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




   LEGISLATIVE HEARING ON H.R. 4062, H.R. 4465, H.R. 4505, AND DRAFT 
                              LEGISLATION

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 27, 2010

                               __________

                           Serial No. 111-81

                               __________

       Printed for the use of the Committee on Veterans' Affairs












                  U.S. GOVERNMENT PRINTING OFFICE
57-025                    WASHINGTON : 2010
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001







                     COMMITTEE ON VETERANS' AFFAIRS

                    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

                               __________

                              May 27, 2010

                                                                   Page
Legislative Hearing on H.R. 4062, H.R. 4465, H.R. 4505, and Draft 
  Legislation....................................................     1

                           OPENING STATEMENTS

Chairman Michael Michaud.........................................     1
    Prepared statement of Chairman Michaud.......................    23
Hon. Henry E. Brown, Jr., Ranking Republican Member..............     5
    Prepared statement of Congressman Brown......................    23
Hon. Harry E. Teague.............................................     5

                               WITNESSES

U.S. Department of Veterans Affairs, Robert Jesse, M.D., Ph.D., 
  Acting Principal Deputy Under Secretary for Health, Veterans 
  Health Administration..........................................    15
    Prepared statement of Dr. Jesse..............................    38

                                 ______

Adler, Hon. John, a Representative in Congress from the State of 
  New Jersey.....................................................     3
    Prepared statement of Congressman Adler......................    28
American Legion, Barry A. Searle, Director, Veterans Affairs and 
  Rehabilitation Commission......................................     6
    Prepared statement of Mr. Searle.............................    29
Iraq and Afghanistan Veterans of America, Tim Embree, Legislative 
  Associate......................................................    11
    Prepared statement of Mr. Embree.............................    36
Kissell, Hon. Larry, a Representative in Congress from the State 
  of North Carolina..............................................     2
    Prepared statement of Congressman Kissell....................    23
Thornberry, Hon. Mac, a Representative in Congress from the State 
  of Texas.......................................................     3
    Prepared statement of Congressman Thornberry.................    24
Veterans of Foreign Wars of the United States, Eric A. Hilleman, 
  Director, National Legislative Service.........................     8
    Prepared statement of Mr. Hilleman...........................    32
Vietnam Veterans of America, Richard F. Weidman, Executive 
  Director for Policy and Government Affairs.....................    10
    Prepared statement of Mr. Weidman............................    33

                       SUBMISSIONS FOR THE RECORD

Disabled American Veterans, Adrian Atizado, Assistant National 
  Legislative Director, statement................................    42
Paralyzed Veterans of America, statement.........................    45
Gold Star Wives of America, Inc., Vivianne Cisneros Wersel, 
  Au.D., Chair, Government Relations Committee, statement........    47

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee 
  on Veterans' Affairs to Hon. Eric K. Shinseki, Secretary, U.S. 
  Department of Veterans Affairs, letter dated June 14, 2010, and 
  VA responses...................................................    49

 
              LEGISLATIVE HEARING ON H.R. 4062, H.R. 4465,
                    H.R. 4505, AND DRAFT LEGISLATION

                              ----------                              


                         THURSDAY, MAY 27, 2010

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:02 a.m., in 
Room 334, Cannon House Office Building, Hon. Michael Michaud 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Michaud, Teague, Rodriguez, Brown 
of South Carolina, and Boozman.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I would like to call the Subcommittee to 
order. It is my understanding we have votes as early as 11:00 
or 11:30, so we will get started, and Mr. Brown is on his way 
down. I would ask unanimous consent that my full statement be 
submitted for the record. Without objection, so ordered.
    I would like to thank everyone for coming today. Today's 
legislative hearing is an opportunity for Members of Congress, 
veterans, the U.S. Department of Veterans Affairs (VA), and 
other interested parties to provide their views and discuss the 
legislation that has been introduced within this Subcommittee's 
jurisdiction in a clear and orderly fashion. This is an 
important part of the legislative process that will encourage 
frank and open discussion of new ideas.
    We have five bills before us, which address a number of 
important issues. First, we have a radiation safety bill that 
requires proper training of all employees at VA hospitals. 
Second, we have a bill that will require the VA to consider 
children under legal guardianship of veterans when determining 
the veterans' copayment amount for medical treatment. And we 
also have a bill that would allow Gold Star Parents access to a 
State Veterans Home if they have had any children who died 
while serving in the armed forces. Then finally we have two 
draft pieces of legislation on improving VA's outreach to 
veterans and another bill that would allow VA to provide 
hearing aids to World War II veterans.
    I want to thank our first panel for coming here today to 
discuss this legislation, as well as the draft legislation that 
we will hear afterwards. On the first panel we have 
Representative Adler from New Jersey, Representative Thornberry 
from Texas, and Representative Kissell from North Carolina. And 
we will start with Mr. Kissell and his legislation. 
    [The prepared statement of Chairman Michaud appears on p. 
23.]

STATEMENTS OF HON. LARRY KISSELL, A REPRESENTATIVE IN CONGRESS 
   FROM THE STATE OF NORTH CAROLINA; HON. MAC THORNBERRY, A 
 REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS; AND HON. 
JOHN ADLER, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW 
                             JERSEY

                STATEMENT OF HON. LARRY KISSELL

    Mr. Kissell. Thank you, Mr. Chairman, and to my friends and 
colleagues on this Subcommittee. I thank you for the 
opportunity to come to you today to talk about H.R. 4465. And 
in light of time and recognizing that we need to move on, and 
in talking to the Chairman earlier that maybe the language of 
our bill might be a little bit confusing. But the intent is 
not, I am going to stick, Mr. Chairman, with the intent.
    In today's society, if we ever did have a nuclear family 
and structured a certain way, certainly today that has changed. 
We know that for many reasons grandparents and great-
grandparents are involved, and oftentimes in their late stages 
of life, in raising their grandchildren or great-grandchildren. 
We have a particular case in our district where a couple aged 
in their seventies, on low income, fixed income, had a 
situation within their family where they took legal 
guardianship of their great-grandchildren 5 years ago. They 
still have that legal guardianship. The children are now 5 and 
10 years old, and once again these are their great-
grandchildren.
    In all ways, by the Internal Revenue Service (IRS), the 
schools, in all ways within society they are recognized as the 
legal guardians of these children. But however, with the VA 
rules when it comes to figuring copays and the income versus 
dependents, they are not given consideration for these being 
dependents and, therefore, they do have to pay a copay. Very 
clearly, if these children were recognized as being the 
dependents that they are, once again in all other aspects of 
society but with this, then they would not have to pay the 
copayment. With such fixed income we are asking within H.R. 
4465 that this legal guardianship with grandparents and great-
grandparents or other relationships be recognized for our 
veterans. If they have legal guardianship for more than 1 year, 
we ask that it be recognized that this is a dependency and it 
should be taken into account.
    We recognize this will not affect many people. The 
Congressional Budget Office has said that this will not affect 
many people. But the ones it will affect, we feel that we need 
to make this change in recognition for their status, and in 
trying to take care of some of our children in whatever way it 
came to them. And I thank you, Mr. Chairman, and the Committee 
for the opportunity to discuss this with you.
    [The prepared statement of Congressman Kissell appears on 
p. 23.]
    Mr. Michaud. Thank you very much, Mr. Kissell. Mr. 
Thornberry.

                STATEMENT OF HON. MAC THORNBERRY

    Mr. Thornberry. Thank you, Mr. Chairman. And I do 
appreciate you having this hearing. I appreciate Dr. Snyder, 
who introduced this legislation, H.R. 4505, with me, and I 
appreciate your cosponsorship of it as well.
    With your permission I would like to make my full statement 
with some attachments part of the record.
    Mr. Michaud. Without objection, so ordered.
    Mr. Thornberry. And then I would just summarize. Mr. 
Chairman, as you know there are 137 State Veterans Homes in all 
50 States around the country, and they serve something over 
28,000 veterans and dependents.
    We all know of Gold Star Parents and think of Gold Star 
Parents as someone who has lost a child in the military. But 
for the purposes of being admitted to one of these State 
Veterans Homes the definition of a Gold Star Parent is you have 
to have lost all your children. So theoretically, you could 
have had three of your children die in the military, if you 
have one still surviving you are not eligible. And so what this 
bill does, it just changes that definition and says a Gold Star 
Parent is someone who has lost a child in the military, and 
would then be eligible for one of these State Veterans Homes. 
That is the basis of what this legislation does.
    Now, these State Veterans Homes have an occupancy rate that 
is about 86 percent, 87 percent, so there is room for 
additional people. The admissions criteria is still run by the 
States. So the States will decide if you have a veteran who 
wants to get in, and a Gold Star Parent, they still make that 
decision. But it just, this bill would just eliminate that 
Federal regulation that makes it very difficult for any parent 
to get into one of these State Homes.
    I might mention that the Consolidated Appropriations Act of 
2010 asked the VA to study this issue and figure out how much 
it would cost to allow a Gold Star Parent who has lost a child 
to get in one of these homes. VA came back and said, ``It is 
not going to cost us anything so there is no use for us to do a 
study on it.'' But they did say in their response that 
legislation is required to change this, indicating they cannot 
do it with a regulatory change, the burden is on our shoulders 
to make a change. And so this bill is supported by the American 
Legion, the National Association of State Veterans Homes, and 
other who I think you will hear from. I know of no opposition 
to it, Mr. Chairman. I think it is a basic issue of fairness. 
When you have capacity, you have some folks who would like to 
be admitted to these homes, to just remove this really Federal 
restriction that makes no sense, I think, to any of us. And I 
would appreciate the Committee's consideration of it.
    [The prepared statement and attachments of Congressman 
Thornberry appear on p. 24.]
    Mr. Michaud. Thank you very much. Mr. Adler.

                  STATEMENT OF HON. JOHN ADLER

    Mr. Adler. I thank you, Chairman Michaud, and Ranking 
Member Brown, and Members of the Subcommittee for the 
opportunity to testify on behalf of H.R. 4062. The need for 
H.R. 4062 came from a very serious matter that occurred at the 
Philadelphia Veterans Affairs Medical Center. Starting in 2003, 
the brachytherapy program at the Philadelphia VA was operated 
by a rogue doctor who botched approximately 86 percent of the 
prostate cancer treatment procedures he was contracted to 
perform on our veterans. These multiple failures, which went 
undetected year after year, highlighted significant problems in 
the VA's oversight system. The VA failed until 2008 to catch 
this pattern of failure.
    H.R. 4062, the ``Veterans' Health and Radiation Safety 
Act,'' is a comprehensive piece of legislation that seeks to 
remedy many of the mistakes that led to the problems 
surrounding the brachytherapy program at the Philadelphia VA 
Medical Center. This bill has three major components. First, 
the bill mandates that the VA conduct an evaluation of all of 
the low volume programs that are currently operating in its 
medical facilities to ensure that they are meeting their safety 
standards. The brachytherapy program at the Philadelphia VA was 
not subjected to independent peer review due to the fact that 
it was such a low volume program, serving only 116 patients 
over a 6-year period. Because of this lack of oversight errors 
that should have been caught and rectified, were allowed to 
continue for 6 years unnoticed.
    Second, H.R. 4062 requires that every VA employee and 
independent contractor working in a VA medical facility be 
trained in what constitutes a medical event, as that term is 
defined by the Nuclear Regulatory Commission (NRC), as well as 
when such an event should be reported, and to whom. Over the 
course of the 6-year period in which the brachytherapy program 
at the Philly VA was in operation, 86 percent of the patients 
were subjected to reportable medical events. However, because 
many of the medical personnel in the program, including the 
independent contractors, were not trained in what constitutes a 
medical event as that term is defined by the NRC, or to whom 
such an event should be reported, these errors were allowed to 
continue, and our veterans remained susceptible to substandard 
medical care for far too long.
    Lastly, this bill requires the Secretary to evaluate all 
medical services provided pursuant to a contract with a 
nongovernment entity. Such evaluations shall include 
independent peer reviews of such medical services, and written 
evaluations of a independent contractor's performance by that 
contractor's supervisors. The bill also states that before a 
contract for medical services can be renewed, the above 
evaluations must be conducted. In Philly one of the problems 
was that year after year that contracts were renewed every 6 
months without any review by anybody, and this doctor continued 
to hurt good veterans.
    The veterans who sought treatment for prostate cancer at 
the Philadelphia VA did not receive the quality of care they 
deserve. Such mistreatment of our veterans is not only 
unacceptable, it violates the bond our country made with them 
when they agreed to fight for our safety and security. It is my 
hope that H.R. 4062 will ensure that the failures that occurred 
at the Philadelphia VA will never happen again.
    I thank the Chairman, and the Ranking Member, for letting 
me speak on this bill.
    [The prepared statement of Congressman Adler appears on p. 
28.]
    Mr. Michaud. Thank you very much. And once again I would 
like to thank all three of you for bringing forward these very 
important pieces of legislation. Having reviewed them, and 
pending the next couple of panels, I think we can actually work 
on all three of them, because I think all three are very 
important, I look forward to working with my Ranking Member Mr. 
Brown to see how we can move forward these pieces of 
legislation. I have no questions. Mr. Brown.

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

    Mr. Brown of South Carolina. Thank you, Mr. Michaud. I 
apologize for being late. We had about 35 businessmen from 
Canada come by my office at 10:00 for a tour. And, you know, 
Canada is a big trading partner with us. And so, I am sorry I 
am late.
    But let me just make a brief statement. Thank you all for 
coming today. When we honor the bravery and service of our 
military members and veterans, we must also honor the sacrifice 
and selflessness of their families. I do not think the loss of 
a child, whether one or many, can be differentiated, and I 
thank Mac for introducing his legislation. We look forward to 
further proceedings on these bills. Thank you.
    [The prepared statement of Congressman Brown appears on p. 
23.]
    Mr. Michaud. Thank you. Mr. Teague, do you have any 
questions or opening statement?

             OPENING STATEMENT OF HON. HARRY TEAGUE

    Mr. Teague. Yes. Chairman Michaud, thank you. Ranking 
Member Brown, thank you for allowing me a few moments to speak 
on my draft legislation, the ``World War II Hearing Aid 
Treatment Act'' and its importance to the veterans of our 
country.
    While many look back at World War II as one of the most 
significant events that the Unites States and humanity was ever 
involved in, it has only been recently as many of yesterday's 
soldiers are passing away that we as a country have really 
reflected on its importance and what it meant to us as a 
Nation. I do not know why that is. I do not know why it has 
taken so long to recognize the sacrifices that were made in 
North Africa, Europe, and the Pacific Theater. Maybe it is 
because those individuals never wanted to make a big fuss over 
what they had done. They were just doing their job.
    As the son of a World War II veteran, my father talked 
about the War occasionally. It was not something he bragged on. 
Instead, it was something that he would mention as part of his 
story. It was just a part of what he was supposed to do. He 
felt it was his duty to go when called. Maybe that is why we 
have taken so long to recognize the many sacrifices of this 
War, because those that fought it were humble and did not want 
to make a big deal about it.
    What I do know is that, as was said by President Clinton, 
``when these men and women were young they saved the world.'' 
That is no exaggeration. That is not just us saying something 
to be nice. That is the truth. Now we are losing World War II 
veterans at a faster rate than any other veteran group. It is 
important that we make sure that we are doing all that we can 
to honor these men and women now while they are still with us.
    I believe that the ``World War II Hearing Aid Treatment 
Act'' is one of the ways we can do that. It will authorize the 
Secretary to furnish a hearing aid device to any veteran who 
served in the active military, naval, or air service during 
World War II, and who is being diagnosed with a hearing 
impairment. It is a simple act that can ensure that we are 
taking care of these historic veterans that did so much for us. 
Thank you, Mr. Chairman. That concludes my statement.
    Mr. Michaud. Thank you, Mr. Teague. Mr. Rodriguez, do you 
have any questions, or a statement? If not, once again I want 
to thank all three of you for coming today and I look forward 
to working with you as we markup these pieces of legislation. 
So once again, thank you very much.
    I would like to call the second panel forward, and while 
they are coming forward I will introduce them. It is Barry 
Searle, who is the Director of the Veterans Affairs and 
Rehabilitation Commission for the American Legion; Eric 
Hilleman from the Veterans of Foreign Wars (VFW); Rick Weidman, 
who is with the Vietnam Veterans of America (VVA); and Tim 
Embree, who is with the Iraq and Afghanistan Veterans of 
America (IAVA). I want to thank all four of you for coming this 
morning, and look forward to your testimony. We will start with 
Mr. Searle.

