections to enactment of this section of the bill. However, we 
remind the Subcommittee of our comments on H.R. 949, a bill that would 
repeal each of the subsections of title 38 that this bill would amend.
   Draft Bill--To Amend Title 38, United States Code, To Improve the
      Continuing Professional Education Reimbursement Provided to
  Health Professionals Employed by the Department of Veterans Affairs
    This bill would expand from VA physicians and dentists to a wider 
group of VHA professional employees who are eligible for annual 
continuing education allowances, and would increase such allowances 
from $1,000 to $1,600 per annum per employee. amendments to effect this 
change would be made to section 7411(1) of title 38, USC, by striking 
``physician or dentist'' and replacing it with ``health professional'' 
employees appointed under paragraph (1) or (3) of section 7401 of the 
title. The bill would also specify that no health professional could 
receive reimbursement under this section in addition to any other 
reimbursement for expenses incurred for education provided by a 
Department medical center.
    While we have no resolution adopted on this specific matter from 
our membership, the purpose of the bill is consistent with VA's 
maintaining technical proficiencies of VA clinical professionals. On 
that basis, DAV would offer no objection to its enactment into law.

  Draft Bill--To Amend Title 38, United States Code, To Authorize the
      Secretary of Veterans Affairs to Waive Certain Requirements
                  Relating to Mental Health Counselors

    This bill would amend section 7202(b)(11)(B) by inserting ``except 
that the Secretary may waive the requirement of licensure or 
certification for an individual licensed professional mental health 
counselor for a reasonable period of time recommended by the Under 
Secretary for Health'' before the period where it appears. We noted a 
technical error in the text in that it refers to ``section 7202,'' a 
section that does not exist in title 38, rather than section 7402, a 
section that refers to ``Qualifications of appointees'' in the VHA.
    Assuming it would apply to section 7402, this bill would grant the 
VA Secretary a temporary period to retain VA mental health professional 
employees while they sought professional certifications and state 
licensures within their fields. Given the shortage of mental health 
professionals today in general, and given VA's need to continue to 
prepare for a major growth of mental health workloads due to the 
anticipated end of wars in Iraq and Afghanistan and the mental health 
legacy associated with these wars, this proposal seems reasonable as a 
needed human resources flexibility. Also, given VA's massive academic 
programs in which tens of thousands of professional and technical 
students rotate in VA facilities each year as a part of their practica, 
this tool might help VA with a number of its chronic recruitment 
challenges. Thus, while DAV has no adopted resolution from our 
membership on this particular issue, we would not object to enactment 
of this bill.
    Mr. Chairman, this concludes DAV's testimony. Again, we thank the 
Subcommittee for its leadership, and for requesting our views on the 
legislation under consideration by the Subcommittee at this hearing. I 
would be pleased to respond to any questions from you or other Members 
of the Subcommittee on these issues.

                                 
  Prepared Statement of Gerald M. Cross, M.D., FAAFP, Deputy Chief for
      Patient Care Services and Chief Consultant for Primary Care,
  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 several bills that would affect Department of 
Veterans Affairs (VA) benefits programs and services. Joining me today 
are Walter A. Hall, Assistant General Counsel; Brian McVeigh, Chief 
Consultant, Human Resources Management; and Patricia Vandenberg, 
Assistant Deputy Under Secretary for Health for Policy and Planning. 
Unfortunately, we do not yet have views and costs for H.R. 84, H.R. 
1075 and a draft bill regarding performance pay and collective 
bargaining. We will forward them as soon as they are available.