 STATEMENTS OF BARRY A. SEARLE, DIRECTOR, VETERANS AFFAIRS AND 
 REHABILITATION COMMISSION, AMERICAN LEGION; ERIC A. HILLEMAN, 
  DIRECTOR, NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN 
   WARS OF THE UNITED STATES; RICHARD F. WEIDMAN, EXECUTIVE 
DIRECTOR FOR POLICY AND GOVERNMENT AFFAIRS, VIETNAM VETERANS OF 
   AMERICA; AND TIM EMBREE, LEGISLATIVE ASSOCIATE, IRAQ AND 
                AFGHANISTAN VETERANS OF AMERICA

                  STATEMENT OF BARRY A. SEARLE

    Mr. Searle. Mr. Chairman and Members of the Subcommittee, 
thank you for the opportunity to present the views of the 
American Legion on legislation and proposed legislation 
important to veterans.
    H.R. 4062, the ``Veterans' Health and Radiation Safety 
Act,'' this legislation would require the Secretary of Veterans 
Affairs to ensure that all employees at a VA hospital where 
radioactive isotopes are used in the administration of medical 
services receive appropriate training on what constitutes a 
medical event and when to whom a medical event should be 
reported. It would require specific evaluations and peer review 
of all medical services provided under contract with a 
nongovernment entity. The American Legion's System Worth Saving 
Task Force annually conducts site visits at the VA medical 
centers nationwide to assess quality and timeliness of VA 
health care. During task force visits, we have found that 
turnover of personnel and shortage of personnel require renewed 
emphasis on standardized procedures, quality review, and 
individual training as well as documentation of that training. 
As technologies continue to change and treatments and 
procedures continue to develop, it is critical that the VA 
staff delivering care be properly trained and are accountable. 
The American Legion supports not only the specified training 
and accountability highlighted in H.R. 4062 but also the 
standardization of all patient care delivered across the VA 
system.
    H.R. 4505, expansion of State Home care for parents of 
veterans who died while serving in the armed forces. The 
legislation permits a State Home to provide VA nursing home 
care to parents who suffered the loss of a child who died 
during service in the armed forces. The American Legion 
believes that a commitment is made not only by servicemembers 
who commit to the service of their country but also family 
members who must say goodbye to their loved ones. The American 
Legion believes that when a servicemember is killed in the line 
of duty and a dependent parent is deemed medically eligible for 
nursing home admission, that parent should be entitled to VA 
Nursing Home Care. We believe the current regulation imposes 
too high a threshold of suffering on surviving parents when it 
requires that all children must have died in the service while 
on active duty. We understand that currently the occupancy rate 
of the nursing homes remains at approximately 85 percent 
nationally. It is felt that the number of parents who would 
utilize the opportunity is small enough to not significantly 
impact occupancy. The American Legion supports H.R. 4505.
    H.R. 4465, the determination of attributable income for 
veterans with children. This legislation would direct the VA 
Secretary, when examining a veteran's attributable income, to 
treat as a dependent child of such a veteran any other person 
who is placed in the legal custody of the veteran and has not 
attained 21, or has not attained age 23 and is enrolled in a 
full-time course of study, or is incapable of self-support due 
to mental or physical incapacity. The American Legion supports 
H.R. 4465.
    Proposed legislation, the ``World War II Hearing Aid 
Treatment Act.'' The American Legion recently adopted a 
resolution acknowledging current advances in scientific 
research, which require review of prior and potential 
environmental threats to servicemembers. It is understood that 
past acceptable norms in environmental exposure for noise have 
been found to be unacceptable in today's environment. 
Especially in the case of World War II veterans the state of 
the art for working environment protection of servicemembers 
had not evolved to the current levels. The fact of service and 
exposure to these environmental exposures would imply the 
potential for hearing loss. The American Legion supports this 
proposed legislation to furnish World War II veterans with 
hearing aids.
    We would further submit, for the Subcommittee's 
consideration, the fact that environmental issues for hearing 
loss were in existence through the Vietnam War. It was not 
until recently that significant efforts have been made to 
protect the hearing of servicemembers. The American Legion 
suggests expanding this bill to cover veterans for the Korean 
and Vietnam War eras also.
    Improved ``VA Outreach Act of 2010,'' the American Legion 
has testified concerning improvements VA could make to further 
outreach to veterans. VA continues to make progress to improve 
its outreach to program veterans. Currently the VA in many 
cases informs veterans service organizations (VSOs) on system 
improvements accomplished. VSOs in turn advise veterans on 
these efforts. This partnership between VA and the VSOs in 
informing veterans is critical to the success in the VA's 
outreach program.
    However, issues remain with the VA's outreach to veterans. 
Earlier this month the American Legion testified that the VA 
continues to struggle with informing veterans of entitlements 
such as efforts to assist transitioning servicemembers through 
the Benefits Delivery at Discharge Program, and the Transition 
Assistance Programs. In particular, Reserve component members 
released from active duty mobilizations at times are rubber 
stamped and returned home with little or no understanding of 
what entitlements they have earned due to their honorable 
service. The American Legion also understands that policies 
developed at Central Office with the best of intentions are for 
the most part executed at the discretion of the director at the 
local level, and therefore, vary in local implementation. For 
example, VA has a veteran employment hiring program policy to 
recruit veterans as outlined in Secretary Shinseki's Memorandum 
dated 21 October, 2009. However, the American Legion has seen a 
variation of hiring from about 25 percent to 79 percent. We 
feel this variation is due to the Director's emphasis on 
outreaching to veterans.
    Many veterans are moving to rural and extremely rural 
areas. Nevertheless, these veterans have earned the right to 
receive information and updates on changes that impact their 
earned benefits. While the VA has made efforts to become more 
user friendly we continue to hear, especially from older 
veterans, that the system requires documentation that is still 
too complicated.
    We are concerned that the VA does not consistently utilize 
this proven partnership between veterans service organizations 
and the VA to optimize outreach to veterans. The establishment 
of a VA Advisory Committee on Outreach as proposed in draft 
legislation requiring representation from members of the VSO 
community and reporting to the VA Secretary will enhance VA's 
outreach program and ultimately better serve America's 
veterans. The American Legion supports the outreach to 
veterans, and in particular Improved VA Outreach Act of 2010. 
Thank you.
    [The prepared statement of Mr. Searle appears on p. 29.]
    Mr. Michaud. Thank you, Mr. Searle. Mr. Hilleman.

                 STATEMENT OF ERIC A. HILLEMAN

    Mr. Hilleman. Thank you, Mr. Chairman, Ranking Member 
Brown, Members of the Subcommittee. On behalf of the 2.1 
million men and women of the VFW and our auxiliaries, it is my 
pleasure to be here representing them before you today. Due to 
the number of bills before this Committee today, I would like 
to limit the bulk of my remarks to two bills and briefly 
comment on the remaining bills.
    H.R. 4505, a bill to enable State Veterans Homes to furnish 
nursing home care to parents whose children died while serving 
in the armed forces. The VFW is proud to support this 
legislation, which would authorize State-run nursing homes to 
accept surviving parents of a child who died while serving in 
the armed forces. Current law requires that a parent must have 
lost all of their children to military service to qualify for 
nursing home care. The VFW believes the care of a Gold Star 
Parent is a sacred trust, and this bill would provide a 
critical benefit at a time when they may need the long-term 
care State Homes offer. We ask Congress to act quickly to enact 
this legislation.
    The next bill is the draft bill, ``World War II Hearing Aid 
Treatment Act.'' The VFW admires the goal of this legislation, 
but cannot support it as written. Millions of Americans 
participated in combat in World War II, where over 416,000 were 
killed, and hundreds of thousands were wounded. Almost 
everything about modern warfare involves loud and often 
incredibly loud noise. Acoustic trauma is a major cause of 
hearing loss. Those who fought in the island campaigns of the 
Pacific, North Africa, Normandy, and the Battle of the Bulge, 
or flew through the flak and fighter filled skies over Germany 
and France were exposed to incredibly loud noises that left 
damage throughout their lives.
    However, training for and fighting a war in terms of noise 
exposure is virtually identical in younger veterans, who 
trained and fought in every other war from Korea, Vietnam, to 
the current conflicts in Iraq and Afghanistan. The Institute of 
Medicine (IOM) studied hearing loss in the military. 
Essentially they said servicemembers are exposed to a wide 
range of noise, from occupational, i.e. trucks, generators, 
planes, to acoustic trauma, machine gun fire, artillery, and 
improvised explosive devices. Their recommendations focused on 
prevention in the military. But they suggested, ``given the 
likely occurrence of maximum noise included hearing loss at 
6,000 hertz, include the measurement of hearing thresholds at 
8,000 hertz in all audiograms to allow for detection of the 
noise notch pattern of hearing loss associated with noise 
exposure.''
    The military widely recognizes that servicemembers are 
exposed to potential hearing damage throughout their training 
and average duties. In addition to exchange of gunfire, 
mortars, and explosions, and those associated with combat, the 
Army has rated and recognizes the basic acoustic trauma that is 
caused by machinery, equipment, and weapons as well. For 
example, a basic Humvee produces between 75 to 100 decibels of 
noise, while a mortar operator endures 180 decibels of noise 
with every mortar fired. The VFW cannot support this 
legislation between the only factual difference World War II 
veterans' exposure to noise and that of every other generation 
are the age of the veterans.
    H.R. 4062, Veterans' Health and Radiation Safety Act, the 
VFW supports the legislation that would amend title 38 of the 
U.S. Code to make certain improvements in the administration of 
medical facilities within the Department of Veterans Affairs.
    H.R. 4465, to amend title 38 of the U.S. Code to direct the 
Secretary of the VA to take into account dependent children 
when determining a veteran's financial status when receiving 
hospital care or medical services. The VFW supports this 
legislation to allow certain dependents to be counted in 
determining earnings threshold for the purposes of seeking 
services with VA.
    Finally, draft bill Improved VA Outreach Act of 2010, the 
VFW supports this Act which would improve outreach within the 
Department of Veterans Affairs by coordinating the efforts 
among the Secretary of Public Affairs, the Veterans Health 
Administration, the Veterans Benefits Administration, and the 
National Cemetery Administration.
    Thank you, Mr. Chairman. This concludes my testimony, and I 
am happy to answer any questions this Committee may have.
    [The prepared statement of Mr. Hilleman appears on p. 32.]
    Mr. Michaud. Thank you. Mr. Weidman.

                STATEMENT OF RICHARD F. WEIDMAN

    Mr. Weidman. Mr. Chairman, thank you for the opportunity 
for Vietnam Veterans of America to present our views here 
today.
    In regard to H.R. 4062, ``Veterans' Health and Radiation 
Safety Act,'' one would think that this piece of legislation 
would not be needed but clearly demonstrated by the situation 
at Philadelphia VA Medical Center, it is. VVA is generally in 
favor of anything that promotes greater reporting and is 
accompanied by greater accountability for quality assurance by 
the VA health care system. And in this particular instance you 
can code the metrics into VistA, and do so without additional 
burdens on the clinician, which takes away from patient-centric 
care. And so we favor this legislation at this point. And to 
add to the analysis of the annual report would also add 
something that we do not talk about very often.
    The size of the staff at the VA has swollen enormously 
since 1994. But the staff, numbers of staff working for the 
Congress and for the Committees on both sides of the Hill is 
less today than it was in 1994. And you need the organization 
capacity here to be able to go through all of the reporting 
mechanisms that you put in place, to be able to absorb that 
information and assimilate it, and work with the Members of the 
Committee to help them understand what situations need more 
close monitoring and oversight hearings. And so we would just 
put in a pitch for, and we will reiterate that to the Speaker 
and to the Republican Leader as well.
    H.R. 4505, which authorizes the VA Secretary to authorize 
VA State Nursing Homes to take in Gold Star Parents is 
something we are very much in favor of. Of all weeks in the 
year, this is the most appropriate week that we all should be 
thinking about Gold Star Families. Not just the moms and dads, 
but also the spouses and the children who are left behind, as 
well as siblings. We very much favor this. The Gold Star Manor 
in California cannot possibly handle most of the folks whose 
sons, primarily, and daughters are not around to care for them 
in their later years. And so this is a needed step. It is not a 
heavy lift. And we very much favor early passage.
    The draft to Improve VA Outreach Act of 2010, we do favor 
this. VA's testimony this morning, written statement says it is 
redundant. But gosh, we cannot see it. There is so little 
outreach and education of the veterans' community as to what 
are the benefits and services available to them, and what are 
the long-term health care risks that result from military 
service depending on what branch did you serve in, when did you 
serve, where did you serve, that we at VVA started Veterans 
Health Council. VVA, it is www.veteranshealth.org. And we are 
partnered with a number of other organizations, more than 50 
organizations, primarily medical societies, like the American 
Academy of Ophthalmology, American Psychiatric Association, 
disease advocacy groups, like American Diabetes Association, 
Men's Healthcare Network, and other veterans service 
organizations like National Association of Black Veterans, the 
United Spinal Cord Association, Veterans First Project, and 
National Association of Uniformed Services, in order to do 
outreach directly to those folks. We have given out over 
100,000 brochures and are getting about 5,000 hits a month on 
our Web site because people are not getting that information in 
a succinct form from VA, one. Two, is to do the outreach 
through the U.S. Department of Health and Human Services (HHS). 
The reason why that is so important is we have to reach out to 
civilian medicine. Less than 20 percent of the VA population 
eligible, potentially eligible, uses the VA medical system as 
their primary health care system. We have to reach that 80 
percent outside in order that they understand what is available 
to them. So we are very much in favor of this.
    Last but not least, I see I am out of time, the WWHAT bill, 
which is, love the name. But we would like to commend you. The 
IOM study that was cited before that was September 2005 that 
looked in depth basically said there was no recordkeeping, 
there was no longitudinal study of any human beings, much less 
military veterans of World War II. Therefore, trying to prove 
that you were exposed to those kinds of noises in World War II, 
they are all octogenarians now, and nonagenarians. It is time 
to give them a hearing aid to improve the quality of their 
lives in the time that they have left. In regard to other 
comments about including the Korean War, we would concur with 
that, as well as other military service. But the bill as it is, 
we favor.
    Thank you very much, Mr. Chairman, for the opportunity.
    [The prepared statement of Mr. Weidman appears on p. 33.]
    Mr. Michaud. Thank you very much, Mr. Weidman. And Mr. 
Embree.

                    STATEMENT OF TIM EMBREE

    Mr. Embree. Thank you, sir. Mr. Chairman, Ranking Member, 
and Members of the Subcommittee, on behalf of Iraq and 
Afghanistan Veterans of America's 180,000 members and 
supporters, I would like to thank you for inviting us to 
testify before your Subcommittee today.
    My name is Tim Embree. I am from St. Louis, Missouri. I 
served two combat tours in Iraq with the United States Marine 
Corps Reserve. This legislation being considered today will 
profoundly affect veterans of all generations and their 
families. We appreciate this opportunity offer our feedback.
    IAVA proudly supports the Improved VA Outreach Act of 2010. 
Too many men and women discharging from the military are not 
enrolling in the Department of Veterans Affairs for their well 
earned benefits. Currently, the burden is on the veteran to 
seek out their benefits within a passive VA. This is 
unacceptable. The VA must develop a relationship with the 
servicemembers while they are still in the military, not after 
the servicemember has traded in his uniform for a t-shirt and 
blue jeans. The VA should learn from successful college alumni 
associations. Those folks did not wait until graduation day to 
find their newest members. They greeted on the 1st day of 
freshman year, and repeatedly engaged them throughout their 
education with planned activities and social events. The VA 
should do the same.
    They should greet servicemembers once they complete basic 
training and build on that relationship throughout the 
servicemember's time in uniform. When a person leaves the 
service the VA should create a regular means of communicating 
with them about events, new programs, and opportunities. The VA 
must aggressively promote VA programs to veterans who have not 
yet accessed their Department of Veterans Affairs benefits. If 
I have half as many letters and emails from the VA as I do from 
my college alumni association that would be a good start.
    To transfer the VA from reactive to proactive, IAVA 
believes the Department of Veterans Affairs must invest in 
aggressive, modern, and innovative outreach. This is not 
happening now and veterans are clearly suffering as a result. 
IAVA was disappointed when there were only a few brief mentions 
of outreach activities in the President's VA budget submission, 
none of which were for a dedicated outreach campaign. We 
believe the VA must include a distinct line item for outreach 
within each VA appropriation account. This line item should 
fund outreach programs such as the Operating Iraqi Freedom/
Operation Enduring Freedom (OIF/OEF) outreach coordinators, 
mobile Vet Centers, and the VA's new social media presence on 
Facebook and Twitter.
    The VA's current outreach campaign is disappointing. When 
the VA announced it had placed ads on more than 21,000 buses 
nationally in order to spread the word about the suicide 
prevention lifeline, we were initially enthusiastic. But then 
we saw the ad. We saw another missed opportunity. The VA bus ad 
had over 30 small print words. The average bus ad is limited to 
five to 10 words. In the short time when a bus passes, a 
veteran would have to go by the bus repeatedly to even read the 
hotline number.
    IAVA has run one of the largest nongovernmental outreach 
campaigns in history. We have partnered with the Ad Council and 
some of the world's best advertising firms. We have learned a 
lot about the best ways to communicate complex and series 
issues through television and print, and we are ready to work 
with the VA to share our expertise.
    The Improved VA Outreach Act will help the VA take their 
current outreach efforts to a whole new level. This bill 
requires the VA to effectively coordinate outreach efforts 
among the different parts of the Department, as well as other 
agencies offering services to returning servicemembers. To work 
closely with HHS in order to promote community health centers. 
These community health centers may be the only medical facility 
a rural vet can reasonably access without spending a full day 
riding in a car or bus. To set up an outreach committee tasked 
with coordinating efforts, which currently are being done on an 
ad hoc basis among many of the VA's separate departments, and 
to submit a 2-year plan fully explaining their outreach 
activities.
    To bring America's next generation of veterans into the VA 
to receive the benefits they have earned will require an 
unprecedented VA outreach program. The Improved VA Outreach Act 
of 2010 is the first step in getting us there.
    Stories about veterans leaving VA facilities sicker than 
when they entered cast a cloud over the confidence veterans 
place in the system charged with their care. Therefore, IAVA 
endorses H.R. 4062, the ``Veterans' Health and Radiation Safety 
Act.'' Improper use of medical equipment, especially 
radioactive isotopes, can lead to unexplained illness, cancer, 
and even death. The VA was recently issued the largest fine by 
the Nuclear Regulatory Commission for misuse of radioactive 
isotopes in the treatment of nearly 100 veterans in 
Philadelphia. H.R. 4062 mandates the proper oversight of these 
treatments so veterans can be confident in the safety of the 
care they receive.
    It is common sense to support of Gold Star Parents, who 
have given so much to our Nation. That is why IAVA supports 
H.R. 4505. This bill expands access for Gold Star Parents to 
State Nursing Homes. H.R. 4505 changes the requirements to 
include Gold Star family members who have no remaining sons or 
daughters, but have lost one of their children in service to 
their country.
    IAVA is proud to continue working with this Committee on 
the many issues facing today's veterans. Thank you very much 
for your time today and I look forward to answering any 
questions you may have.
    [The prepared statement of Mr. Embree appears on p. 36.]
    Mr. Michaud. Thank you very much, Mr. Embree. Mr. Brown, do 
you have any questions for the panel?
    Mr. Brown of South Carolina. Thank you, Mr. Chairman, no I 
do not. I appreciate the input on these bills. I know we are 
pretty much in agreement, except maybe on the hearing aid 
issue. And we will certainly look forward to further discussion 
on that. Thank you all for being here.
    Mr. Michaud. Mr. Teague.
    Mr. Teague. No, I do not have any questions at this time. 
And for the sake of speed, we will save them for later. Thank 
you.
    Mr. Michaud. Mr. Boozman.
    Mr. Boozman. No, I also do not have any questions. Again, 
we appreciate your guys' hard work, and all that you represent, 
and giving us your opinion regarding this. So thank you very 
much.
    Mr. Michaud. Mr. Rodriguez.
    Mr. Rodriguez. Yes, let me also just take this opportunity 
to thank you and maybe inquire about one comment. The 84 
percent vacancies in the nursing home, is this nationwide? 
Because I know in Texas we only have about six or seven of 
them, and we do not have too many nursing homes for veterans. I 
am not sure if we even have any vacancies. Does anybody want to 
make any comments on that? I know we usually have a waiting 
list.
    Mr. Searle. Yes, sir. Those come from VA's numbers 
themselves that they reported on average that that is where 
their numbers are. There are some homes that are less. But on a 
national average it is about an 84 percent occupancy rate in 
the nursing homes.
    Mr. Rodriguez. Yes, because I know in Texas we never had 
them until just in the last decade or so, perhaps the last two 
decades. I do not have any in my district, and in my previous 
district, I only had one. Okay, thank you.
    Mr. Michaud. Thank you. I have a question for everyone on 
the panel, and which some of you touched upon in your 
testimony. VA states in their written testimony that they do 
not support H.R. 4062, the ``Veterans' Health and Radiation 
Safety Act,'' because they either met or are working to meet 
the recommendations provided in the May 2010 Inspector General 
(IG) report. What is your response to VA's rationale for not 
supporting this legislation? And can you explain whether you 
believe the VA has made sufficient progress in improving the 
handling of radioactive isotopes at the VA medical facilities? 
I know some of you have touched upon this question in your 
opening remarks. Mr. Searle, do you want to start?
    Mr. Searle. Again, through our System Worth Saving Task 
Force we have gone to the various medical centers. We have 
found that there are, and we can forward to you in detail some 
of the results, but we have found that there is a turnover of 
personnel, and that the training of the personnel needs to be 
standardized and it needs to be reinforced. Because new 
personnel with the activities that are going on need to be 
reinforced.
    Mr. Hilleman. Mr. Chairman, thank you for this question. In 
the mind of the VFW it is a confidence issue. Here we had an 
incident where a number of veterans were harmed by medical 
procedures that they trusted, doctors that they had faith in. 
And that faith has been undermined. So Congress taking action 
to ensure that an event like this never happens again is 
something we strongly support. Not only that, but the reporting 
mechanisms in the bill will help to ensure that the steps VA is 
already taking are followed through on. Thank you, sir.
    Mr. Weidman. Much of what happens in this room and with the 
distinguished Members of this Committee that you focus on are 
things that all you have to do is have common sense and VA 
would already be doing. And in some instances they do not have 
the authority to move forward, but in many others they do. And 
this is one of those instances. Clearly, there has not been put 
in place the metrics to measure this systemwide and to report 
on it. And once again, as I said in both our written statement 
and in the oral statement, it can be designed to have metrics 
that are not onerous on the service providers that will allow 
VA to know what is going on at X, Y, and Z service delivery 
point.
    The biggest problem within the VA systemwide, and certainly 
with in the medical health care system, is what you measure and 
how do you measure it, and how well do you measure it? It is 
the quality assurance that is the primary failure of this 
system. To know where there are deficiencies, one, and two, 
holding people accountable at the supervisory and management 
level has been lacking, in our view, for a very long time and 
that is where we need to go with this system. To ensure that we 
are getting the bang for the buck, we have had over a third 
increase in the health care budget in the last 4 years. And the 
question is whether or not we are getting the bang for the 
buck. We are not convinced that we are yet, but it is certainly 
possible. But it is going to take a lot of oversight on a 
bipartisan basis but this Committee and we encourage you to do 
that. And this is one more step in that road.
    Mr. Embree. Mr. Chair, thank you for the question. 
Actually, this kind of ties into the VA outreach. Right now 
from the OIF and OEF era veterans, it is tough enough to get 
these folks into the VA system, for them to learn about the VA 
system. And to learn about the quality of VA health care. VA 
health care is very, very good. Unfortunately, when situations 
like this arise where it breaks down the trust, and it hurts 
the appearance of the VA health, then we need to fix that right 
away. And there needs to be strong oversight. And we need to 
restore confidence in this system. And that helps with the 
outreach to these young veterans that are now coming from the 
battlefields of Afghanistan and Iraq.
    So it is so important for programs like this to have strong 
oversight to instill confidence in the new veterans that are 
now trying to come into the system. Because we want to bring 
these new veterans into the system, but we want them to have 
confidence in the system that we are trying to convince them to 
enter.
    Mr. Michaud. Great. Once again, I want to thank each of you 
for your testimony this morning. I look forward to working with 
you as we move forward with the legislation that we heard this 
morning. And I am sure there will probably be additional 
questions that staff will submit to you in writing. So once 
again, thank you very much.
    I would like to ask the third panel to come forward. And 
while they are coming forward, the third panel includes Dr. 
Jesse, who is the Acting Principal Deputy Under Secretary for 
Health with the VHA. He is accompanied by Walter Hall, who is 
the Assistant General Counsel to the VA. I want to thank you 
both for coming this morning. And we will turn it over to Dr. 
Jesse.

STATEMENT OF ROBERT JESSE, M.D., PH.D., ACTING PRINCIPAL DEPUTY 
  UNDER SECRETARY FOR HEALTH, 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

    Dr. Jesse. Yes, good morning Mr. Chairman and Members of 
the Subcommittee. It is a pleasure to appear before you for the 
first time today as Acting Principal Deputy Under Secretary for 
Health. I am accompanied by Mr. Walter Hall, the Assistant 
General Counsel. We appreciate the opportunity to testify on 
five pending bills and offer VA's views.
    H.R. 4062, the ``Veterans' Health and Radiation Safety 
Act,'' would require VA to submit an annual report to Congress 
on low volume programs, require employees working at VA 
hospitals where radioactive isotopes are used to receive 
training in recognizing medical events, and require VA to 
provide frequent evaluations of nongovernment medical service 
contractors. While we appreciate the intent of H.R. 4062, there 
are a number of reasons why VA does not support it at this 
time.
    Mr. Chairman, we all acknowledge the lapses that occurred 
at a brachytherapy program at one of our facilities and as a 
result the Office of the Inspector General has issued a report 
with five recommendations. VA has taken specific actions to 
comply with all of these recommendations, which are detailed in 
my written statement. Consequently, we believe we have 
addressed most of Congress' concerns that are reflected in H.R. 
4062. We have other issues with the legislation that are 
specifically related to terminology, the scope of the 
legislation, and reporting requirements, and these are also 
expanded in my written testimony.
    VA would like to work with the Committee to better 
understand the intent of H.R. 4465, which would change the 
attributable income for the purposes of determining 
eligibility. On its face the bill benefits only a small 
population, namely those persons placed in the legal custody of 
a veteran as a result of a court order. Such persons would be 
considered children under more generous criteria than the 
veteran's natural children. If this differentiation was not 
Congress' intent, and it does not appear that it is, VA is 
ready to work with the Committee to develop a proposal that 
would achieve its objective.
    VA supports H.R. 4505, which would permit a State Home 
constructed with VA's resources to provide services to the 
parents of veterans if any of the parents' children died while 
serving in the armed forces. The legislation provides for fair 
and more equitable treatment of all parents whose son or 
daughter died while on active military duty. There are not 
additional costs to the VA for this.
    The first draft bill under consideration is the Improved VA 
Outreach Act of 2010. I am pleased to report that VA is already 
meeting the intent of the legislation. VA recently created a 
National Outreach Office in the Office of Public and 
Intergovernmental Affairs, which is responsible for ensuring 
the effective coordination of outreach activities across all VA 
sectors. In addition, VA has five advisory committees on 
homeless veterans, minority veterans, women veterans, 
readjustment, and rural health that provide outreach direction 
in their annual reports to the Secretary and to Congress. VA 
has already established a work group to better coordinate 
services between Indian Health Service and VA, and is working 
on a memorandum of agreement to improve that coordination.
    The final bill on the docket today is a draft bill that 
would expand eligibility for hearing aids to all veterans of 
active duty service in World War II, even if those veterans are 
not otherwise entitled to compensation under title 38 of the 
United States Code. We currently have authority to provide 
hearing aids to veterans with service-connected hearing loss as 
well as to veterans whose hearing loss is not service-connected 
but is so severe that it impedes their communication and 
participation in their medical care.
    While hearing loss can be frustrating and dangerous, 
especially for older adults, VA does not support the 
legislation as it would result in inequitable treatment of non-
World War II veterans with hearing loss. The legislation would 
also create special benefits for veterans needing hearing aids 
in relation to veterans needing other prosthetic appliances 
that are equally crucial to the veterans, well being and 
quality of life. The discretionary cost of this legislation 
would be approximately $14.8 million in the 1st year, $350 
million over 5 years, and $509.7 million over 10 years.
    This concludes my statement, Mr. Chairman. I would be 
pleased at this time to answer any questions you or other 
Members of the Subcommittee may have.
    [The prepared statement of Dr. Jesse appears on p. 38.]
    Mr. Michaud. Thank you very much, doctor. I have a question 
concerning the facts that you just stated, about all the 
veterans who are eligible for hearing aids. There are 
approximately 2.4 million World War II veterans who are 
service-connected. You mentioned even those that might not be 
service-connected still access hearing aids?
    Dr. Jesse. Yes, sir.
    Mr. Michaud. How did you come up with that outrageous 
number? The cost?
    Dr. Jesse. I would have to go back through the math of all 
that. But we can certainly get that to you for the record.
    Mr. Michaud. I would hope so, and I would hope that it is 
very explicit, because that math does not seem to add up. Once 
you exclude those veterans who are not service-connected, it 
just does not add up. There are currently, as I mentioned, I 
think 2.4 million World War II veterans. How many are non-
service-connected out of that amount? Do you know that number 
off the top of your head?
    Dr. Jesse. I do not know that number, no sir.
    [The VA subsequently provided the following information:]

        According to VA's latest official estimate of the veteran 
        population, VetPop2007, approximately 2.0 million World War II 
        Veterans were alive in September 2010. In FY 2010, 11 percent 
        (217,449) of World War II Veterans received disability 
        compensation benefits.