H.R. 949--Repeal of 38 U.S.C. Sec. 7422 Collective Bargaining 
        Exclusions; Adverse Action Decisions and Appeals; Disciplinary 
        Appeals Board Transcripts
    When Congress first authorized VA clinicians to engage in 
collective bargaining in 1991 it did so acknowledging that clinical 
decisions and clinical management decisions should not be decided 
through the collective bargaining process. Congress provided that only 
the Secretary, and by delegation the Under Secretary for Health may 
decide when one of the statutory bargaining exclusions in section 7422 
applies. However they did provide that, if a party believes that the 
Under Secretary for Health has acted arbitrarily or capriciously in 
issuing a 7422 decision, the party may seek judicial review of the 
decision pursuant to section 7422(e).
    The key provision of H.R. 949 would make matters relating to direct 
patient care and the clinical competence of clinical health care 
providers subject to collective bargaining. It would repeal the current 
restriction on collective bargaining, arbitrations, and grievances over 
matters that the Secretary determines to concern or arise out of the 
professional conduct or competence, peer review, or compensation of 
title 38 employees. In addition, the bill would impose a very tight 
time limit on the issuance of final agency decisions on employee 
grievances and would make such decisions subject to judicial review. 
Finally, the bill would require VA to provide employees who appeal 
adverse actions under section 7462 with a full and correct copy of the 
Disciplinary Appeals Board transcript at least 21 days before post-
hearing briefs are submitted, despite the existence of a 120-day 
deadline for the issuance of Disciplinary Appeals Board decisions.
    We appreciate the many positive contributions collective bargaining 
and labor-management partnership make to VA's mission. H.R. 949 would 
have an adverse impact on VA's ability to deliver quality patient care. 
Consistent with our views on a similar Senate bill, we strongly oppose 
it. Section 1 of H.R. 949, if enacted, would imperil VA's ability to 
furnish timely and quality care for veterans. H.R. 949 would open VA's 
responsibility under title 38 to (1) make direct patient care and 
clinical competency decisions, (2) assess title 38 professionals' 
clinical skills, and (3) determine discretionary compensation for title 
38 professionals, to review other non-clinical third parties who lack 
the clinical training and health care expertise to make such 
determinations.
    In September 2009, following extensive discussions with the 
American Federation of Government Employees (AFGE) regarding friction 
over differences of interpretation over collective bargaining 
authorities, VA and its labor partners signed a charter for a 38 U.S.C. 
7422 Workgroup, with the purpose of formulating recommendations for the 
Secretary to improve knowledge, understanding, and consistent use of 
the authorities and limitations in section 7422. The Workgroup consists 
of representatives from VA's five national unions (AFGE, National 
Federation of Federal Employees, National Association of Government 
Employees, Service Employees International Union, and United American 
Nurses). VA's team is headed by the Assistant Secretary for Human 
Resources and Administration, Mr. John Sepulveda, and includes subject 
matter experts from the Veterans Health Administration, Office of 
General Counsel, and Office of Labor Management Relations. The 
Workgroup charter charged its members with: (1) establishing a dialogue 
about the meaning of the 7422 bargaining and grievance exclusions; (2) 
making recommendations to the Secretary regarding consistent use of 
section 7422; (3) developing joint training about the section 7422 
exclusions and decision process; (4) identifying strategies for 
enhancing collaborative efforts to resolve disputes at all levels; (5) 
recommending approaches for capturing data reflecting informal and 
formal efforts to resolve section 7422 disputes; and, (6) developing a 
strategic communication plan for the results of the Workgroup. Over the 
past 6 months, the 7422 Workgroup has held a series of multi-day face-
to-face sessions, conducted in a partnership manner, where the parties 
engaged in a productive dialog. We are hopeful this process, when 
concluded, will result in actions and understandings that will address 
many of the unions' concerns about the manner in which section 7422 
exclusions are applied.
    H.R. 949 would create a number of significant problems that would 
impede VA's ability to operate a safe, effective and responsive health 
care system. The rules for collective bargaining often lead to 
protracted negotiations and third-party proceedings. On average, it 
takes 120 days to negotiate national Memorandums of Understanding (MOU) 
with VA's largest union, the AFGE. The 120-day average does not include 
local level bargaining over facility-specific aspects of a change, 
which can add another 30-60 days. While this kind of timeline may be 
acceptable for most workplace matters, it is not when it comes to 
patient-care matters. If H.R. 949 is enacted, critical changes in 
patient care, safety procedures, and policies could not be implemented 
until national and local bargaining had been completed. This could 
result in less than optimal care for veterans. Such delays, and the 
very practice of negotiating clinical matters, are inconsistent with 
patient-centered medicine.
    H.R. 949 would allow title 38 professionals to grieve matters or 
file unfair labor practice charges on clinical matters currently 
exempted from collective bargaining. Grievances not resolved at the 
informal stage are decided by a third-party arbitrator and may be 
subsequently appealed to the Federal Labor Relations Authority. Labor 
grievance arbitrators, the Federal Labor Relations Authority, and the 
Federal Service Impasses Panel would have considerable discretion to 
impose a clinical or patient care resolution on the parties. VA would 
have limited, if any, recourse if such an external party erred in its 
consideration of a clinical or patient care issue; VA would be bound by 
that third-party's decision. VA opposes this change in the strongest 
possible terms--clinicians must be able to make the clinical decisions 
to ensure care is furnished in compliance with VA and prevailing 
medical practice standards. Actions concerning direct patient care and 
the clinical competence of VA providers must be made and reviewed by 
clinicians, not arbitrators.
    Moreover, non-clinical third-parties are not accountable for 
ensuring the health and safety of the veterans receiving their care 
through the Department. If the Secretary and the Under Secretary for 
Health are going to be held responsible and accountable for the quality 
of care provided to veterans, they must be able to make decisions 
relating to patient care and the clinical competence of VA providers. 
Decisions must be based on what is best for our veterans from a medical 
perspective rather than what is the best that can be negotiated through 
collective bargaining, or on what a non-clinical arbitrator or the 
Federal Labor Relations Authority decides is appropriate in the context 
of collective bargaining. Our veteran patients cannot be expected to 
understand why their VA providers--a group of highly qualified, 
trained, and trusted professionals--have no option but to follow the 
decisions of third-parties with whom they disagree on matters affecting 
patient care.
    This provision would also require collective bargaining related to 
VA's Peer Review process by which VA assess the clinical skills of 
title 38 health care professionals and assesses whether our patients 
are receiving the high standard of care they deserve. Matters relating 
to peer review are now expressly exempted from collective bargaining 
under section 7422. H.R. 949 would change that, again subjecting the 
process of assessing the clinical skills of title 38 professionals and 
determining whether they are clinically competent in their area of 
practice to review by non-VA, non-clinical third-parties.
    In addition to clinical-care issues, H.R. 949 would permit unions 
to bargain over, grieve, and arbitrate subjects that are even exempted 
from collective bargaining under title 5, including the determination 
of the amount of an employee's compensation. Permitting title 38 staff 
to negotiate the discretionary aspects of their compensation would be 
at complete odds with a basic premise of Federal labor management 
relations.
    Section 2 of the bill would establish a new section 7463(f)(1), 
which would require VA to decide grievance appeals no later than 60 
days after a grievance is filed and would subject such decisions to 
judicial review. VA opposes section 2 of H.R. 949. In many cases, 
because of the complexity of the issues, the need to develop and review 
evidence, or secure the availability of witnesses, a grievance 
examiner's review can take most or all of those 60 days, leaving no 
time for a VA higher level official to review, and decide upon, the 
grievance examiner's findings and recommendations as called for in 
section 7463(d)(3). Sixty days is not sufficient for this process.
    Finally, section 3 of the bill would amend the Disciplinary Appeals 
Board or DAB statute in section 7462 to require the provision of a full 
and correct copy of a DAB transcript to an employee at least 21 days 
before the submission of post-hearing briefs. DABs are conducted when a 
title 38 employee appeals a major adverse action arising out of a 
question of professional conduct or competence. VA opposes section 3 of 
H.R. 949 because it would unnecessarily constrain the time available to 
DABs to make their decisions, which by law must be rendered within 45 
days of the DAB hearing and no later than 120 days after commencement 
of the appeal. There may be instances where it will be impossible to 
provide the transcript to an employee within 21 days and meet the 120-
day statutory time limit because of the timing of the oral hearing or 
the length of time it takes to prepare a full and complete transcript. 
Cases can involve complex clinical issues and extensive medical and 
expert testimony and evidence. Moreover, post-hearing briefs are 
neither necessary for nor required by many DABs because the issues are 
sufficiently fleshed out in the DAB's oral hearing, the written notices 
provided to the employee, and the employee's written reply, oral reply, 
and DAB appeal.
    In sum, VA's ability to manage its health care facilities and to 
monitor the professional conduct and competence of its employees must 
be reserved for the VA professionals and clinicians who are responsible 
for delivering quality patient care. Current law provides the 
appropriate balance between rightful subjects for collective bargaining 
and clinical need, and, as noted above, VA and its unions are engaged 
in a productive dialog to resolve issues of interpretation of the 
contours of how 7422 is applied.

H.R. 2698--``Veterans and Survivors Behavioral Health Awareness Act''
    VA does not support section 2 of H.R. 2698 which would direct VA to 
provide scholarships to individuals pursuing education or training in 
behavioral health care specialties in order to recruit and retain 
individuals for service in Vet Centers. In exchange for the 
scholarship, an individual would be required to fulfill a service 
obligation with VA. The total amount available for scholarships could 
not exceed $2,000,000 in any fiscal year.
    VA appreciates the concept of using scholarships to enhance 
succession planning. However, this section is unnecessary. Under 
existing authority, VA can establish a special scholarship program to 
identify, educate and hire individuals for difficult-to-recruit and 
difficult-to-retain health care positions including individuals 
pursuing degrees in mental health specialties. Additionally, 
implementation of section 2 of H.R. 2698 would result in substantial 
costs to VA over a long period of time with little short-term benefits. 
It takes 2 to 7 years of education to qualify to become a VA behavioral 
health specialist. Congress has authorized and VA has taken other 
actions to promote recruitment and retention of qualified health 
professionals, including the Education Debt Reduction Program and the 
Employee Incentive Referral Initiative. VA takes this opportunity to 
again endorse reauthorization of the Health Professional Educational 
Assistance Scholarship Program. This program would be a more effective 
and broader program to support recruitment and retention efforts in a 
variety of career fields, including mental health counselors.
    VA has not had difficulties hiring new counselors, and in the past 
3 years, VA has hired more than 5,800 additional mental health workers. 
VA has also expanded funding for mental health training by supporting 
the expansion of training positions in psychology by 206 positions. 
Seventy percent of current VA psychologists participated in a VA 
training program, demonstrating that these initiatives are an 
exceptional resource for addressing future recruitment needs. The 
legislation also appears to duplicate provisions from the Montgomery GI 
Bill and the Post-9/11 GI Bill, which already provide mechanisms for 
funding graduate and post-graduate degree programs for eligible 
veterans. These measures do not include a specific service obligation, 
but do allow veterans to pursue an advanced education in the behavioral 
health sciences.
    We have not formulated costs at this time, but will provide them 
for the record when they become available.
    VA supports section 3 of H.R. 2698, which would direct VA, on 
receipt of a request for counseling from an individual who has been 
discharged or released from active service but who is not otherwise 
eligible for such counseling, to: (1) provide referrals to assist the 
individual in obtaining mental health care and services outside VA; and 
(2) if pertinent, advise such individual of the individual's rights to 
apply for review of the discharge or release.
    This provision would allow VA to provide referral services to 
veterans with problematic discharges by referring them to services 
outside VA and by advising such veterans of their right to apply for a 
discharge upgrade. There are no significant costs associated with 
enactment of this section.
    Section 4 of H.R. 2698 would direct VA to carry out a program to 
award grants to nonprofit organizations that provide emotional support 
services (i.e., bereavement counseling) for survivors of deceased 
members of the Armed Forces and deceased veterans through the 
survivors' peers.
    VA currently has authority to provide bereavement services to the 
surviving military family members of servicemembers who die while on 
active duty, and to family members of veterans who die while receiving 
VA treatment for a service connected condition in a VA facility. 
Section 4 would expand bereavement services to family members of all 
veterans. VA has not had time to develop costs for this section, but 
will provide our views and costs as soon as they are available. With 
regards to bereavement services provided to families of servicemembers, 
Vet Centers have adopted standards of care to ensure that family 
members are contacted the same day as the referral is received, and to 
schedule an appointment with a counselor at the nearest Vet Center 
within 24 to 48 hours of receiving the referral. Through February 2010, 
Vet Centers have assisted the families of 1,939 fallen servicemembers; 
1,152 (60 percent) were in-theater casualties in Operation Enduring 
Freedom/Operation Iraqi Freedom (OEF/OIF).