    Mr. Michaud. Because I think once we exclude those veterans 
who are non-service-connected, I think we can have a better 
idea. I believe a hearing aid costs approximately, $6,000? Or 
less? I am not sure of the exact number. But I question very 
much the fiscal note on this legislation.
    As another issue, one of the frustrations that I know a lot 
of us have, including the VSOs at both the national level and 
the State level, is the difficulty of trying to get veterans to 
sign up for VA health care. Part of it is due to some mistrust 
about the quality of service that veterans might receive when 
they go to the VA. I think the other part is, quite frankly, 
they do not know what they are eligible for. And it is 
confusing. To give you a good example from my neck of the 
woods; when Great Northern Paper Company filed bankruptcy and 
closed their doors, the drugs companies actually offered some 
programs within their respective companies on how the members 
or individuals could access prescription drugs at low or no 
cost. The problem was there were over 300-some odd programs 
between all of the drug companies. There were 11 or 12 pages of 
applications you would have to fill out. And if you are 
unemployed, you are not going to do that. However, with the 
efforts of Senator Snowe and myself, we were able to get the 
drug companies to narrow the applicaton down to four questions, 
and the computer system figured out which programs they were 
eligible for. That is manageable.
    There must be a way where VA can help educate or encourage 
veterans to participate in the VA. For instance, working with 
the IRS to simplify something that the IRS or social security 
can send out to taxpayers to see whether they qualify for VA 
benefits. I think between the IRS and social security you are 
going to be able to hit the bulk of the American population. 
And there has to be a way for VA to do more of that type of 
outreach. Have you thought about anything in that regard?
    Dr. Jesse. A couple of things. One of the major roles of 
the Office of Public and Intergovernmental Affairs was to 
really begin at the VA level to not just address this but to 
actually coordinate all of the other activities that are going 
on. I actually take to heart the comment about college alumni, 
and how they try and engage people earlier on. And I think that 
the real key to outreach is to start before they get discharged 
from the military, even to the point that they are enlisting, 
to understand that there are clear benefits that come along 
with this commitment to serve their country. And, at the time 
of separation from the service, to be much more robust in 
ensuring that the veterans understand their benefits. A lot of 
effort is going on now in coordinating this with the U.S. 
Department of Defense, including coordinating some of the 
discharge exams with the eligibility exams for VA, and the 
attempt to make sure that these are coordinated. This is the 
first impression many of these veterans will get of VA. And 
then those delays, any issues there, may actually turn people 
off. And we are spending a tremendous amount of energy to work 
in that regard as well.
    Mr. Michaud. Those are good efforts. I appreciate Secretary 
Shinseki's and Secretary Gates' efforts to work for those who 
are newly sworn in to the military. I think that those efforts 
are going to work. But we also have a huge amount who have 
already gone through the process. And we have to look at trying 
to get those individuals into the VA system. I think one area 
where we can have the biggest outreach impact on the American 
people is either through the IRS, social security, or through 
HHS for those who are on Medicare or Medicaid. I think there 
definitely has to be a real concerted effort to get individuals 
into the system. I can understand that there is some reluctance 
in doing that because ultimately that would mean that there 
would be more cost to the VA, and Congress would probably have 
to appropriate more funding to take care of those individuals. 
But that is what we are here for, to take care of the veterans.
    Dr. Jesse. Well, absolutely, sir. And it is really our 
explicitly stated goal that we want to be the health care 
system that they want to belong to, and we feel this is very 
important.
    Mr. Michaud. Thank you. Mr. Boozman.
    Mr. Boozman. Thank you, Mr. Chairman. In regard to H.R. 
4062, the IG came out I think with five things that they feel 
like needed to be implemented. I guess the question I would 
have, do you agree with those five? Do you have some concerns 
about them? If so, what? If not, how are we doing in regard to 
implementing the five things that they suggest?
    Dr. Jesse. Well actually, we agree with all five of those 
recommendations. We have been working diligently to get all 
those components in place and, you know, very much appreciate 
their input in identifying the problems and moving those 
forward. Most of these, I think, are well along the way. It 
will take some time to get all of these components in place. 
But we, you know, we agreed on the, Dr. Petzel, the Under 
Secretary, had agreed to their recommendations, and we are 
moving forward.
    Mr. Boozman. And so we do have a timeline that we are 
moving towards to get implementation?
    Dr. Jesse. Yes, in the sense that we have, you know, we do 
have a meeting with the NRC.
    Mr. Boozman. Kind of yes and no?
    Dr. Jesse. Well, have we set an exact date for this piece 
and this piece and this piece? The answer is no. But we----
    Mr. Boozman. This is something I think, Mr. Chair that we 
might ask you all to maybe come up with a timeline so that we 
can----
    Dr. Jesse. Certainly.
    Mr. Boozman [continuing]. Check in periodically as to what 
is happening in that regard.
    Dr. Jesse. We would be glad to do that.
    [The VA subsequently provided the following information:]

        The Department of Veterans Affairs (VA) Office of Inspector 
        General (OIG), in VA OIG Report 09-02815-143, published May 3, 
        2010, identified five recommendations to improve brachytherapy 
        treatment of prostate cancer at the Philadelphia VA Medical 
        Center and other VA Medical Centers.

        Recommendation 1:

             ``VHA's National Director of Radiation Oncology Programs 
        should have sufficient resources, to ensure that VHA provides 
        one high quality standard of care for the prostate 
        brachytherapy population. To achieve this end, VHA should 
        standardize, to a practical extent, the privileging, delivery 
        of care, and quality controls for the procedures required to 
        provide this treatment.''

        VA issued standard procedures for training, written directives 
        and clinical requirements in January 2009 and implemented them 
        in May 2009. All service chiefs, medical physicists, and 
        Radiation Safety Officers (RSO) in prostate brachytherapy 
        program completed mandatory training in January 2009. The 
        Veterans Health Administration (VHA) finished adapting 
        Radiation Oncology (RO) guidelines from the American College of 
        Radiology (ACR) in September 2009. On September 27, 2010, VA's 
        Radiologic Physics Center awarded a contract for medical 
        physics quality assurance. VA's National Health Physics Program 
        (NHPP) completed its annual inspections of seed implant 
        programs in August 2009, January 2010, and September 2010. The 
        inspections for all active programs in this annual cycle should 
        be complete by February 2011. VA continues to track and monitor 
        progress to ensure all RO programs are ACR inspected and 
        accredited; as of September 2010, 22 facilities have received 
        ACR site surveys, 10 of these facilities have received 
        accreditation, 8 facilities submitted ACR applications, and 6 
        of 22 facilities deferred pending corrective action plan 
        approval. By December 2010, VA will expand National Cancer 
        Institute Radiation Policy Council medical physics quality 
        assurance coverage to all RO programs, including an inspection 
        of linear accelerators every year and on-site peer review of 
        physics practice every 3 years.

        Recommendation 2:

             ``VHA should take the steps required to ensure that 
        patients who received low radiation doses in the course of 
        brachytherapy be evaluated to ensure that their cancer 
        treatment plan is appropriate.''

        VA reviewed all 114 brachytherapy cases and notified and 
        reevaluated under-dosed Veterans for possible additional 
        treatment by the Philadelphia VA Medical Center (VAMC). VA 
        referred 18 patients to the VA Puget Sound Health Care System 
        for the placement of additional seeds. VA referred patients to 
        Puget Sound if the patients had completed their brachytherapy 
        treatment within the past year of discovery and had been 
        considered to have been under-dosed. Eight Veterans were 
        identified as needing additional treatment, and these Veterans 
        received treatment consisting of a second procedure to boost 
        areas of low dose implantation at the Puget Sound facility. 
        Seven of the eight Veterans are being followed by the 
        Philadelphia VAMC, and the eighth is being followed by the Erie 
        VAMC. The remaining 10 Veterans did not have a second prostate 
        brachytherapy procedure as VA determined it was not necessary 
        or the Veteran refused this treatment. VA continues to provide 
        health care to these Veterans.

        Each Veteran is seen every 6 months for followup cancer care. 
        The Philadelphia VAMC's RO Service performs these evaluations, 
        and continues to provide ongoing evaluations for 5 years of 
        cancer-free survival, after which the primary care clinic 
        follows the Veteran at least annually for the lifetime of the 
        Veteran.

        Recommendation 3:

             ``VHA should review the controls that are in place to 
        ensure that VA contracts for health care comply with applicable 
        laws and regulations, and where necessary, make the required 
        changes in organization and/or process to bring this 
        contracting effort into compliance.''

        All VA facilities are required to ensure contractors comply 
        with applicable regulations and standard procedures. VA 
        established this requirement in standard procedures and 
        implemented it in May 2009. VA is revising VA Directive 1663, 
        ``Health Care Resources Contracting--Buying,'' based on section 
        8153 of title 38, United States Code, to clarify some areas of 
        the previous directive. The goal is to define the requirements 
        so that contracting officers will be able to comply in a timely 
        manner. Service Area Training Officers will be working with the 
        Contracting Officer's Technical Representatives (COTR) to 
        establish a more formal program and to develop specialized COTR 
        training by types of contracts. While the rewrite of VA 
        Directive 1663 is ongoing, all new contracts are consistently 
        being reviewed and all areas of concern are being addressed 
        prior to the solicitation to ensure the contracts are 
        technically sufficient. The National RO Program Office reviews 
        all solicitations for RO contracts before the contract begins. 
        Beginning in December 2010, standard language for RO contracts, 
        including quality assurance programs, will be posted on VHA's 
        Procurement and Logistics Office intranet Web site.

        VHA supports the Veterans Affairs Acquisition Academy (VAAA) in 
        implementing the newly developed Medical Sharing (1663) course. 
        This Academy will begin holding a Medical Sharing Training 
        Class in fiscal year (FY) 2011.

        Recommendation 4:

             ``Senior VA leadership should meet with Senior NRC 
        leadership to determine if there is a way forward that will 
        ensure the goals of both organizations are achieved.''

        VA's Under Secretary for Health and National Director for 
        Radiation Oncology met with the Nuclear Regulatory Commission 
        (NRC) Chairman and officials on June 8, 2010. VA's National 
        Director for Radiation Oncology presented VHA's position on the 
        proposed medical events rules at the NRC Commission Meeting on 
        Part 35, Proposed Rule on Medical Events Definitions, on July 
        8, 2010. The Commissioners disapproved the proposed rule and 
        have requested VHA and other stakeholders to assist in this 
        process. VA is working with a group of experts representing the 
        relevant professional societies to help NRC staff draft new 
        rules concerning medical events.

        Recommendation 5:

             ``VHA should work with the OIG to develop a list of 
        documents that should routinely be provided to the OIG when an 
        outside agency is notified of a (possible) untoward medical 
        event.''

        VHA has surveyed its program offices to compile a list of 
        events that are possibly reported to other agencies, and 
        discussions are ongoing in regard to coordinating the reporting 
        of incidents to OIG.

    Mr. Boozman. Are there provisions in the bill that go 
beyond the actions that you are currently taking?
    Dr. Jesse. The provision in the bill that goes beyond the 
actions we are currently taking, and the one that I think has 
the greatest concern to us, is one that is, I think maybe is a 
little bit lost in the definition. But there is a requirement 
that we review all medical services contracts weekly. We have 
looked, and that does not specifically refer just to nuclear 
medicine related contracts. So as we look at that, and not 
including contracts related to the Community-Based Outpatient 
Clinics, and other things along those lines, we currently have 
just under 1,000, I think 971 medical services contracts. If we 
review them weekly, that is 50,000 reports a year. Which I 
think would basically pull our people away from doing clinical 
work and we would be a reporting agency.
    Mr. Boozman. Okay.
    Dr. Jesse. So I think, you know, that piece is probably one 
of the greatest concerns. The other is the terminology related 
to training of all personnel in nuclear related, what are 
called reportable medical events. Currently, all personnel who 
work in nuclear medicine receive that training. And that is 
where that training needs to be. To say that we would have to 
train all medical center employees would be a huge burden, a 
huge cost, and probably not productive. Those are the main 
concerns we have.
    Mr. Boozman. And that would be different from the typical 
hospital setting? Or the typical setting in, out there in the 
private sector versus the----
    Dr. Jesse. Oh, the private sector? I think what we do is in 
line with what happens in the private sector, yes. It is the 
people who work in nuclear medicine and with these patients 
that are trained and recognize that.
    Mr. Boozman. Right. Very good. One more thing, H.R. 4505 is 
seeking to modify a regulation. Is that something that VA could 
look and do without----
    Dr. Jesse. Yes, sir. We have actually discussed that. We 
could change that through regulation----
    Mr. Boozman. And I guess my comment is would you be willing 
to look at it, and kind of come back and----
    Dr. Jesse. No, absolutely, we would be very glad to do 
that. The one, as I understand it, if we do it through 
regulation it will take about a year. If it is done through 
legislation it could be facilitated. But either way, we fully 
support this. We think this is a gap in current regulations.
    Mr. Boozman. Right.
    Dr. Jesse. We think it needs to be corrected, and our 
preference would be to correct it as expediently as possible.
    Mr. Boozman. Good. Well maybe you and us working with Mr. 
Thornberry can figure out what is the best way to pursue it.
    Dr. Jesse. We would be happy to.
    Mr. Boozman. Okay. Thank you, Mr. Chair.
    Mr. Michaud. Thank you very much, and I appreciate that. 
And having dealt with the VA, particularly on the nursing home 
issues, the length of time that it takes them to go through the 
regulatory process would be a concern. And I agree with 
Representative Thornberry that we should look to work with VA 
on this. But I think we ought to try to deal with that as soon 
as possible, and I know the regulatory process sometimes does 
not work that swiftly. And sometimes that outcome might not be 
what we want, either.
    Mr. Boozman. Will the gentleman yield? No, I agree. If we 
can get a statement from VA and a strong statement from the 
Committee, then perhaps we can go ahead and get that done.
    Mr. Michaud. Great. Thank you. I have no further questions. 
I want to thank you both for coming. I want to thank you both 
for your testimony. I look forward to working with you, and I 
am sure there will be some additional questions as we move 
forward with the two draft pieces of legislation and the three 
bills that we have before us today. Thank you for your 
continued service working with our veterans and your employees. 
We still have a ways to go. As you heard from the previous 
panel, there are some concerns with the perception of what VA 
is doing and not doing, and I look forward to working with you 
to make sure that we do have and improve on the system we 
currently have today. So once again, I want to thank both of 
you for coming today. If there are no further questions, I will 
close this hearing. Thank you.
    Dr. Jesse. Thank you, sir.
    [Whereupon, at 11:05 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 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 five bills before us today which address a number of 
important issues. First, we have a radiation safety bill that requires 
proper training of all employees at VA hospitals where radioisotopes 
are used to provide medical care. Next, we have a bill which requires 
the VA to consider children under the legal guardianship of a veteran 
when determining the veteran's co-payment amount for medical treatment. 
We also have a bill which would allow gold star parents access to the 
state veterans homes if they had any child who died while serving in 
the Armed Forces. Finally, we have draft legislations on improving the 
VA's outreach to veterans and the provision of hearing aids to World 
War II veterans.
    I look forward to hearing the views of our witnesses on the bills 
before us today.