H.R. 2699--``Armed Forces Behavioral Health Awareness Act''
    Section 2 of H.R. 2699 would make members of the Armed Forces, 
including the Reserve components, who are deployed in support of OEF/
OIF eligible for readjustment counseling and related mental health 
services operated by VA as authorized under 38 U.S.C. Sec. 1712A. The 
Department will provide its views and the cost estimate for section 2 
soon.
    VA defers to the Department of Defense concerning section 3 of H.R. 
2699 and to the Department of the Army concerning section 4 of H.R. 
2699.

H.R. 2879--``Rural Veterans Health Care Improvement Act of 2009''
    Section 2 of H.R. 2879 would amend 38 U.S.C. Sec. 111 by setting 
the beneficiary travel allowance rate at 41.5 cents per mile and 
repealing the requirement that allowances be determined using the 
mileage reimbursement rate under 5 U.S.C. Sec. 5707(b) for the use of 
privately owned vehicles by government employees on official business. 
In addition, this section would repeal VA's authority to modify the 
allowances or reimbursement amounts in excess of the rate determined by 
5 U.S.C. Sec. 5707(b). This section would also repeal the requirement 
that certain beneficiaries must be unable to defray the expenses of 
such travel pursuant to regulations; repeal the requirement that 
payments may not exceed the cost of such travel by public 
transportation if accessible and not medically inadvisable; and repeal 
the requirement that payments must not exceed the actual expense 
incurred as certified in writing by the person. Last, this section 
would require that the Veterans Health Administration (VHA) Handbook on 
beneficiary travel be revised to clarify that a travel allowance based 
on mileage may exceed the cost of such travel by public transportation 
regardless of medical necessity.
    VA does not support section 2 of H.R. 2879. While 41.5 cents per 
mile is the current reimbursement rate, VA would lose the authority to 
decrease or increase the rate using the mileage reimbursement rate 
under 5 U.S.C. Sec. 5707(b). VA would also lose the flexibility to 
exceed the section 5707(b) rate should funding and circumstances 
warrant. The requirement to allow for mileage reimbursement greater 
than the cost of travel by public transportation regardless of medical 
necessity would eliminate VA's authority to pay only for the most cost-
effective available and appropriate mode of transport. As a result, in 
some cases VA would reimburse more than the veteran actually expended 
for transport.
    VA estimates the cost of implementing this section to be $16.24 
million over 5 years, and $35.56 million over 10 years.
    Section 3 would require the establishment of one to five centers of 
excellence for rural health research, education, and clinical 
activities, through the Director of the Office of Rural Health. The 
centers would be required to conduct research, develop specific models 
for furnishing health services, provide education and training for 
health care professionals, and develop and implement innovative 
clinical activities and systems of care.
    VA does not support section 3 of H.R. 2879 because the ``Centers of 
Excellence'' proposed in this provision would be duplicative of the 
Veterans Rural Health Resource Centers (VRHRC) and of the efforts of 
VA's Veterans Rural Health Advisory Committee.
    VA established the VRHRCs to improve care and services for veterans 
residing in geographically isolated areas. The VRHRCs conduct policy-
oriented studies and analyses; function as field-based clinical 
laboratories for policy-relevant pilot projects and evaluations; serve 
as regional rural health experts organizing and sharing information 
within and across Veterans Integrated Service Network (VISN) 
boundaries; and serve as an educational repository and academic and 
clinical information clearinghouse. The VRHRCs are operational and 
conducting important work, such as a pilot project designed to develop 
a simulation tool for modeling rural health care access; telephone-
based telehealth initiatives for diabetes, hypertension, and chronic 
pain; rural workforce development; utilization of mobile clinics as an 
alternative care delivery model; and a study on clinical practice 
intensity to compare VA to private sector physicians in urban and rural 
settings. VA's Veterans Rural Health Advisory Committee membership 
includes affected veterans, rural health experts in academia, State and 
Federal professionals who focus on rural health, State-level veterans 
affairs officials, and leaders of Veterans Service Organizations. The 
purpose of the Advisory Committee is to examine ways to enhance VA 
health care services for veterans in rural areas by evaluating current 
programs and identifying barriers to health care.
    VA estimates the minimum cost of implementing section 3 to be 
$10.76 million over 5 years and $23.67 million over 10 years.
    Section 4 would require the establishment of a grant program to 
provide innovative transportation options to veterans in rural areas. 
Under this section, grants awarded could be used by State Veterans' 
Service Agencies and Veterans Service Organizations to assist veterans 
in highly rural areas with travel to VA medical centers, or otherwise 
assist in providing medical care to these veterans. A grant awarded 
under this section could not exceed $50,000.
    VA agrees with the intent of this legislation and agrees that 
veterans in rural areas need more transportation options when seeking 
VA health care, but VA does not support section 4 of H.R. 2879. The 
specific provisions of this legislation are unnecessary, and VA already 
has efforts underway that will address this problem more quickly than 
new legislation would. VA is currently developing pilot programs to 
implement innovative transportation services at various rural health 
care facilities. Funds that would be spent for grants would be more 
effectively and efficiently used by VA to develop these initiatives 
that would include but not be limited to integrating the services of 
networks of volunteer, community, state and other transportation 
providers with veteran transportation services offered in its health 
care facilities. Furthermore, the administration of the grant program 
proposed in this section would be costly, diverting resources from 
either supporting new transportation options or health care for rural 
veterans.
    VA estimates the cost of this section to be $3 million per year, 
and $15 million over 5 years.
    Section 5 would require demonstration projects to examine the 
feasibility and advisability of alternatives for expanding care for 
veterans in rural areas, through the Director of the Office of Rural 
Health, at facilities that are geographically distributed throughout 
the United States. The required projects would include (1) a 
partnership between VA and the Centers for Medicare and Medicaid 
Services of the Department of Health and Human Services (HHS) to 
coordinate care for veterans in rural areas at critical access 
hospitals, (2) a partnership between VA and HHS to coordinate care for 
veterans in rural areas at community health centers, and (3) expanding 
coordination between VA and the Indian Health Service (IHS) to expand 
care for Indian veterans. It would authorize the appropriation of 
$350,000,000 for each of fiscal years 2009 through 2011 to carry out 
the projects.
    VA does not support section 5 of H.R. 2879 for three reasons. 
First, VA already is encouraging and examining strategies to improve 
collaboration to increase service options for veterans in rural areas; 
examples include the Patient Navigator Pilot in VISN 5 that is focusing 
on expanding and developing public-public collaborations, and the 
community-based outpatient clinic (CBOC) partnership for improving 
rural mental health in VISN 16 that is focused on establishing 
collaborations within the rural health community. Second, additional 
legislation would impose burdens and specific restrictions upon our 
ability to explore these opportunities and may impede us from pursuing 
the best health care options for veterans. Finally, VA already is 
undertaking pilot programs at the direction of Congress in sections 107 
and 403 of Public Law 110-387, and VA believes it is more appropriate 
to evaluate the results of these pilot projects before beginning new 
initiatives so that we can ensure resources are best used to serve 
veterans. Section 107 of that law requires VA to carry out a pilot 
program to assess the feasibility and advisability of providing peer 
outreach, peer support, readjustment counseling, and other mental 
health services to Operation Iraqi Freedom and OEF/OIF veterans, with 
readjustment counseling and other mental health services provided to 
certain rural veterans through community health centers, IHS, or other 
appropriate entities. Section 403 requires VA to conduct a pilot 
program under which VA provides covered health services to certain 
highly rural veterans through qualifying non-VA health care providers. 
These pilots will be exploring opportunities for collaboration.
    VA estimates the cost of implementing section 5 to be $3.04 billion 
through fiscal year (FY) 2011, as indicated in the legislation.
    Section 6 would require a program to provide peer outreach, peer 
support, readjustment counseling, and mental health services to OEF/OIF 
veterans, particularly veterans who served in OEF/OIF while in the 
National Guard and Reserves, to be established no later than 180 days 
after enactment. The program would also provide education, support, 
counseling, and mental health services to immediate family members of 
OEF/OIF veterans during the 3 years after the veteran's return from 
deployment. The services provided to immediate family members would 
assist in the readjustment of the veteran to civilian life, the 
recovery of the veteran (if the veteran incurred an injury or illness 
during deployment), and the readjustment of the family following the 
return of the veteran.
    In carrying out this program, this section would require contracts 
with community mental health centers and other qualified entities only 
in areas not adequately served by VA health care facilities. In 
addition, this section would require a training program for clinicians 
of those community mental health centers or entities to ensure that the 
clinicians recognize the unique experiences of OEF/OIF veterans, and 
utilize best practices and technologies when providing services under 
this section. This section would also require a contract with a 
national not-for-profit mental health organization to carry out a 
national training program for OEF/OIF veterans to be trained to provide 
peer outreach and peer support services. Finally, this section would 
require reports to the House and Senate Committees on Veterans' 
Affairs.
    VA opposes section 6 of H.R. 2879 because this provision duplicates 
existing authorities and is unnecessary. Section 107 of Public Law 110-
387 requires VA to carry out a pilot program to assess the feasibility 
and advisability of providing OEF/OIF veterans with peer outreach, peer 
support, readjustment counseling, and other mental health services, 
with readjustment counseling and other mental health services provided 
to certain rural veterans through community health centers, IHS, or 
other appropriate entities. VA is implementing this pilot. Section 6 
proposes a plan similar to that outlined in section 107. VA believes 
that results from the section 107 pilot will provide experience and 
information on how best to serve the mental health needs of the rural 
OEF/OIF veteran population.
    In addition, VA's authority to furnish readjustment counseling 
services already includes authority to furnish limited mental health 
services to family members necessary for effective treatment of 
veterans' readjustment issues. The Vet Center program is also taking 
steps to enhance access for veterans' families. Within the context of 
the Vet Center mission, family members are central to combat veterans' 
readjustment. VA is implementing a plan to enhance its capacity to 
serve families by hiring the additional staff necessary to place a 
qualified family counselor in every Vet Center.
    Vet Centers provide professional counseling for combat-related PTSD 
and co-morbid conditions such as depression and substance abuse. When 
necessary for the treatment of more complex mental health conditions, 
Vet Centers refer veterans to VA medical facilities. For veterans 
leaving a VA facility after receiving care for an injury or illness 
sustained during deployment, VA provides education and training prior 
to the veteran's discharge from care to ensure that family members can 
tend capably to the needs of the veteran. As a result, the authority to 
provide readjustment counseling and education to family members is 
unnecessary.
    Further, VA is expanding access to mental health care to assist 
rural veterans. VA is integrating mental health into all of its primary 
care clinical settings and is significantly expanding the number of Vet 
Centers to almost 300 by the end of the fiscal year. VA has already 
deployed 50 Mobile Vet Centers to provide services and outreach to 
veterans, including rural veterans. Moreover, VA continues to expand 
the use of telemental health to connect veterans in rural areas with 
clinical experts from across the country. In addition, VA contracts for 
mental health treatment and for readjustment counseling and related 
readjustment services, as needed with private-sector community mental 
health agencies and other qualified professional entities. Most of 
these contract providers are located in rural areas. Section 6 is also 
duplicative and unnecessary because the Vet Center's model for veteran-
centric services already utilizes veteran peer outreach and counseling. 
Almost 70 percent of all Vet Center staff members are veterans, and 
more than 30 percent of Vet Center staff members are OEF/OIF veterans.
    VA estimates the cost of implementing section 6 to be $115.58 
million over 5 years and $253.46 million over 10 years.
    Section 7 would address improving care for American Indian 
veterans. Because section 7 is almost identical to H.R. 4006, VA views 
on this bill are addressed under our discussion of H.R. 4006 (which 
follows below).
    Section 8 would require an annual report to Congress on the 
implementation of the provisions of this bill and the establishment and 
function of VA's Office of Rural Health. VA does not support section 8 
of H.R. 2879. VA already provides a number of periodic reports 
(including quarterly and annual reports) to Congress on the status of 
our programs for rural and highly rural veterans. For example, Senate 
Report 110-428, which accompanied the Military Construction and 
Veterans Affairs and Related Agencies Appropriations Act, 2009 
(Division E of Public Law 110-329), directed VA to provide a quarterly 
report to Congress on rural health initiatives funded through rural 
health appropriations. A Conference Report (H. Rept. 110-424), 
accompanying the Consolidated Appropriations Law, 2008, required a 
report to Congress on access to health services in rural areas. If the 
Committee would like additional information on any of our programs, VA 
staff members are available to conduct a briefing at your request.
    VA estimates the cost of implementing section 8 to be $70,596 over 
5 years, and $155,173 over 10 years.

H.R. 3926--``Armed Forces Breast Cancer Research Act''
    H.R. 3926 would direct the Department of Defense (DoD) and VA to 
conduct a joint study on the incidence of breast cancer within the 
Armed Forces and among veterans. VA supports the objective of H.R. 
3926, but cannot support the bill as proposed. H.R. 3926 would provide 
only an estimate of incidence of one disease at one point in time. A 
broader study of health care outcomes would be much more cost effective 
and useful. A broader study would provide information regarding the 
frequency of occurrence of breast cancer as well as other illnesses and 
chronic disease outcomes of interest to veterans. For less than the 
costs required to conduct such a study, we could support a longitudinal 
study that considers breast cancer as one condition among many. This 
would be accomplished by collecting information on a representative 
sample of veterans, including demographic variables such as age, 
gender, era of service, and frequency of occurrence of various health 
outcomes of concern to veterans. Establishing a survey mechanism of 
this type would allow VA to repeat the study and identify trends over 
time, such as increases or decreases in the occurrence of various 
diseases, such as breast cancer.
    In order to satisfy the complex requirements of H.R. 3926, the 
study requirements currently proposed in the bill would demand much 
more time than the 18-month timeframe envisioned. We estimate it would 
take 3 to 5 years to accomplish this work.
    The total cost of this study is estimated to be $6.34 million.