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

    Thank you, Mr. Chairman, and thank you for holding this legislative 
hearing.
    I am pleased to be here and eagerly anticipate consideration of the 
five bills before us that cover a variety of issues regarding our 
veterans.
    I want to thank all of the Members who have sponsored these bills 
and taken the time to participate in our hearing today.
    I am particularly interested in hearing about H.R. 4505, which was 
introduced by my friend and colleague from Texas, Mac Thornberry.
    In order to receive VA per diem payments, a State Veterans Home 
must maintain an occupancy rate of 75 percent veterans. However, 
veteran spouses or parents who have lost all of their children due to 
military service are also eligible for admission, if allowed by State 
policy. H.R. 4505 would permit a State Home to also provide services to 
a parent if one of their children died while serving in the Armed 
Forces.
    When we honor the bravery and service of our military members and 
veterans, we must also honor the sacrifice and selflessness of their 
families. And, I do not think the loss of a child--whether one or 
many--can be differentiated. I thank Mac for introducing this 
legislation.
    As we continually attempt to improve services and increase the 
well-being of our veterans, it is vital that we continue to work 
together and have candid discussions about the best ways to improve 
services and move forward with legislation to benefit our veterans. 
And, I look forward to hearing more about all of the bills on our 
calendar this morning.
    I want to thank our witnesses for being here and in the interest of 
moving forward with our discussion, I yield back the balance of my 
time.

                                 
     Prepared Statement of Hon. Larry Kissell, a Representative in
               Congress from the State of North Carolina

    Chairman Michaud and Ranking Member Brown, thank you for your 
invitation to this hearing and allowing me to share with you the 
importance of H.R. 4465. As I am sure all Congressional members 
experience in their various states and districts, our constituents' 
concerns come in a wide range of shapes and sizes. Some of these 
concerns require major legislation to address the issues, while others 
may require incremental changes to bring relief to those hurting the 
most.
    As our Nation's socio-economic dynamic changes, we as a Congress 
must ensure we address the emerging needs of our veterans. This 
Committee does an outstanding job of identifying needs and providing 
legislation to honor those who served our Nation. Today I present to 
you H.R. 4465. This bill provides assistance to the growing number of 
veterans who are accepting custody of additional dependents.
    H.R. 4465 acknowledges the efforts of veterans who accept legal 
custody of a child that is not their own. This bill amends the current 
law so that the VA considers children placed in the legal custody of a 
veteran as dependents when determining if a veteran must pay a co-
payment for medical treatment. Although not all veterans are required 
to pay co-payments, those that do receive additional consideration 
based on their household income and number of dependents. Dependent 
children are defined as biological, adopted, and step-children. The 
current law does not address veterans who voluntarily assume the 
parenting role for a child and receive full custody from the courts.
    I am not sure of the number of veterans that are accepting these 
roles. When CBO scored the bill they reported only a few veterans would 
be affected and the bill would have an insignificant effect on spending 
pending appropriations. I became aware of the problem after Robert and 
Miriam Preiser approached me. The Preisers have been married for 13 
years. Robert is 70 and Miriam is 79 years old. Between the two of them 
they have 10 children, 24 grandchildren, and 17 great-grandchildren. 
They are on a fixed income. Because of his 2 year tour in the Army 
about 60 years ago, Robert receives a great deal of his care through 
the Veterans Administration.
    About 5 years ago a number of unfortunate events resulted in Child 
Protective Services assuming custody of two of the Preiser's great 
grandchildren, a 5 year old boy and a 2.5 month old girl. I will not go 
into the details of the case, but ultimately CPS determined the parents 
were not fit to raise the children. The Preisers immediately stepped in 
and volunteered to become the children's guardian. After about a year 
of court proceedings, the courts granted the Preisers full custody.
    The Internal Revenue Services, the courts, the local school 
district, Child Protective Services, and other state and federal 
entities consider the children as dependents. The IRS allows the 
Preisers to claim the children as dependents due to the court documents 
they possess. If you choose to proceed with this bill and it eventually 
passes, it will ensure that the VA considers children in the legal 
custody of a veteran are considered as dependents when determining if 
the veteran must pay a co-payment for medical treatment.

                                 
     Prepared Statement of Hon. Mac Thornberry, a Representative in
                    Congress from the State of Texas

    I appreciate the opportunity to testify before the Subcommittee 
today on H.R. 4505.
    There are 137 State Veterans Homes located in all 50 States and in 
Puerto Rico that provide hospital and skilled nursing care to 
approximately 28,500 veterans and dependents. State Veterans Homes are 
institutions that many of our veterans and their dependents have relied 
upon for nearly 150 years.
    Gold Star Parents are parents who have lost a son or daughter who 
died while serving our country in the military. However, to be eligible 
for admission to a State Veterans' Home, a Gold Star Parent must have 
lost all of his or her children while in military service. State 
Veterans' Homes must deny admission to a Gold Star Parent if they have 
any surviving children.
    H.R. 4505 would allow State Veterans Homes to admit the parents of 
service-members who died while serving our Nation to VA Nursing Homes. 
My legislation would permit admission into a State Veterans' Home to 
any parent who lost at least one son or daughter while serving our 
Nation to protect our freedoms and way of life.
    Those we ask to fight and die in our wars should have the assurance 
that their families will be cared for by their country.
    Losing a child to war is a stunning and life altering event, which 
is why I am pushing for this bipartisan legislation to become law in 
the coming weeks.
    Additionally, the financial impact to the Federal Government will 
be minimal, since the VA does not pay a per diem to state homes for 
Gold Star Parents. In our conversations with state officials, they 
expect that the impact to state budgets would be minimal as well.
    The Consolidated Appropriations Act of 2010 required the VA to 
conduct a feasibility study to identify the potential impact of 
providing State Veterans' Home care to Gold Star Parents. The VA 
determined that such feasibility study would be useless because there 
would be no additional cost to the VA by providing this service.
    The bill is supported by the American Legion and the National 
Association of State Veterans Homes, and I know of no opposition.
    In closing, I appreciate your consideration of this bill and ask 
for your support to ensure that Gold Star Parents are able to receive 
the support they need. I look forward to answering any questions you 
might have about my bill.
    Again, thank you for holding this hearing and allowing me to 
testify.

                               __________
                  Department of Veterans Affairs (VA)
                 Report to Congress on State Home Care

    Issue: The Joint Explanatory Statement accompanying Public Law 111-
117, Transportation, Housing and Urban Development and Related Agencies 
Appropriation Act, 2010, urges the Department to undertake a 
feasibility study to identify any potential impacts of permitting State 
Home Care facilities to provide services to non-Veterans who have had a 
child die while serving in the Armed Forces, as long as such services 
are not denied to a qualified Veteran seeking those services. The 
Department is directed to report back to the Committees on 
Appropriations of both Houses of Congress within 90 days of enactment 
of this Act on what steps, if any, have been taken to undertake the 
feasibility study and any findings, should the study be completed.
Background Information:
    General eligibility requirements for admission to a State Veterans 
Home: Veterans in need of skilled nursing care and who have a general 
honorable military discharge are given admission priority. Spouses, 
surviving spouses, and Gold Star parents in need of skilled nursing 
care are also eligible for admission, if allowed by state policy. VA is 
prohibited by law from exercising any supervision or control over the 
operation of a State Veterans Home, including setting admission 
criteria. Admission requirements are determined exclusively by the 
state. The states also establish and manage operating procedures, 
personnel practices, and other operational matters.
Discussion:
      VA Medical Centers of jurisdiction and State Veteran 
Homes must comply with the 75 percent Veteran residency rule (title 38 
U.S.C. 8131-8137), i.e., State Homes are required to maintain an 
occupancy rate of 75 percent Veterans to be eligible for VA per diem 
payments.
      Admission requirements for State Veterans Homes are 
determined exclusively by the state.
      Current authority does not allow VA per diem payments for 
services provided in a State Veterans Home to Gold Star parents or any 
other non-Veteran residents.
      The Veterans Health Administration believes it is 
feasible to permit State Home Care facilities to provide services to 
non-Veterans who have had a child die while serving in the Armed 
Forces, as long as such services are not denied to qualified Veterans 
seeking those services. Legislative authority would need to be enacted.
      There would likely be some financial impact on the states 
to support non-Veterans in State Veterans Homes.
Recommendation:
    A feasibility study is not required because there would be no 
additional cost to VA by permitting State Home Care facilities to 
provide services to non-Veterans who have had a child die while serving 
in the Armed Forces.

Veterans Health Administration
April 2010

                               __________
                                                The American Legion
                                                    Washington, DC.
                                                   January 26, 2010
Honorable Mac Thornberry
U.S. House of Representatives
2209 Rayburn House Office Building
Washington, DC 20515-4313

    The American Legion fully supports your proposed legislation to 
enable State Veterans' Homes to furnish nursing home care to parents 
any of whose children died while serving in the Armed Forces of the 
United States. Such parents are respectfully referred to as Gold Star 
parents.
    Currently, Gold Star parents may receive care in a State Veterans' 
Home only if they have lost all of their children in service to the 
country. The loss of a single servicemember brings much grief and 
sadness to a grateful nation. The American Legion believes this benefit 
was granted with good intention, but unrealistic expectations of 
personal sacrifice. As a nation at war, to maintain such a standard for 
an earned benefit is unacceptable. The pain of loss for parents of an 
only child is just as unbearable as the loss for parents with more than 
one child.
    Thank you Representative Thornberry for offering legislation that 
would extend the heartfelt gratitude of a grieving nation to parents of 
a fallen hero. The American Legion fully supports your proposed 
legislation to address this injustice. The American Legion appreciates 
your continued leadership in addressing the issues that are important 
to veterans, members of the Armed Forces, and their families.

            Sincerely,

                                                    Steve Robertson
                          Director, National Legislative Commission

                               __________
                                          Texas General Land Office
                                                        Austin, TX.
                                                   January 26, 2010
Honorable Mac Thornberry
U.S. House of Representatives, District 13
2209 Rayburn House Office Building
Washington, D.C. 20515-4313

Dear Congressman Thornberry:

    I am writing you to express my complete support of S.1450, a bill 
to allow the parents of service-members who died while serving the 
Nation access to VA Nursing Homes. Currently, an individual is allowed 
admission into a State Veterans Home if the individual is an eligible 
veteran, the spouse of an eligible veteran, or a Gold Star parent. The 
problem that arises is the way the term ``Gold Star parent'' is 
currently defined in the Code of Federal Regulations (CFR) administered 
by the VA. According to the CFR, Gold Star parents are eligible for 
admission to State VA Nursing Homes if they have lost all of their 
children who were serving our country on active duty military service. 
This legislation would rectify this and permit admission into a State 
VA Nursing Home to any parent that lost at least one son or daughter, 
while fighting to protect our freedoms and way of life.
    As chairman of the Texas Veterans Land Board, I oversee our Texas 
State Veteran Nursing Home program where we provide skilled nursing 
care to over 1,000 Texas veterans and their family members in one of 
our seven facilities. As most people are aware, State Veterans Homes 
were founded for wounded and homeless veterans following the American 
Civil War and have become institutions that many of our veterans and 
their dependents have come to rely on for nearly 150 years. Currently 
there are 137 State Veterans Homes located in all 50 States and in 
Puerto Rico that on a daily basis provide hospital, skilled nursing, 
rehabilitation, long-term, dementia and Alzheimer's, domiciliary, 
respite, end of life, and adult day health care, to approximately 
28,500 veterans and dependents.
    I believe that it is only fair that the parents who lost a son or 
daughter in military service have access to these first class 
facilities. This legislation is strongly supported by the National 
Association of State Veterans Homes.
    Please join me in supporting our parents who have given more than 
we as a nation could ever ask of them by changing the definition of a 
Gold Star Parent.
    If you have any additional questions, please contact my federal 
liaison Jim Darwin at 512-463-2623 or email at 
[email protected].

            Sincerely,

                                      JERRY PATTERSON, Commissioner
                                          Texas General Land Office
                               __________
              National Association of State Veterans Homes
                           RESOLUTION 2010-2
          SUPPORT FOR ADMISSION TO STATE VETERANS HOMES OF ANY
        PARENT WHOSE CHILD PERISHED WHILE SERVING ON ACTIVE DUTY
                IN THE ARMED FORCES OF THE UNITED STATES

    WHEREAS, State Veterans Homes were founded for soldiers and sailors 
following the American Civil War, and have ably served veterans and 
some of their immediate dependents and survivors for nearly 150 years; 
and
    WHEREAS, currently there are 140 State Veterans Homes in all States 
and in Puerto Rico, on a daily basis providing hospital, skilled 
nursing, skilled rehabilitation, long-term care, dementia and 
Alzheimer's care, domiciliary care, respite care, end of life care, and 
Adult Day Health Care to 28,500 veterans and dependents; and
    WHEREAS, Title 38, United States Code, authorizes State Veterans 
Homes to care for non-veteran residents, but only to the extent that 
non-veteran residents constitute no more than twenty-five percent of 
bed capacity at Such State Veterans Homes; and
    WHEREAS, Title 38, Code of Federal Regulations, defines eligible 
non-veteran residents of State Veterans Homes as immediate dependents 
and survivors of veterans with antecedent residence in State Veterans 
Homes, and parents, all of whose children died while serving in active 
military service to the United States; and
    WHEREAS, recognizing the contemporary trend of the all-volunteer 
military force, the wide array of career paths available to American 
citizens, and modern asymmetrical wars and military conflicts that 
require both periodic and episodic deployments to combat engagements 
throughout the world, a post-World War II policy that requires all of a 
parent's children to have perished in war as a precondition of eligible 
residence of a parent in a State Veterans Home under Title 38, United 
States Code, as interpreted in its Code of Federal Regulations, is 
unwarranted and exhibits an exclusionary intent toward parents who have 
suffered irreparable loss of a child, or children, who served their 
Nation in uniform.
    NOW, THEREFORE, BE IT RESOLVED, that the National Association of 
State Veterans Homes (NASVH) supports an amendment to Title 38, Code of 
Federal Regulations, or in absence of such revision, amendment to Title 
38, United States Code, to authorize admission to State Veterans Homes 
of any parent whose child perished in active military service to the 
United States; and fully supports the legislative objectives of the 
National Association of State Veterans Homes (NASVH) to receive from VA 
a per diem payment that equals 50 percent of the national average cost 
of providing care in a State Veterans Home.