H.R. 4006--``Rural, American Indian Veterans Health Care Improvement 
        Act of 2009''
    Section 2(a) would require that an Indian Veterans Health Care 
Coordinator be assigned at each of the ten VA medical centers that 
serve communities with the greatest number of Indian veterans per 
capita. The coordinators would be responsible for improving outreach to 
tribal communities; coordinating the medical needs of Indian veterans 
on Indian reservations with VA and IHS; expanding the access and 
participation of VA, IHS, and tribal members in the VA Tribal Veterans 
Representative program; acting as an ombudsman for Indian veterans 
enrolled in VA for health care; and advocating for the incorporation of 
traditional medicine and healing in the VA treatment plans for Indian 
veterans. This section would define ``Indian'' as defined in 25 U.S.C. 
Sec. 450b (`` `Indian' means a person who is a member of an Indian 
tribe'').
    VA does not support section 2(a) of H.R. 4006 because VA's Office 
of Rural Health (ORH) is already providing support to American Indian/
Alaskan Native (AI/AN) veterans specifically as it relates to ongoing 
rural health initiatives. VA is also working to address the unique 
health care needs of all enrolled veterans residing in rural areas, 
including AI/AN veterans. VA encourages cooperation and resource 
sharing between IHS and VA to deliver quality health care services and 
enhance the overall health of AI/AN veterans. Most VISNs are engaged in 
a variety of outreach activities including: meetings and conferences 
with IHS program and tribal representatives; VA membership in the 
Native American Health Care Network; VA participation in traditional 
Native American ceremonies; and transportation support to AI/AN. The 
Veterans Rural Health Resource Center, Western Region, established a 
partnership with IHS and is currently working on several fronts to 
support expanded benefits and services, such as tele-psychiatry clinics 
for AI/AN veterans on rural reservations, infrastructure focused on the 
needs of AI/AN veterans, and a Memorandum of Understanding with IHS 
concerning telemental health services for AI/AN veterans.
    VA estimates the cost of implementing section 2(a) to be $5.30 
million over 5 years, and $11.65 million over 10 years.
    Section 2(b) would require an MOU no later than 1 year after 
enactment, between VA and the Department of the Interior to ensure that 
the health records of Indian veterans may be transferred electronically 
between IHS and VA facilities. VA agrees with the objectives of section 
2(b), but notes that implementation would not be possible without 
legislative changes to 38 U.S.C. Sec. 7332. That law restricts the 
ability of VA to provide health information concerning human 
immunodeficiency virus (HIV), sickle cell anemia and drug abuse or 
alcohol abuse. VA does not object in principle to requiring a MOU, but 
notes that VA and IHS have already taken the position that sharing of 
VA and IHS electronic health records should be done through the 
Nationwide Health Information Network (NHIN). As a result, the MOU 
would be unnecessary, because each party participating in the NHIN will 
be required to be a signatory to the Data Use and Reciprocal Support 
Agreement. We note that section 2(b) of H.R. 4006 refers to the 
Secretary of the Interior, rather than the Secretary of Health and 
Human Services. VA believes this is a clerical error, since IHS is 
responsible for providing Federal health services to AI/AN.
    VA estimates there will be no costs associated with this provision.
    Section 2(c) would permit VA to transfer surplus VA medical and 
information technology equipment to IHS as is considered appropriate 
for IHS purposes by the Secretaries of VA and HHS jointly. VA does not 
object to the authority to provide surplus medical and information 
technology equipment, but notes that VA generally only surpluses 
equipment when it can no longer reasonably be used; IHS is unlikely to 
find such equipment of practical use. While the title of the section 
refers to medical equipment per se, the text of the section refers to 
both medical and information technology equipment. VA estimates there 
would be negligible costs associated with this provision.
    Section 2(d) would require a report to Congress, no later than 1 
year after enactment, jointly submitted by VA and HHS on the 
feasibility and advisability of VA and IHS jointly establishing and 
operating health clinics on Indian reservations to serve the 
populations of those reservations, including Indian veterans. VA does 
not support this requirement because it is unnecessary. VA would 
welcome the opportunity to provide a briefing to address current 
collaborations with IHS and efforts to support AI/AN veterans.
    VA estimates that the cost of implementing this section would not 
be substantial.

Draft Bill--``Expanding VA Reimbursement of Continuing Medical 
        Education Expenses to VA Health Professionals''
    This bill would require VA to reimburse any full-time board 
certified health professional for expenses, up to $1,600 per year, for 
continuing professional education, but prohibits VA from reimbursing 
for education provided by a Department medical center.
    VA opposes this draft bill because of the cost of implementation 
and because our current programs are sufficient to address this need. 
There are currently over 170,000 health care professionals in VHA. The 
total cost of implementing this legislation would be $282,000,000 per 
year for the next 10 years. Moreover, VA's Employee Education Service 
provides continuing education credits (those needed to maintain current 
licensure or certifications) through online learning, content 
distribution network and face-to-face sponsored training. In addition, 
medical centers host on-site training to provide continuing education 
credits and purchase online products that allow health care 
professionals to gain needed continuing education. Medical centers also 
have a mechanism in place for all employees (not just health care 
professionals) to request funding or reimbursement for training and 
education.
    The potential cost to provide up to $1,600 to each health care 
professional would be $272 million.

Draft Bill--``Authority to Waive Requirements for Mental Health 
        Counselors''
    This bill would create an exception to the statutory requirements 
for eligibility for employment of licensed professional mental health 
counselors by allowing the Secretary to waive the licensure or 
certification requirement for a reasonable period of time recommended 
by the Under Secretary for Health. VA does not oppose the legislation. 
VA currently has a parallel statutory authority to appoint 
psychologists and clinical social workers for up to 2 years before they 
have completed their licensure or certification. These employees are 
closely supervised by a licensed mental health professional when 
administering care. These are temporary, conditional appointments, and 
VA believes a similar model would be appropriate if this legislation is 
enacted.
    This proposal would be cost neutral.
    This concludes my prepared statement. Mr. Chairman, we would be 
pleased to respond to whatever questions you may have.

                                 
   Statement of American Federation of Government Employees, AFL-CIO

    Mr. Chairman and Members of the Subcommittee:
    The American Federation of Government Employees (AFGE) appreciates 
the opportunity to submit a statement for the record on H.R. 949 and 
draft bills relating to performance pay and collective bargaining 
(draft dated March 8, 2010 (2:49 p.m.) and continuing professional 
education (draft dated December 9, 2009 (11:42 a.m.).)
    AFGE represents nearly 200,000 employees in the Department of 
Veterans Affairs (VA), more than two-thirds of whom are proud employees 
of a world class health care system that provides unsurpassed 
specialized care to the men and women who have served our Nation.
    The VHA workforce includes in its ranks many physicians, registered 
nurses (RN), physician assistants (PA) and other clinicians who bring 
to this great health care system invaluable experience and compassion 
from their own military service where they provided medical care on the 
battlefield.
    Sadly, back home, these fine clinicians face work environments 
plagued by fear, disrespect and exclusion. Their deep desire to care 
for veterans is challenged every day by personnel policies that 
demoralize them and deprive them of the basic rights and dignity 
provided to their colleagues working outside the VA. VA's ability to 
recruit and retain professionals who want to build a career in the VA 
is getting more difficult every day.

H.R. 949 and Draft Collective Bargaining Language
H.R. 949
    Two years ago, this Subcommittee considered this legislation to 
restore equal collective bargaining rights to these dedicated VA 
clinicians. At that time, the VA's arguments in opposition to the 
legislation were riddled with fear and distortion, claiming it would 
``jeopardize[e] the lives of our veterans'' (Senate Committee on 
Veterans Affairs, May 21, 2008 hearing).
    A great deal has changed in the past 2 years and the Department 
appears ready to embrace a 21st century transformation of VHA labor-
management relations. We urge this Subcommittee to capture that 
momentum through passage of H.R. 949.
    The most recent example of the Department's shift away from its 
former, counterproductive interpretation of title 38 collective 
bargaining law (38 U.S.C. Sec. 7422, or ``7422'') is evident in the 
implementation plan provided to the White House pursuant to Executive 
Order (EO) 13522. Its plan to fulfill this White House goal, i.e. 
``Creating Labor-Management Forums to Improve Delivery of Government 
Services,'' recognizes that ``[c]ooperative, constructive working 
relations between labor and management are essential to achieving 
common labor-management goals and objectives.'' (Link: http://
www.lmrcouncil.gov/plans/index.aspx).
    The Implementation Plan also specifically addresses bargaining and 
negotiation rights:

          ``[T]he Department is committed to pre-decisional involvement 
        in workplace matters, without regard to whether those matters 
        are negotiable subjects of bargaining under 5 U.S.C. Sec. 7106. 
        . . . The Department is committed, wherever appropriate, to 
        engage the labor partners on issues that historically have been 
        outside the scope of bargaining.'' (emphasis added).

    Equally significant, last fall, the Department supported 
legislation to provide full bargaining rights for 2 years to VA 
physicians and RNs converting from the Defense Department (DoD) 
personnel system at the joint DoD-VA medical facility in North Chicago 
(P.L. 111-84). Despite all its past allegations that full bargaining 
rights will endanger patients, the Department agreed to give full title 
5 rights to new VA clinicians treating veterans and active duty 
personnel at a unique joint facility that is designed to serve as a 
national model for the future. These clinicians, will full rights to 
grieve and negotiate over routine employment matters such as schedules, 
assignments, and additional pay for good performance or weekend shift 
work, will be working side by side with VA clinicians with the same 
titles and duties who have very limited rights because of ``7422.''
    Therefore, AFGE urges this Subcommittee to vote for H.R. 949. It is 
time to align the law with VHA's new workforce goals. It is time to put 
an end to VHA personnel policies that have decimated valuable 
legislation that Congress passed to improve recruitment and retention. 
It is time to end the inequality and arbitrariness that keep new 
physicians and RNs from seeking VA careers. It is time to end the 
demoralization of long term, valuable VA physicians, dentists, RNs, 
PAs, chiropractors, optometrists, and podiatrists who must work without 
a voice and without redress for unfair and illegal management actions. 
It is time to end the senseless inequality between VA clinicians 
without full rights and VA ``hybrid'' clinicians, such as pharmacists, 
psychologists and practical nurses with full rights. It is time to end 
the equally senseless inequality between physicians and nurses who 
treat veterans and physicians and nurses who treat active duty 
personnel and Federal prisoners at other Federal facilities.

Draft Collective Bargaining Language
    In the alternative, AFGE asks the Subcommittee to support section 2 
of the March 8, 2010 draft. This draft language is significantly 
narrower than H.R. 949 which also addresses bargaining rights in peer 
review matters, the rights of title 38 clinicians to appeal final 
agency decisions and arbitration decisions to Federal court, and needed 
changes in the Disciplinary Appeals Boards process. However, the March 
8th draft focuses on the two most harmful VA ``7422'' exclusions to 
bargaining: compensation and patient care. Enactment of this draft 
language will yield significant benefits for workplace morale and VHA 
recruitment and retention.
    More specifically, Subsection 2(a)(1) inserts a single word--
``rates''--in 38 USC Sec. 7422 to clarify what Congress intended in 
1991 when it enacted title 38 bargaining rights. This proposed change 
addresses opponents' assertions that employees will try to set pay 
rates, in violation of Federal law. Compensation issues other than pay 
rates cover pay issues that Congress has specifically addressed in 
legislation to help the VA recruit and retain such as nurse locality 
pay and physician performance pay. Compensation issues other than pay 
rates also cover wage law violations that public and private employees 
throughout this country have a right to challenge, such as failure to 
pay overtime or shift differential pay for weekend work.
    AFGE notes that the VA has never offered an example of an 
employee's attempt to use bargaining rights to set Federal pay rates, 
and that there are no Under Secretary of Health 7422 cases involving 
such an attempt.
    Subsection 2(a)(2) also clarifies Congressional intent in 
established routine bargaining rights for title 38 clinicians for 
matters only indirectly related to patient care--rights that are no 
greater than the routine bargaining rights of Federal employees covered 
by title 5, including hybrid title 38 VHA health care professionals and 
DoD and BOP clinicians with the exact same job titles and scopes of 
practice. This subsection will not allow employees to interfere with 
management rights to determine the best medical procedures or skill 
sets for patient care, or its right to take needed actions during 
medical emergencies. Rather, Subsection (2)(b) only makes clear that 
these Federal employees have the same, routine rights to a voice in 
scheduling and assignment policies that other Federal employees have 
when they care for patients in hospitals and clinics.
    Again, AFGE notes that the VA has never offered an example of 
labor's attempt to use bargaining rights in scheduling and assignment 
matters to interfere with management's choice of medical procedures, 
determination of needed medical skills or other direct patient care 
matters. VA has never offered an example of labor's attempt to prevent 
management from responding timely to emergency medical needs. We 
further note that there is no Under Secretary of Health 7422 case 
involving any such attempts.

Draft Language on Physician and Dentist Performance Pay Criteria
    AFGE supports the enactment of the December 9, 2009 draft language 
to provide a long overdue fix to problematic performance pay polices at 
local facilities. Such policies have virtually stripped this valuable 
recruitment and retention tool any benefit.
    The problem is twofold. First, local management does not issue 
performance criteria in accordance with deadlines set by Congress, and 
in many cases, never issues them. Second, when management does set 
criteria, they very widely from facility to facility, and/or they 
measure improper factors beyond the individual clinician's control, 
such as missed appointments, clinical utilization and patients' 
satisfaction with their overall hospital experiences.
    This draft language will improve the uniformity and effectiveness 
of these measures, which in turn, will improve recruitment and 
retention. First, section 1(a) clarifies that these criteria should 
measure individual, not group, performance--a clarification that is 
already in VA regulations (but regularly ignored.) Second, section 1(b) 
ensures that the Secretary fulfills a requirement that Congress put on 
the books 6 years ago that has been ignored to date, specifically, to 
prescribe specific goals at performance objectives at the national 
level (``Performance pay shall be paid to a physician or dentist on the 
basis of the physician's or dentist's achievement of specific goals and 
performance objectives prescribed by the Secretary.'') (emphasis added) 
(P.L. 108-445).

Draft Language on Continuing Professional Education Reimbursement
    AFGE urges the Subcommittee to approve this draft language to 
increase the annual reimbursement for continuing professional medical 
education (``CME''). The CME amount provided under current law has not 
increased since 1991 and other health care employers currently offer 
much higher reimbursement to their clinicians. We also support draft 
language extending CME reimbursement to other title 38 clinicians who 
need to meet licensing and certification requirements and update their 
skills.
    AFGE urges the Subcommittee to add additional language to clarify 
the following: at facilities where some, but not sufficient internal 
CME courses are offered to maintain licensure, the law should clearly 
state that reimbursement for outside CME is still available.
    Thank you for the opportunity to share AFGE's views on these 
critical recruitment and retention legislative proposals.

                                 
           Statement of David J. Holway, National President,
        National Association of Government Employees (SEIU/NAGE)

    Mr. Chairman and Members of the Subcommittee:
    On behalf of the National Association of Government Employees 
(SEIU/NAGE), and the more than 100,000 workers we represent, including 
20,000 at the Department of Veterans Affairs (VA), I would like to 
thank you for the opportunity to submit testimony regarding pending 
legislation before the Subcommittee.