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

------------------------------------------------------------------------
                                 Adopted
------------------------------------------------------------------------
                                 With Change
------------------------------------------------------------------------
                                 Rejected
------------------------------------------------------------------------


                                        COLLEEN RUNDELL, M.S., LNHA
                                                          President
                       National Association of State Veterans Homes

                                   Dated this __ day of _____, 2010

                                 
       Prepared Statement of Hon. John Adler, a Representative in
                  Congress from the State of New Jersey
    I would like to thank Chairman Michaud, Ranking Member Brown, and 
Members of the Subcommittee for the opportunity to testify on behalf of 
H.R. 4062, the Veterans' Health and Radiation Safety Act. This 
Subcommittee has been integral in ensuring that the health care needs 
of our veterans are being met. I commend you on your leadership.
    The need for H.R. 4062 came from a very serious matter that 
occurred at the Philadelphia Veterans Affairs Medical Center. Starting 
in 2003, the brachytherapy program at the Philadelphia VA Medical 
Center was operated by a rogue doctor who botched approximately 86 
percent of the prostate cancer treatment procedures he was contracted 
to perform on our veterans. These multiple failures, which went 
undetected year after year, highlighted significant problems in the 
VA's oversight system. The VA failed until 2008 to catch this pattern 
of failure.
    Upon learning of these glaring oversights, I became outraged that 
the brave men who so selflessly served our country had been subjected 
to such poor treatment and were neglected by a hospital and system 
created to protect them.
    H.R. 4062, the Veterans' Health and Radiation Safety Act is a 
comprehensive piece of legislation that seeks to remedy many of the 
mistakes that led to the problems surrounding the brachytherapy program 
at the Philadelphia VA Medical Center.
    This bill has three major components centered on increasing 
oversight and ensuring reform throughout the VA Health Care System.
    First, my bill mandates that the VA conduct an evaluation of all of 
the low-volume programs that are currently operating in its medical 
facilities to ensure that they are meeting their safety standards. The 
brachytherapy program at the Philadelphia VA Medical Center was not 
subjected to independent peer review due to the fact that it was such a 
low volume program, serving only 116 patients over a 6-year period. 
Because of this lack of oversight, errors that should have been caught 
and rectified were allowed to continue for 6 years unnoticed.
    Second, H.R. 4062 requires that every VA employee and independent 
contractor working in a VA medical facility be trained in what 
constitutes a ``medical event,'' as that term is defined by the Nuclear 
Regulatory Commission, as well as when such an event should be reported 
and to whom. The bill also provides that if a VA hospital has failed to 
administer such training, the use of radioactive isotopes at that VA 
medical facility may be suspended by the Secretary.
    Over the course of the 6-year period in which the brachytherapy 
program at the Philadelphia VA was in operation, 86 percent of the 
patients were subjected to ``reportable medical events.'' However, 
because many of the medical personnel in the program, including the 
independent contractors, were not trained in what constitutes a 
``medical event,'' as that term is defined by the NRC, or to whom such 
an event should be reported, these errors were allowed to continue and 
our veterans remained susceptible to substandard medical care for far 
too long.
    Lastly, my bill requires the Secretary to evaluate all medical 
services provided pursuant to a contract with a non-government entity. 
Such evaluations shall include independent peer reviews of such medical 
services and written evaluations of an independent contractor's 
performance by that contractor's supervisor. The bill also states that 
before a contract for medical services can be renewed, the above 
evaluations must be conducted.
    One of the biggest problems that occurred at the Philadelphia VA 
was the lack of oversight and supervision VA officials had over the 
independent contractors they contracted with to provide medical 
services in their brachytherapy department. What is particularly 
troubling is that these contracts were re-upped every 3 to 6 months 
with little to no scrutiny as to the performance of the independent 
contractors. It is my hope that this provision in the bill will 
increase oversight throughout the VA Health care system.
    The veterans who sought treatment for prostate cancer at the 
Philadelphia VA Hospital did not receive the quality health care their 
selfless service to our country earned them. Such mistreatment of our 
veterans is not only unacceptable; it violates the bond our country 
made with them when they agreed to fight for the safety and security of 
this Nation. It is my hope that H.R. 4062 will help ensure that the 
failures that occurred at the Philadelphia VA Medical Center will never 
happen again within the VA.
    I would again like to thank Chairman Michaud, Ranking Member Brown, 
and Members of the Subcommittee for allowing me the time to testify on 
this important matter. I would be happy to answer any questions you 
might have.

                                 
 Prepared Statement of Barry A. Searle, Director, Veterans Affairs and 
               Rehabilitation Commission, American Legion

    Mr. Chairman, Ranking Member and Members of the Subcommittee:
    Thank you for the opportunity to present the views of The American 
Legion on H.R. 4062: The Veterans' Health and Radiation Safety Act; 
H.R. 4505: Expansion of State Home Care for Parents of Veterans Who 
Died While Serving in the Armed Forces; H.R. 4465: Determination of 
Attributable Income for Veterans with Children; and two pieces of 
proposed legislation: ``Improve VA Outreach Act of 2010'' and ``The 
World War II Hearing Aid Treatment Act''.
H.R. 4062--Veterans' Health and Radiation Safety Act
    This legislation would require the Secretary of Veterans Affairs to 
report annually to Congress on the low-volume (treating 100 patients or 
less) programs at each VA medical facility. It would further direct the 
Secretary to ensure that all employees at a VA hospital where 
radioactive isotopes are used in the administration of medical services 
receive appropriate training on what constitutes a medical event and 
when and to whom a medical event should be reported. It would prohibit 
such isotopes from being used at a VA hospital where such training is 
not provided. Finally, H.R. 4062 would require the Secretary to carry 
out specified evaluations and peer reviews of all medical services 
provided under contract with a non-government entity.
    The American Legion's ``System Worth Saving'' Task Force annually 
conducts site visits at VA Medical Centers nationwide to assess the 
quality and timeliness of VA health care. In preparing for these 
visits, The American Legion team researches Government Accountability 
Office (GAO) reports, VA's Office of Inspector General (VAOIG) reports, 
and news articles relating to potential breakdowns in a system that we 
consider, ``The Best Care Anywhere.''
    During The American Legion ``System Worth Saving'' Task Force 
visits, and in our research, we have found that turnover of personnel 
and the shortage of personnel at most facilities require renewed 
emphasis on standardized procedures, quality review and individual 
training, as well as documentation of that training. Further, The 
American Legion believes that VA must maintain proper oversight of 
medical care, utilization of facilities and resources in order to 
ensure veterans receive the highest quality of care.
    In a May 2010, VAOIG report concerning the review of Brachytherapy 
Treatment of Prostate Cancer at Philadelphia, PA and other VA Medical 
Centers, a recommendation was made for VHA to ``standardize to a 
practical extent, the privileging, delivery of care, and quality 
controls for the procedures required to provide treatment.'' As 
technologies continue to change and treatments and procedures continue 
to develop, it is critical that VA staff delivering care be properly 
trained and are accountable. H.R. 4062, ``Veterans' Health and 
Radiation Safety Act,'' continues and enhances protections for veterans 
through required reporting, training, and evaluation of services 
provided by Veterans' Health Administration (VHA). The American Legion 
supports not only the specified training and the accountability 
highlighted in H.R. 4062, but also the standardization of all patient 
care delivered across the VHA system.

    The American Legion supports H.R. 4062.

H.R. 4505--Expansion of State Home Care for Parents of Veterans Who 
        Died While Serving in the Armed Forces
    This legislation would authorize the Secretary of Veterans Affairs 
to permit a state home to provide VA nursing home care to parents who 
suffered the loss of a child who died while serving in the Armed 
Forces.
    The American Legion is well known for its long history of 
advocating on behalf of veterans and their families. We believe firmly 
that a commitment is made not only by the servicemembers who raise 
their hand in service to this country, but also their family members 
who must say good bye to their loved ones who head into combat to 
protect the freedoms of this Nation. President Lincoln, during his 
Second Inaugural Address made the statement that would later become the 
mission of VA, ``To care for him who shall have borne the battle and 
for his widow, and his orphan.'' The American Legion strongly believes 
that when a servicemember is killed in the line of duty and a dependent 
parent is deemed medically eligible for nursing home admission, that 
parent be entitled to VA nursing home care. Currently, Title 38 Code of 
Federal Regulations (CFR) imposes too high a threshold of suffering on 
surviving parents when it requires that all children must have died 
while serving on active duty. H.R. 4505 amends section 51.210(d) of 
Title 38, CFR, to provide services to ``a non-veteran any of whose 
children died while serving in the Armed Forces.''
    The American Legion at its 2009 Convention approved a resolution 
which recommends amending section 51.210(d) Title 38, CFR, ``To 
authorize admission to State Veterans Homes the parents of any 
servicemember who perished while on active military service to the 
United States.''
    Additionally, in January 2010, The American Legion sent letters to 
Members of Congress to express full support of this legislation. The 
American Legion believes the original intent and wording of section 
51.210(d) of Title 38, CFR, was granted with good intention. But 
unrealistic expectations of personal sacrifice exist when requiring 
that all children of a parent must die in the service to this Nation in 
order to qualify for admission to a nursing home.

    The American Legion supports H.R. 4505.

H.R. 4465--Determination of Attributable Income for Veterans with 
        Children
    This legislation would direct the VA Secretary, when examining a 
veteran's attributable income for purposes of determining whether a 
veteran is unable to defray the necessary expenses of hospital, nursing 
home, and domiciliary care, to treat as a dependent child of such 
veteran any unmarried person who:

    1.  Is placed in the legal custody of the veteran for at least 12 
consecutive months;
    2.  Either has not attained age 21, has not attained age 23 and is 
enrolled in a full-time course of study at an institution of higher 
learning, or is incapable of self-support due to mental or physical 
incapacity;
    3.  Is dependent on the veteran for over one-half of the person's 
support; or
    4.  Resides with the veteran, unless separated to receive 
institutional care.

    The American Legion believes a pension is an earned and defined 
benefit for a veteran through their honorable service to the Nation. We 
do not believe that pension should be reduced or offset based upon 
other income earned by the dependent children of a veteran.

    The American Legion supports H.R. 4465.

Proposed Draft Legislation--``World War II Hearing Aid Treatment Act''
    The American Legion recently adopted a resolution acknowledging 
current advancements in scientific research to review prior and new 
potential environmental threats to servicemembers. It was resolved 
that, ``The American Legion's comprehensive policy on environmental 
exposures be an all inclusive policy and vigorously support the 
liberalization of the rules relating to the evaluation of studies 
involving exposure to any environmental hazard.''
    It is understood that past acceptable norms of environmental 
exposure for noise, for example weapon's qualification in basic 
training conducted without proper hearing protection, have been found 
to be unacceptable in today's environment. These instances could lead 
to the possibility of a service connection for hearing loss if claimed. 
Also, especially in the case of WWII veterans the ``state of the art'' 
for working environmental protection of servicemembers had not evolved 
to the current levels. The fact of service and exposure to these 
environmental exposures would imply the potential for hearing loss.
    Furthermore, the only measure of assessing hearing loss on 
separation from service in this era was the so-called ``Whisper Test,'' 
which has been found insufficient to measure actual hearing loss by 
both medical experts and the courts. As VA's procedures for 
adjudication of benefits claims rely heavily on the status of hearing 
at separation, these inadequate exams unfairly prejudice the system 
against the veterans who clearly suffered traumatic noise exposure 
during their service. The fact that hearing loss can have a gradual 
onset and is not always immediately detectable after traumatic noise 
further contributes to the difficulties that veterans of earlier eras 
face in becoming service connected for their loss.
    The bill could potentially save VA development time related to 
determining the etiology of hearing loss conditions and could alleviate 
some of the workload contributing to the claims backlog.

    The American Legion supports this proposed legislation to furnish 
WWII veterans with hearing devices.

    We would further submit for this Subcommittee's consideration the 
fact that environmental noise exposure issues that this proposed 
legislation is attempting to address were in existence through the 
Vietnam War and that it was not until relatively recently that 
significant efforts were made to protect the hearing of servicemembers. 
Therefore, The American Legion recommends this Subcommittee consider 
expanding the bill to cover veterans from the Korean and Vietnam War 
eras also.
                  ``Improve VA Outreach Act of 2010''
    In May 2008, The American Legion testified concerning improvements 
VA could make to improve outreach to veterans. VA had made progress at 
that time and continues to make progress to improve its outreach 
program to veterans. Currently, in the case of the Veterans' Benefits 
Administration (VBA), efforts have been made to inform and involve 
Veterans' Service Organizations (VSOs) in finding solutions to improve 
the claims process. VSOs, in turn, advise veterans on efforts made by 
VA to assist them. This partnership between VA and VSO's in informing 
veterans is critical to the success of VA's outreach program.
    However, while VA has made improvements in outreach significant 
issues remain and there is much work to be done. Earlier this month, 
The American Legion testified that VA continues to struggle with 
informing veterans of entitlements. The joint efforts of the Department 
of Defense (DoD) and VA to assist transitioning servicemembers through 
the Benefits Delivery at Discharge (BDD) program and the Transition 
Assistance Program (TAP) briefings are laudable. Progress is being 
made, but outreach efforts vary both in quality and effectiveness. In 
particular, Reserve component members released from active duty 
mobilizations are often rubber stamped and returned to their home 
station with little or no understanding of what entitlements they have 
earned due to their honorable service.
    The American Legion understands that policies developed at VA 
Central Office, with the best of intentions, are for the most part 
executed at the discretion of the Regional Office Director or the 
Veterans Integrated Service Network (VISN) Director; and therefore, 
vary in local implementation. For example, VA has a veteran employment 
hiring program policy to recruit veterans, as outlined in Secretary 
Shinseki's Memorandum dated 21, October 2009. However, The American 
Legion has seen a wide variation in hiring of veterans at the Regional 
Office level. The variation ranges from about 25 percent to 79 percent 
depending on the Regional Office. We feel that this is due to the 
discretion given to the Regional Office Director in interpreting the 
policy. It further depends on that individual's emphasis on hiring 
veterans. We do not believe that there is a substantial difference in 
qualified veterans in one area as compared to another. The American 
Legion feels that a greater amount of accountability for success in 
outreach to veterans to identify opportunities for employment should be 
required for the subordinate offices in VA.
    Many veterans are moving to rural and extremely rural areas. 
Nevertheless, these veterans have earned the right to receive 
information and updates on changes that impact their earned benefits. 
While VA has made efforts to become more ``user friendly'' we continue 
to hear, especially from older veterans and those in rural areas, that 
the system and required documentation is still too complicated.
    The American Legion urges strong improvements to outreach. In 
addition to upgrading our Web site www.legion.org to make it more user 
friendly, The American Legion Magazine and the Web site have regular 
updates on such issues as the new Post-9/11 GI Bill and recent changes 
to veterans' entitlements. Additionally, The American Legion's 
Veterans' Affairs and Rehabilitation Commission publishes periodic 
``Bulletins'' based on VA information, which are utilized by the 
Department (State) Service Officers to further assist with VA's 
outreach to veterans. As a recent example, a ``Bulletin'' was 
distributed after receiving a request for information from VA 
concerning ``brown water Navy veterans'' concerning vessels that were 
in inland waters of Vietnam and whose crews may be impacted by Agent 
Orange.
    The American Legion is also assisting VA to improve its outreach to 
Priority Group 8 veterans. This endeavor is focused on advising 
veterans of new regulations that allow VA to enroll certain Priority 
Group 8 veterans who have been previously denied enrollment in the VA 
health care system because their income exceeded VA's income 
thresholds.
    These successful partnerships between VA and VSOs continue to 
benefit the veteran population. This demonstrates that extended VA 
outreach has an immediate impact on the lives of veterans, and VA must 
not lag behind in the modernization and scope of their own outreach to 
veterans.
    The establishment of a VA Advisory Committee on Outreach as 
proposed in the draft legislation, with representation from members of 
the VSO community reporting to the VA Secretary, will enhance VA's 
outreach program and ultimately better serve America's veterans. 
Requiring an analysis of the recommendations of the Advisory Committee, 
as part of the strategic plan submitted to Congress, will enhance the 
value of these recommendations.

    The American Legion supports all reasonable efforts toward 
improving outreach to veterans and The Improved VA Outreach Act of 
2010, in particular.

    As always, The American Legion thanks this Subcommittee for the 
opportunity to testify and represent the position of the over 2.5 
million veteran members of this organization and their families. This 
concludes my testimony.