H.R. 949
    SEIU/NAGE strongly supports H.R. 949. This bill would restore a 
meaningful scope of bargaining for title 38 health care providers at 
the VA, a critical necessity to boost morale and strengthen recruitment 
and retention at the agency. Giving health care providers a meaningful 
voice in their workplace will without question lead to better care for 
the American veteran.
    In 1991, Congress amended title 38 to provide VA medical 
professionals with collective bargaining rights (which include the 
rights to use the negotiated grievance procedure and arbitration). 
Under sec. 7422 of title 38, covered employees can negotiate, file 
grievances, and arbitrate disputes over working conditions, except for 
matters concerning or arising out of professional conduct or 
competence, peer review, or compensation. In recent years, VA 
management has interpreted these exceptions very broadly, and refused 
to bargain over virtually every significant workplace issue affecting 
medical professionals. The broad interpretation sec. 7422 has created 
significant dissatisfaction among rank-and-file VA health care 
providers.
    We have heard from our members across the country, and they have 
urged our union to make passage of H.R. 949 our top legislative 
priority for legislation impacting the VA workforce. Their concern is 
that too many highly qualified, outstanding health care professionals 
have left the VA for other employment because they were unsuccessful in 
getting someone of authority at the agency to listen to or address 
legitimate concerns because managers claimed the issue fell under the 
ever-growing umbrella of sec. 7422.
    The agency has been unwilling to address those issues that are most 
important to title 38 employees, including time schedules, shift 
rotations, evaluations, fair and equal opportunity to be considered for 
a different position within the facility, and fair treatment among 
colleagues. Rather than suffer under a system where they have no 
mechanism to provide input or air grievances, disenfranchised VA 
employees simply move on to other employment. This has gone on too 
long, and it has to stop.
    VA medical professionals have extremely limited collective 
bargaining rights in the first place, and the broad interpretation of 
sec. 7422 of title 38 is narrowing the scope of bargaining to the point 
that it is practically meaningless. As a result, RNs, doctors, and 
other impacted employees at the VA are experiencing increased job 
stress, low morale and burnout. This in turn exacerbates the VA's well-
documented recruitment and retention problems. Chronic short-staffing 
has been shown to adversely impact quality of care, patient safety, and 
workplace safety, leading to costly stopgap measures such as the 
overuse of contract nurses and doctors.
    Passing H.R. 949 would help to address many of these concerns. This 
bill would restore a meaningful scope of bargaining for title 38 VA 
professionals by eliminating the ``7422 exceptions'' (conduct, 
competence, compensation, and peer review) under the law.
    Eliminating these exceptions will provide these health care 
providers with the same rights as other VA providers, including 
psychologists, LPNs, and pharmacists, as well as other Federal 
employees. Title 5 health care providers at the VA have full collective 
bargaining rights. Even nurses and doctors at Army medical centers such 
as the Walter Reed Army Medical Center, who perform the same exact 
function as nurses and doctors at the VA, have full collective 
bargaining rights. Many private sector health care providers have a 
meaningful voice on working conditions and are allowed participation in 
hospital affairs. There is no reason for title 38 VA workers to have 
these critical rights taken away.
    Late last year, the VA engaged SEIU/NAGE and other unions in 
discussions to produce recommendations we hope will reduce the VA's 
invocation of sec. 7422. Our discussions through the 7422 Work Group 
are ongoing. Though we continue to hope that the 7422 Work Group will 
produce reforms, it cannot address the fundamental issue of limited 
collective bargaining rights. Only Congress can address that issue.
    Restoring meaningful bargaining rights will greatly increase morale 
at the VA. It will also address recruitment and retention issues, which 
are critical at this time, given the veterans returning home from 
conflicts abroad. All this will lead to better care for our Nation's 
veterans.
    SEIU/NAGE strongly urges the Congress to pass H.R. 949. I greatly 
appreciate the Subcommittee's decision to hold this hearing. I thank 
the Subcommittee for the opportunity to provide this statement.

                                 
                    Statement of William R. Dougan,
      National President, National Federation of Federal Employees

    On behalf of the National Federation of Federal Employees (NFFE) 
and the 110,000 Federal employees our union represents throughout the 
United States and abroad, including more than 5,000 Department of 
Veterans Affairs (VA) health care providers, I thank you for the 
opportunity to submit this statement regarding H.R. 949.
Summary of NFFE's Position on H.R. 949
    Over the last several years, Department of Veterans Affairs (VA) 
health care professionals have seen their collective bargaining rights 
diminish appreciably. Agency management's improperly broad 
interpretation of a certain provision in Federal labor law has allowed 
them to circumvent the bargaining process on numerous critical issues, 
and the effect is taking its toll on the morale of VA health care 
providers. It is time for Congress to do what is right for VA workers 
and the veterans for whom they provide care by passing H.R. 949, which 
will eliminate the collective bargaining exceptions under sec. 7422 of 
title 38.

Background on Collective Bargaining for VA Title 38 Health Care Workers
    In 1991, title 38 was amended by Congress to give health care 
providers at the VA collective bargaining rights. This was a necessary 
change that was supported by our union. This change allowed title 38 
health care providers access to basic collective bargaining rights, 
including a negotiated grievance procedure and the ability to take an 
unsettled grievance to arbitration. However, under sec. 7422 of title 
38, VA health care providers are permitted to negotiate contracts, 
arbitrate disputes, and file grievances over working conditions except 
for matters concerning or arising out of professional conduct or 
competence, peer review, and compensation. We refer to these as ``7422 
exceptions.''
    In the years immediately following the change in law, these 7422 
exceptions were interpreted narrowly, which in our view was an 
appropriate interpretation of the law. However, over the past decade, 
the VA has greatly expanded their interpretation of sec. 7422 of title 
38 so that practically any matter the VA wished to avoid bargaining 
with the union over could be circumvented. When you take away the right 
to collectively bargain over conduct, competence, peer review, and 
compensation, you make the negotiated grievance procedure all but 
meaningless. The VA's broad interpretation of sec. 7422 has been a 
great disservice to VA health care providers that we represent. It has 
also been a disservice to the American veterans for whom our members 
provide care.

Why H.R. 949 Should Be Passed Into Law This Congress
    For the following reasons, NFFE believes that it is critical for 
Congress to pass H.R. 949 in this session of Congress:

      Veterans' care suffers from the toxic labor-management 
climate caused by sec. 7422.
      The 7422 exceptions are completely unnecessary and 
inconsistent with the health care industry.
      Health care providers use collective bargaining to 
maintain fairness in the workplace and improve patient care; bargaining 
does not hurt patient care.
      There are veterans groups that support this legislation; 
veterans groups do not tend to support legislation that will hurt 
veterans' care.
      Only legislation can solve the 7422 problem permanently.
      With thousands of veterans returning from conflicts 
abroad, the time to address this cancer at the VA is now.

Veterans' Care Suffers from the Toxic Labor-Management Climate Caused 
        by Sec. 7422 of Title 38
    I would classify the labor-management atmosphere throughout most of 
the VA as toxic. Our members from across the country, who provide care 
to the American veteran, report that the VA's willingness to use the 
7422 exceptions to circumvent their bargaining obligations and avoid 
legitimate employee grievances is an enormous problem that is taking a 
very large toll on the morale of VA health care providers.
    A year ago, we were optimistic that a new Administration might 
usher in a new approach to labor-management relations at the 
Department. It is with great disappointment that I report that the 
labor-management relations climate at the VA is unchanged from a year 
ago. In fact, from many accounts we get from the field, labor-
management relations at the VA are currently at an all-time low.
    We believe that the failure of the VA to establish effective labor-
management relationships stem from sec. 7422 of title 38. VA management 
have grown quite accustomed to standing behind the 7422 exceptions to 
avoid bargaining over workplace issues or to settle legitimate 
grievances that involve management's wrong-doing, including the 
improper firing of VA employees or the failure to provide employees 
with due process. The VA's broad interpretation of the 7422 exceptions 
has given management the ability to trump almost any action taken by 
the union to enforce workplace rules or defend employees against 
adverse actions. It is no surprise that VA employees are feeling great 
frustration over the practice.
    Many of the issues that VA employees lose the ability to bargain 
over because of the 7422 exceptions are very important to the VA rank-
and-file workforce. Some of these issues include: time schedules, shift 
rotations, evaluations, fair and equal opportunity to be considered for 
promotion, and fair treatment among colleagues. VA management 
frequently handles issues like these in ways that warrant grievances 
from VA employees, but workers have their efforts to maintain fairness 
blocked by the VA's 7422 exceptions. VA employees experience great 
frustration when they have no mechanism to demand fairness in the 
workplace.
    This toxic labor-relations climate results in many title 38 health 
care providers being terrified to come forward with concerns--some that 
directly impact patient care--because VA employees know that if they 
are retaliated against by management, there is little that the union 
can do to protect them. For many VA employees, this kind of atmosphere 
is more than they are willing to tolerate, especially when the health 
care skills they have are in demand, and in all likelihood, they can 
get paid more elsewhere.
    Poor recruitment and retention rates at the VA are well documented, 
and these problems adversely impact patient care. The elimination of 
the 7422 exceptions, which would be accomplished by passing H.R. 949, 
would lead to a substantially improved labor-relations climate at the 
VA. Improved labor-relations would lead to a fairer workplace, a 
happier workforce, and better recruitment and retention of VA health 
care providers. Improved recruitment and retention would lead to fewer 
staffing problems, and ultimately, better care for American veterans.

The 7422 Exceptions are Completely Unnecessary and Inconsistent with 
        the Health Care Industry
    Eliminating the 7422 exceptions to restore the scope of bargaining 
for title 38 employees at the VA would bring VA health care providers 
in line with the collective bargaining and grievance rights already 
enjoyed elsewhere in the health care industry. The VA is unique in its 
ability to avoid bargaining over issues concerning conduct, competence, 
compensation, and peer review. The rest of the roughly 12 million 
health care workers in the United States have a full scope of 
bargaining should they choose to be represented by a union; and yes, 
they can bargain and file grievances over issues concerning conduct, 
competence, compensation, and peer review.
    Eliminating the 7422 exceptions under title 38 would level the 
playing field with regard to collective bargaining for title 38 and 
title 5 employees of the VA. Some of the title 5 VA health care 
providers include psychologists, LPNs, pharmacists, and those holding 
other positions. These VA employees enjoy a broader scope of bargaining 
because they are under title 5. It is only title 38 VA employees who 
are singled out under the law, and have their scope of bargaining 
limited by sec. 7422 of title 38.
    Even Federal employees who have the exact same positions as title 
38 VA employees, but work in other Federal agencies, have a broader 
scope of bargaining. For example, nurses and doctors at the Army 
medical centers such as Walter Reed, who perform the very same function 
as nurses and doctors at the VA, have broader collective bargaining 
rights. Even VA physicians and RNs converting from a Department of 
Defense personnel system at the joint DoD-VA medical facility in North 
Chicago will be granted broader bargaining rights. All these federally 
employed health care providers have basic bargaining rights that the 
majority of Federal employees enjoy under title 5.
    The bottom line is, VA title 38 health care providers are in the 
same basic positions as those working at DoD medical facilities, joint 
DoD-VA facilities, and private sector hospitals. Title 38 VA employees 
are just treated differently because the VA is taking advantage of, and 
in our opinion abusing, an outdated provision that should be eliminated 
from the law.
    There is no real reason for title 38 VA workers to be singled out 
in the health care community and forced to have their critical rights 
taken away. There are, however, many compelling reasons to eliminate 
the disparity in treatment that title 38 VA health care providers are 
experiencing. The VA is at a distinct disadvantage to employers in 
other sectors of the economy, and even elsewhere in the Federal 
Government, where employees have a meaningful voice in the workplace on 
critical conditions of employment. The VA would be in a better position 
to recruit and retain a talented workforce if H.R. 949 was passed into 
law, and the 7422 exceptions under title 38 were eliminated.
Health Care Providers Use Collective Bargaining to Maintain Fairness in 
        the Workplace and Improve Patient Care; Bargaining Does Not 
        Hurt Patient Care
    The VA, over the last several years, has perpetuated the 
misconception that collective bargaining would imperil the VA's ability 
to provide timely and quality care for veterans. This is 100 percent 
false, and it is offensive to the tens of thousands of dedicated VA 
health care providers who provide this service to veterans.
    For example, last year, Gerald M. Cross, Principal Deputy Under 
Secretary for Health testified before the Senate Veterans' Affairs 
Committee on April 22, 2009 at a hearing on pending health-related 
legislation. Mr. Cross's testimony includes grossly inaccurate 
statements such as ``[S. 362/H.R. 949] would give [union members] 
bargaining rights on clinical care matters that would clearly and 
foreseeably endanger the well-being of our veteran-patients'' and 
``would thwart VA's ability to immediately re-assign staff from direct 
patient care duties to administrative duties based on an allegation 
that the staff committed patient abuse.''
    These claims are nothing but fear tactics. Millions of health care 
providers in the private sector and elsewhere in government have full 
collective bargaining rights, and those rights do not lead to 
endangering the well-being of patients. They would not lead to the 
endangering of veteran-patients at the VA either.
    The reality is that collective bargaining improves patient care 
because VA health care providers have the best interest of their 
patients at heart. When employees have protections, they come forward 
when they see a practice that could be endangering veteran-patients. On 
the other hand, if they are intimidated by management and worried that 
coming forward will lead to retaliation, they will think twice about 
coming forward. Veterans deserve to have their care administered by 
employees who have basic workplace rights.
    Eliminating the 7422 exceptions, which would give title 38 VA 
employees a sense of fairness in the workplace, would give VA employees 
peace of mind in speaking up about patient care problems. Not giving VA 
employees basic protections is, in my opinion, what leads to situations 
like the one experienced in the VA medical center in Marion, IL, where 
nine patients died due to surgical mistakes and poor post-surgical 
care. Giving employees the peace of mind to come forward when they see 
problems like these will help keep these problems from occurring. Right 
now, sec. 7422 of title 38 is preventing it from happening throughout 
the VA. Veterans deserve better.

There are Veterans Groups that Support this Legislation; Veterans 
        Groups Do Not Tend to Support Legislation that Will Hurt 
        Veterans' Care
    The fact that some veterans groups support this legislation 
demonstrates that the VA's assertions that collective bargaining will 
hurt patient care are preposterous. Plain and simple, veterans groups 
do not support legislation that is going to hurt veterans' care.
    The Paralyzed Veterans of America (PVA) have endorsed H.R. 949. The 
Disabled American Veterans (DAV) have indicated that they support the 
intent of the bill.

Only Legislation Can Solve the 7422 Problem Permanently
    The VA and five VA employee unions, including NFFE, have assembled 
a 7422 Work Group to make a recommendation to the Secretary of the VA 
aimed at improving the consistent use of the authorities and 
limitations on sec. 7422 of title 38. While we hope to make some 
improvements, we do not expect to reach a permanent solution from this 
7422 Work Group. Regardless of what changes the VA agrees to, the Work 
Group recommendation would not be binding on future Administrations 
without a change in law. The 7422 problem is a significant one that is 
hurting veterans' care. We should address this issue permanently by 
passing H.R. 949. A non-statutory fix will have very little impact on 
the ability to maintain a fair workplace for title 38 VA employees over 
the long-term.

With Thousands of Veterans Returning From Conflicts Abroad, the Time to 
        Address This Cancer at the VA is Now
    The VA is anticipating a large increase in the number of veteran-
patients to whom it provides service as American veterans return from 
conflicts abroad. The VA should take necessary steps to improve labor-
relations in anticipation of the increased demands on the Department's 
workforce. Our veterans deserve the best care this nation can provide 
them. Let's take the necessary steps to ensure the nurse or doctor who 
actually provide care to veterans are given basic protections under the 
law.

Conclusion
    By passing H.R. 949, many of the concerns that that I have 
described would be sufficiently addressed. This bill would restore a 
meaningful scope of bargaining for title 38 VA health care 
professionals by eliminating the 7422 exceptions (conduct, competence, 
compensation, and peer review) under the law that the VA has continued 
to exploit.
    The restoration of meaningful bargaining rights for title 38 VA 
employees will increase the morale at the VA greatly. It will also 
serve to improve recruitment and retention rates, issues which have 
been areas of great concern at the VA. With thousands of veterans 
returning home from conflicts abroad, the time to address this critical 
issue is now. Restoring a broader scope of bargaining will lead to 
better care for our Nation's veterans.
    NFFE greatly appreciates the Subcommittee's decision to hold a 
hearing on this matter. I thank the Subcommittee for the opportunity to 
provide this statement.

                                 
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