                                 
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.
H.R. 4062, Veterans' Health and Radiation Safety Act
    VFW supports legislation that would amend Title 38, United States 
Code, to make certain improvements in the administration of medical 
facilities within the Department of Veterans Affairs.
    Section II mandates that VA conduct annual reporting to Congress on 
low volume programs, treating less than 100 patients a year. Section 
III demands adequate training for employees and contractors on 
appropriate reporting of medical services and programs where the use of 
radioactive isotopes is present. Section IV requires all contractors 
and contracting offices to adhere to rigorous guidelines when using 
this method of health care treatment.
    The use of radioisotopes at VA hospitals has increased the levels 
of risk to patients who undergo these potentially life-saving 
treatments and tests. Diagnostic techniques in nuclear medicine allow a 
non-invasive method of detecting and evaluating most cancers. Further, 
some cancerous growths can be controlled or eliminated by irradiating 
the detected growth.
    VFW asks Congress and VA to strongly demonstrate that safety and 
training are provided to all employees, contractors, and non-government 
entities who are employed at VA where radioactive isotopes are used. We 
believe this bill is the correct step toward this goal.
H.R. 4465, to amend Title 38, United States Code, to direct the 
        Secretary of VA to take into account dependent children when 
        determining the veteran's financial status when receiving 
        hospital care or medical services
    The VFW supports this legislation to allow certain dependents to be 
counted in determining earnings thresholds for the purpose of seeking 
benefits and services at VA.
    This legislation requires VA to recognize children placed in the 
legal custody of the veteran as a result of a court order. Under the 
bill, in order for the child to be counted as eligible, they must be in 
the custody of the veteran for at least 12 consecutive months, require 
support at least 50 percent of the time, and/or be under the age of 21 
(or 23 if enrolled as a full-time student). Currently, children placed 
in the legal custody of a veteran are not counted for the purposes of 
health care categories or qualification for pension or benefits. VFW 
believes H.R. 4465 will correct that inequity and passing it is the 
right thing to do.
H.R. 4505, to enable State homes to furnish nursing home care to 
        parents, whose children died while serving in the Armed Forces
    VFW supports this legislation, which would authorize state-run 
nursing homes to accept the surviving parents of a child who died while 
serving in the armed services. The VFW believes the care of all Gold 
Star parents is a sacred trust and this bill would provide a critical 
benefit at a time when they may need long-term care. We ask Congress to 
enact this legislation quickly.
Draft Bill, World War II Hearing Aid Treatment Act
    VFW admires the goal of this legislation but cannot support it as 
written. Millions of Americans participated in combat where nearly 
300,000 were killed and 671,000 were wounded. Almost everything about 
modern warfare involves loud, often incredibly loud, noise. Acoustic 
trauma is a major cause of hearing loss. Those who fought in the island 
campaigns of the Pacific, North Africa, Normandy, the Battle of the 
Bulge to the River Elbe, or flew through the flak and fighter filled 
skies of France and Germany were exposed to incredible amounts of 
hearing damaging noise. However, their experiences in training for and 
fighting a war are, in terms of noise exposure, virtually identical to 
their younger brothers and sisters who trained and fought in every 
other war from Korea to Vietnam to the current conflicts in the Middle 
East.
    We cannot support this legislation because the only factual 
difference between their exposure to noise and that of all veterans is 
that they are older. We believe the bill is inequitable as it 
discriminates against other veterans based on age. We would be happy to 
work with the Committee on clarifying hearing aid benefits for all 
veterans.
Draft Bill, Improved VA Outreach Act of 2010
    The VFW supports the Improved VA Outreach Act of 2010. This bill 
aims to improve outreach activities within the Department of Veterans 
Affairs by coordinating the efforts among the offices of the Secretary, 
Public Affairs, Veterans Health Administration, Veterans Benefits 
Administration and the National Cemetery Administration.
    In order to increase the effectiveness of VA outreach, it also 
directs the Secretary to annually review activities performed by VHA, 
VBA, state veterans agencies, county veterans agencies, VSOs and other 
federal departments (referred to in section 6306), to include the 
National Guard and Reserve component bureaus under Section 561 of Title 
38, CFR
    The VFW has always encouraged and supported increased awareness of 
benefits and services provided by VA to veterans. We believe that all 
veterans and their survivors should have access to up-to-date 
information about services and benefits for which they may be eligible. 
However, a key component missing in the language of this bill is 
training. We believe that effective outreach can only be achieved 
through the proper training of individuals performing outreach 
activities. We also note that since any successful initiative will 
result in increased claim submissions to VA, funding for VBA 
adjudication must keep pace with increases in the number of claims 
filed as a result of greater outreach.
    We applaud sections 4 and 5, which establish an advisory committee 
to provide a biennial report on outreach activities. The Committee will 
bring together various experts in veterans' issues to make 
recommendations on how to improve VA benefits, services and programs. 
Reaching out to Federal, state and local stakeholders encourages the 
sharing of best practices and helps VA in identifying the needs of 
eligible veterans and their families. This is especially critical now 
with many injured servicemembers returning from the current conflicts 
unaware of their benefits.
    Mr. Chairman, Members of the Committee, this concludes my 
testimony. I would be happy to address any questions you may have. 
Thank you.

                                 
Prepared Statement of Richard F. Weidman, Executive Director for Policy
          and Government Affairs, Vietnam Veterans of America

    Mr. Chairman, Ranking Member Miller, Distinguished Members of the 
House Veterans' Affairs Subcommittee on Health and honored guests, 
Vietnam Veterans of America (VVA) thanks you for the opportunity to 
present our views regarding H.R. 4062, H.R. 4505, the draft legislation 
on Outreach, and the draft legislation entitled the WHAT Act. With your 
permission, I shall keep my remarks brief and to the point.
H.R. 4062 Veterans' Health and Radiation Safety Act
    Requires the Secretary of Veterans Affairs to report annually to 
Congress on the low-volume (treating 100 patients or less) programs at 
each medical facility of the Department of Veterans Affairs (VA); and, 
Directs the Secretary to ensure that all employees at a VA hospital 
where radioactive isotopes are used in the administration of medical 
services receive appropriate training on what constitutes a medical 
event and when and to whom a medical event should be reported. 
Prohibits such isotopes from being used at a VA hospital where such 
training is not provided; and, requires the Secretary to carry out 
specified evaluations and peer reviews of all medical services provided 
under contract with a non-government entity.
    The recent events at the Philadelphia VA Medical Center where 
veterans were harmed over an extended period by clinicians and 
technicians who were not properly trained have quite naturally caused 
great concern in the veterans' community about both efficacy and 
safety.
    The provisions of H.R. 4062 will take sensible and prudent steps to 
require the VHA to ensure that quality assurance mechanisms are in 
place so that those who are engaged in nuclear medicine activities 
anywhere within the Veterans Health Care system are properly trained, 
understand proper reporting of untoward incidents and record keeping 
with a view toward quality assurance in general, have proper 
supervision, have in place written procedures for quality assurance, 
and require periodic peer reviews to ensure that the treatments 
provided are at the proper dosing to actually work, but not so high as 
to cause the individual being treated harm.
    VVA always favors sensible reporting that does not place undue 
burdens on the practicing clinician at the service delivery level. If 
the VHA sets up proper metrics all of the reporting that is necessary 
to accomplish the objective in this case (and most others) can be 
programmed to pick up the salient data on the VistA electronic health 
care records system. Therefore, requiring that a synopsis of activity 
over the course of a year, as well as an analysis of the program, be 
included in the VA's Annual Report is a potentially useful step. VVA 
does not generally favor more staff for the sake of more staff in any 
branch of government, but it is key that the Committees on Veterans 
Affairs on both sides of the Hill have the organizational capacity to 
dig into the Annual Report, the Strategic plan for VA, and other key 
reporting mechanisms to be able to assist the distinguished Members of 
this Committee to hold the VA much more accountable than it has been in 
the past.
    VVA favors passage of H.R. 4062.
H.R. 4505, Authorizes the Secretary of Veterans Affairs (VA) to permit 
        a state home to provide VA nursing home care to parents who had 
        any children who died while serving in the Armed Forces.
    It is fitting that this proposed legislation should come for a 
hearing this week proceeding Memorial Day. Of all weeks in the year, 
this is when we should all be thinking about the terrible price of 
freedom in lives lost early, cut down in the early prime of life by 
virtue of service to country.
    Each of the young people lost early left a web of bother and sister 
war fighters, as well as family and friends for whom the loss is 
particularly harsh. This is especially true for the Gold Star parents, 
the mothers and fathers who have lost their son or daughter in military 
service to country. What this proposed bill would do is give the 
Secretary of Veterans Affairs the authority to permit states who wish 
to do so to provide any needed care to these Gold Star Mothers and Gold 
Star fathers.
    VVA certainly hopes that most states, if not all, would choose to 
provide such care as needed to these fine Americans who have suffered a 
loss so great that most of us cannot even imagine how great the pain 
must be. When they age their son or daughter is not there to care for 
them as the years take their toll. It is incumbent on the rest of us in 
our society to then step up and fill the void left by the early death 
of our comrade in arms. Insofar as possible those of us in veterans 
service organizations should and do step up to assist Gold Star 
families, and particularly gold star mothers. Supporting this move to 
cover nursing care as needed is the minimum we can and should do, as 
this is something that is beyond the span of control of the things we 
already do for and with the families.
    VVA strongly supports early passage of this legislation.
Draft to Improve VA Outreach Act of 2010 Legislation
    The fact is, only 20 percent of veterans actively use the VA for 
their health care, and even many of these are not familiar with the 
health care and other benefits to which they are entitled by virtue of 
their service. What of the other eighty percent who never go to a VA 
regional office or medical center? Most of them are, quite simply, 
ignorant of these benefits--ignorant because they are uninformed. And 
they are uninformed because the VA has not in the past even tried to do 
a concerted, coordinated, comprehensive job of reaching out to them.
    VVA believes the VA has both a legal responsibility and an ethical 
obligation to reach out to all veterans and their families to inform 
them of the benefits to which they are entitled, and of the possible 
long-term health risks and problems they may experience due to where 
and when they served. Populating kiosks in VA medical centers with 
booklets and pamphlets is fine for those who make it to a VA medical 
facility. However, these do not get into the hands of either the very 
poor who do not use the system or the better off who do not need to use 
the system.
    What is needed is a real strategic plan, one that will employ TV 
and radio ads, billboards, and public service announcements, as well as 
cooperative efforts with civilian organizations and entities in a 
coordinated effort, yet one that adapts to regional and local 
realities. The proposed legislation would mandate such a comprehensive 
plan. What VVA suggests is requiring the Secretary of Veterans Affairs 
to establish a separate account for the funding of the outreach 
activities of the Department. This would establish a separate 
subaccount for the funding of the outreach activities of each element 
of the Department of Veterans Affairs.
    The way to make things happen at the VA is to make sure that they 
plan for it, and then require that they specifically provide the line 
item budget for it, and then to monitor the dickens out them to ensure 
that it is done, and done correctly.
    VVA has specifically started a project called the Veterans Health 
Council (www.veteranshealth.org) because the VA does such a poor job of 
informing veterans and their families as to the wounds, maladies, 
injuries, diseases, and other adverse health risks they may be subject 
to depending on what branch of the military they served, when and where 
they served, their military occupational specialty, and what actually 
happened to them while in military service. The primary mission of the 
VHC is to partner with medical societies, professional medical 
organizations, disease advocacy groups, other veterans organizations, 
and interested parties to inform civilian medicine about these special 
health risks of veterans, so they can provide better care to the their 
patients, and so we can educate the veteran and their families through 
their civilian provider.
    While we are making some progress with the work of the Veterans 
Health Council, we are under no illusion that we have or are likely to 
ever have the resources or the reach to get this job done correctly. 
But at least we have started, whereas the VA has not done so. This bill 
would require them to start doing what they should have been doing all 
along.
    VVA strongly favors early passage of this much needed legislation.
Draft World War II Hearing Aid Treatment WHAT Act Legislation
    The dangers and risks of military service to hearing, because of 
the loud noises that are so prevalent in every branch of the military, 
have been so well known for so long that we have tended to either 
ignore this important subject or to joke about aspects of it with wry 
military humor. Until recently we have not seriously looked at the very 
serious medical conditions of irreversible damage to one of the five 
basic human senses that is so often resulting from military service.
    Earlier in this decade the Congress, led by the Members on this 
distinguished Subcommittee, mandated that VA contract with the 
Institute of Medicine of the National Academy of Sciences to take a 
comprehensive look at the damage to hearing as well as the generally 
thought of as being closely associated with hearing loss, but equally 
debilitating condition of tinnitus. That mandate led to a project of 
the little known but quite extraordinary Medical Follow Up Agency 
(MFUA) convening a panel of experts and conducting a consensus study 
that resulted in a report being issued in September of 2005.
Noise-Induced Hearing Loss and Tinnitus Associated with Military 
        Service from World War II to the Present

Type:                                    Consensus Study

Topics:                                  Veterans Health (http://
                                          www.iom.edu/Global/Topics/
                                          Veterans-Health.aspx)Boards:                                  Medical Follow-Up Agency http://
                                          www.iom.edu/About-IOM/
                                          Leadership-Staff/Boards/
                                          Medical-Follow-Up-Agency.aspx
Activity Description
    A congressionally mandated study by the Institute of Medicine 
assessed noise-induced hearing loss and tinnitus associated with 
military service from World War II to the present, the effects of noise 
on hearing, and the availability of audiometric testing data for active 
duty personnel.
    The expert committee was charged with providing recommendations to 
the Department of Veterans Affairs (VA) on the assessment of noise-
induced hearing loss and tinnitus associated with service in the Armed 
Forces. The Committee was asked to
      review staff-generated data on compliance with 
regulations regarding audiometric testing in the services at specific 
periods of time since World War II,
      review and assess available data on hearing loss,
      identify sources of potentially damaging noise during 
active duty,
      determine levels of noise exposure necessary to cause 
hearing loss or tinnitus,
      determine if the effects of noise exposure can be of 
delayed onset,
      identify risk factors for noise-induced hearing loss, and
      identify when hearing conservation measures were adequate 
to protect the hearing of servicemembers.

    Staff of the Medical Follow-up Agency identified populations of 
veterans from each of the armed services (Army, Navy, Air Force, Marine 
Corps, and Coast Guard) and from each of the time periods from WWII to 
the present. The service medical records of a sample of these 
individuals were obtained and reviewed for records of audiometric 
surveillance (including reference and termination audiograms).
    The Committee's final report, Noise and Military Service: 
Implications for Hearing Loss and Tinnitus, was released in September 
2005. That report can be accessed at the link below:
    http://www.iom.edu/Reports/2005/Noise-and-Military-Service-
Implications-for-Hearing-Loss-and-Tinnitus.aspx
    Essentially what this report detailed is what we already knew and 
what was not known, because there were no significant longitudinal 
studies of humans and audionomic hearing loss, much less such studies 
of military personnel. Moreover, the study confirmed that there was 
little if any attention made to protecting the hearing of military 
personnel until the 1970s, and even then the efforts were minimal and 
usually restricted to highly controlled training situations (e.g., the 
rifle ranges used in basic training). For obvious reasons, soldiers in 
combat situations were (and are today) unlikely to wear hearing 
protective gear because it does not allow them to be at the highest 
state of situational awareness of the enemy or potential enemies (i.e., 
what you can't hear can and will hurt/kill you).
    World War II veterans are now in their eighties and nineties. It is 
clear that there are no good records to research to prove service 
connection for hearing loss for these men and women who still survive 
today. It is as likely as not that many, if indeed not most, of them 
first suffered damage that led to greater hearing loss than they would 
have otherwise experienced started in military service. For most who 
experience hearing loss today being able to have access to use of 
decent hearing aids and devices is perhaps the one single thing that 
would improve the quality of life for the most of these veterans. It is 
long past the time when these folks should be subjected to the 
adversarial system of proving service connection to the satisfaction of 
VBA personnel (and it is adversarial, despite the assertions of VBA 
officials). We urge you to pass this legislation to provide the hearing 
devices to these men and women who need and want them without cost on a 
no fault basis, without making them have to prove a nexus in military 
service more than sixty 5 years ago.
    VVA commends the Chairman, Ranking Member, and the other 
distinguished Members of this Committee for moving to assist these men 
and women with early passage of the WHAT act.
    I shall be glad to answer any questions you might have. Again, I 
thank you on behalf of the Officers, Board, and members of VVA for the 
opportunity to speak to this vital issue on behalf of America's 
veterans.

                                 
   Prepared Statement of Tim Embree, Legislative Associate, Iraq and 
                    Afghanistan Veterans of America

    Mr. Chairman, Ranking Member, and Members of the Subcommittee, on 
behalf of Iraq and Afghanistan Veterans of America's one hundred and 
eighty thousand members and supporters, I would like to thank you for 
inviting us to testify before your Subcommittee. My name is Tim Embree. 
I am from St Louis, MO and I served two tours in Iraq with the United 
States Marine Corps Reserves. The legislation being considered today 
will profoundly affect veterans of all generations and their families. 
We appreciate this opportunity to offer our feedback.
Executive Summary:
    Three bills being considered today will positively affect our 
members and their families so IAVA supports them. The ``Improve VA 
Outreach Act'' addresses the need for a concerted VA effort to reach 
out to veterans and their families to promote the services and benefits 
available to them. H.R. 4062, the ``Veterans' Health and Radiation 
Safety Act,'' insures the safety of veterans receiving specialized 
treatments involving radioactive isotopes. H.R. 4505 expands access for 
gold star parents to state nursing homes.
Full Testimony:
H.R. XXXX, Improve VA Outreach Act of 2010
    IAVA proudly supports the ``Improve VA Outreach Act of 2010.'' Too 
many men and women, discharging from the military, are not enrolling in 
the Department of Veterans Affairs (VA) for their well earned benefits. 
Currently, the burden is on them to seek out their benefits, within a 
passive VA. This is unacceptable. It is long overdue for the VA to 
aggressively recruit veterans and their families into VA programs.

        ``The VA could be more aggressive in contacting OIF/OEF 
        veterans and at least talking to them before the veteran has a 
        mental health crisis. They need to be proactive instead of 
        reactive.''--IAVA Member

    The VA must develop a relationship with the servicemember while 
they are still in the military, not after the servicemember has traded 
their uniform for a t-shirt and jeans. The VA should learn from 
successful college alumni associations, which do not wait until 
graduation day to find their newest members. Instead, they greet them 
on the first day of freshman year and stay with them throughout school 
with engagement activities and social events. The VA should do the 
same: greet servicemembers as they complete basic training and build on 
that relationship throughout the servicemember's time in uniform.
    When a person leaves the service, the VA should create a regular 
means of communicating with them about events, new programs and 
opportunities. And the VA must reach out to aggressively promote VA 
programs to veterans who have not yet accessed their VA benefits. If I 
got half as many letters and emails from the VA, as I do from my 
college alumni association, that would be a great start.
    To transform the VA from ``reactive'' to ``proactive,'' IAVA 
believes the VA must invest in aggressive, modern, innovative outreach. 
This is not happening now--and veterans are clearly suffering as a 
result. IAVA was disappointed that there were only a few brief mentions 
of outreach activities in the President's VA budget submission; none of 
which were for a dedicated outreach campaign. We believe the VA budget 
must include a distinct line item for outreach within each VA 
appropriation account. This line item should fund successful outreach 
programs such as the OEF/OIF Outreach Coordinators, Mobile Vet Centers 
and the VA's new social media presence on Facebook and Twitter.
    The VA's current outreach campaign is disappointing. When the VA 
announced that it had placed ads on more than 21,000 buses 
nationally,\1\ to spread the word about the suicide prevention 
lifeline, we were initially enthusiastic; an image of the ad is below. 
When we saw the ad, it was clearly a failure. The ad has over 30 small 
print words; the average bus ad is limited to 5-10 words. In the short 
time in which a bus passes, a veteran would have to go by the bus 
repeatedly to even read the hotline number.
---------------------------------------------------------------------------
    \1\ http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1707.




    

    IAVA has run one of the largest non-governmental outreach campaigns 
in history, through a partnership with the Ad Council and some of the 
world's best advertizing firms. We have learned a lot about the best 
ways to communicate complex and serious issues through television and 
print. We are ready to work with the VA and share our expertise.
    The ``Improve VA Outreach Act'' will help the VA take their current 
outreach efforts to a whole new level. It requires the VA to:

    1.  Effectively coordinate outreach efforts among the different 
parts of the department as well as other agencies offering services to 
returning servicemembers;
    2.  Work closely with the Department of Health and Human Services 
to promote community health centers. These community health centers may 
be the only medical facility a rural veteran can reasonably access 
without spending a full day riding in a car or bus;
    3.  Set up an outreach committee tasked with coordinating efforts 
which currently are being done on an ad hoc basis among many of the 
VA's separate departments; and
    4.  Submit a 2-year plan fully explaining their outreach 
activities.

    To bring America's next generation of veterans into the VA, to 
receive the benefits they have earned, will require an unprecedented VA 
outreach program. The ``Improve VA Outreach Act of 2010'' is the first 
step in getting us there.
H.R. 4062, Veterans' Health and Radiation Safety Act (Adler)
    IAVA endorses H.R. 4062, the Veterans' Health and Radiation Safety 
Act. Improper use of medical equipment, especially radioactive 
isotopes, can lead to unexplained illness, cancer and even death. The 
VA was recently issued the second largest fine by the Nuclear 
Regulatory Commission for misuse of radioactive isotopes in the 
treatment of nearly 100 veterans in Philadelphia. Stories about 
veterans leaving VA facilities sicker than when they entered casts a 
cloud over the confidence veterans place in the system charged with 
their care. H.R. 4062 mandates the proper oversight of these treatments 
so veterans will be confident in the safety of the care they receive.
H.R. 4465, Adjusting veterans financial status based on the number of 
        their dependents (Kissell)
    IAVA does not take a position on H.R. 4465 because it appears to be 
duplicative of current law. This bill requires the VA to take into 
consideration that veterans seeking care in a state nursing home may 
have children and therefore the veteran's ``attributable income'' 
should be adjusted accordingly, when deciding whether a veteran can pay 
for nursing home care. Section 1722 of title 38 establishes this 
eligibility and already accounts for each dependent a veteran might 
have by increasing the ``attributable income'' threshold for free care 
for each dependent the veteran has. If H.R. 4465 somehow expands or 
clarifies the definition of dependent, IAVA would gladly support it.
H.R. 4505, Authorizing state homes to provide services to gold star 
        parents (Thornberry)
    IAVA supports H.R. 4505, and stands with Gold Star mothers (or 
whoever carries weight from that community) which expands access for 
gold star parents to state nursing homes. Previously, a gold star 
family member would only be eligible for these services only if all 
their sons and daughters died in combat. This bill changes that 
requirement to include a gold star family member, who has no remaining 
sons and daughters, but has lost one of their children in the service 
of their country. It is a common-sense way to support our Gold Star 
parents--who have given so much for our Nation.
H.R. XXXX, World War II Hearing Aid Treatment Act (Teague)
    IAVA supports the draft legislation known as the ``WHAT Act-WWII 
Hearing Aid Treatment Act.'' We believe that any veteran with a 
diagnosed hearing impairment, whether they served in Baghdad or 
Normandy, should have access to free hearing aid devices from the VA. 
Again, this seems like common sense.

                                 
   Prepared Statement of Robert Jesse, M.D., Ph.D., Acting Principal 
                                 Deputy
      Under Secretary for Health, Veterans Health Administration,
                  U.S. Department of Veterans Affairs

    Mr. Chairman, thank you for inviting me here today to present the 
Department of Veterans Affairs' (VA) views on pending legislation. 
Accompanying me this morning is Assistant General Counsel Walter A. 
Hall. We appreciate the Committee's support of Veterans and VA, and we 
appreciate being able to comment on these bills as we both work to 
improve the benefits provided to those who served.
H.R. 4062
    H.R. 4062, the ``Veterans' Health and Radiation Safety Act,'' would 
require VA to submit an annual report to Congress on low-volume 
programs (defined as programs that treat 100 patients or fewer 
annually) at VA medical facilities. The report would have to include 
the Secretary's evaluation and findings with respect to such programs. 
Additionally, H.R. 4062 would require that employees working at VA 
hospitals where radioactive isotopes are used receive training on 
recognizing and reporting medical events. Hospitals failing to provide 
this training would be prohibited from using radioactive isotopes for a 
period of time determined by the Secretary. Lastly, VA would be 
required to evaluate non-government medical services contractors 
through weekly independent peer reviews, written evaluations, and other 
evaluations VA determines are appropriate. A contracting officer must 
review and consider the results of these evaluations before VA renews 
any contracts with non-government medical service contractors.
    Mr. Chairman, we all are aware of a very unfortunate lapse that 
occurred at a brachytherapy program at one of our facilities. We 
testified about this incident before this Committee on July 22, 2009. 
On May 3, 2010, the Office of the Inspector General (OIG) issued a 
report on this incident with five recommendations. Specifically, OIG 
recommended that the Veterans Health Administration (VHA) standardize, 
to a practical extent, the privileging, delivery of care, and quality 
controls for the procedures required to provide this treatment. This 
has been accomplished. Standardized procedures have been developed and 
site visits have verified they are uniformly in place at all facilities 
and steps have been taken to ensure that patients who received low 
radiation doses in the course of brachytherapy be evaluated to ensure 
that their cancer treatment plan is appropriate. We have contacted all 
Veterans that were potentially impacted for follow-up testing and 
monitoring at other VA and private facilities and are reviewing the 
controls that are in place to ensure that VA contracts for health care 
comply with applicable laws and regulations, and where necessary, will 
make the required changes in organization and/or process to bring this 
contracting effort into compliance. A template that outlines basics 
requirements for all contracts is currently in development.
    The report also recommended that senior VA leadership meet with 
senior Nuclear Regulatory Commission (NRC) leadership to determine if 
there is a way forward that will ensure the goals of both organizations 
are achieved. VA is currently working to arrange this meeting. Finally, 
the report recommended that VHA should work with the OIG to develop a 
list of documents that should routinely be provided to the OIG when an 
outside agency is notified of a possible untoward medical event. VHA 
will work closely with OIG to meet this recommendation.
    We appreciate the intent of H.R. 4062 but for a number of reasons 
we do not support it. First we note that section 2 requires the 
Secretary to submit annual reports to Congress on low volume programs. 
However, the definition of a ``program'' is not clear. Any treatment 
``program'' could be defined so narrowly that no facility treats 100 
patients or more a year in a particular program, or so broadly that 
almost every program includes more than 100 patients annually. 
Moreover, treatment quality is not always related to patient volume or 
patient volume just within a given VA facility. Many VA facilities have 
on staff specialist providers who also work elsewhere in the community. 
When you combine all care provided by a specialist, the volume can be, 
and many times is, significantly more than can be accounted for just 
within VA workload. In addition, standard credentialing, privileging, 
and review of quality of care are required at every facility regardless 
of the size of a program.
    All procedures that are performed and all medical care provided at 
all VA facilities involve quality assessment (QA) and oversight. The 
first procedure each year has precisely the same QA requirements as the 
last, whether the annual procedure total is 5, 50 or 500. Further, each 
procedure is performed by a fully credentialed and privileged 
physician. Instead of the requirement to provide an annual report on 
``low volume'' programs, we would like to work with Congress to 
identify what information would be useful for Congress to receive on an 
annual basis.The mandatory training that would be required by section 3 
would apply to all VHA staff and would not be limited to staff directly 
involved in the use of radioactive materials. The NRC regulations 
already require all staff involved in the use of radioactive materials 
to have training and further require that facilities provide evidence 
of that training. Competency and training requirements for staff are 
based upon their defined duties and risks associated with those duties. 
In VHA, radiation safety training and education are provided annually, 
through the VA Learning Management System, to all staff involved in the 
use or handling of radioactive material. This includes all contract 
staff or physicians working in VA Nuclear Medicine services as a 
condition of their authorization to practice at a VA medical center. 
The definition of a medical event and reporting requirements are taught 
to and reviewed annually with all Nuclear Medicine technologists and 
physicians. VA's National Health Physics Program provides a mechanism 
to ensure that the training provided is completed as required by VA 
policy. In addition, VA currently supports and trains all staff in 
reporting any untoward events or potential events consistent with 
guidance provided by the National Center for Patient Safety and the 
facility safety programs. As a result, many of the requirements of 
section 3 are duplicative of current VA policy.
    The requirement in section 4 to obtain weekly independent peer 
review of all medical services provided pursuant to a contract, and 
written evaluations of the services carried out by the supervisor or 
manager of the employee providing the services, are excessive and would 
add unwarranted cost in staff time spent procuring and developing the 
reports. The requirement to undertake peer reviews each week may be 
ineffective if there are an insufficient number of procedures to carry 
out a statistically valid review. The requirement for additional 
reporting and oversight of all medical services provided by contract, 
most of which have not reported adverse events, would be a waste of 
resources. Given current VA procedures related to peer review and 
reporting, some of the provisions in this bill are not necessary. We 
are available to meet with Committee staff to discuss these issues in 
more detail.
    While VA appreciates the Committee's focus on this issue, we 
believe with the above regulatory requirements, safeguards, and 
training, these additional measures are not necessary. We are still 
developing costs for this bill and will provide them for the record.
H.R. 4465
    This bill would amend 38 U.S.C. 1722, which describes how VA 
determines that Veterans are considered unable to defray the expenses 
of necessary care for purposes of determining eligibility for health 
care under 38 U.S.C. 1705 and 1710. Section 1722 states that the term 
``attributable income'' is determined in the same manner that 
eligibility for pension is determined under 38 U.S.C. 1521. H.R. 4465 
would amend section 1722 to provide that the term ``attributable 
income'' is determined in the same manner that eligibility for pension 
is determined under section 1521 except that the Secretary shall treat 
as a child an unmarried person who is placed in the legal custody of 
the Veteran for a period of at least 12 consecutive months; either has 
not attained the age of 21, has not attained the age of 23 and is 
enrolled in a full time course of study at an institution of higher 
learning approved by the Secretary, or is incapable of self support 
because of a mental or physical incapacity that occurred while the 
person was considered a child of the Veteran; is dependent on the 
Veteran for over one-half of the person's support; and resides with the 
Veteran unless separated to receive institutional care as a result of 
disability or incapacitation or under such other circumstances as the 
Secretary may prescribe by regulation.
    VA would like to work with the Committee to better understand the 
intent of this legislation. On its face it would affect only a person 
placed in the legal custody of a Veteran as a result of an order of a 
court and would count the person as a child of a Veteran until age of 
21 unless he or she is a full-time student or incapacitated. Currently 
all other persons (other than full-time students or those who are 
incapacitated) are not considered children once they reach 18 years of 
age. Thus, the effect of the bill would be that persons placed in the 
legal custody of a Veteran by a court would be considered children 
under more generous criteria than the Veteran's natural children. The 
purpose of this differentiation is unclear.
    If the intention is to extend the broader criteria (the age 21 cut-
off) to all children of Veterans, the language should be clarified. 
Moreover, all conditions in the bill as it is drafted are conjunctive 
so that it may also be read to provide that only persons placed in the 
custody of a Veteran by a court shall be treated as a child.
    VA currently neither tracks nor has access to databases that would 
provide numbers of individuals, or Veterans (either currently enrolled 
or potential users of VA health care) with a child (or children) as 
defined in the proposed legislation. Thus, we are unable to determine 
the potential financial impact the passage of this legislation would 
have upon VA health care enrollment, expenditures, and first and third 
party collections.
H.R. 4505
    Pursuant to VA regulations (38 CFR 51.210), state homes constructed 
with VA grants are required to maintain an occupancy rate of 75 percent 
Veterans to be eligible to receive VA per diem payments. The only non-
Veterans who are authorized to reside at state homes are either spouses 
of Veterans or parents of Veterans if all of their children have died 
while serving in the armed forces of the United States. H.R. 4505 would 
require that in administering section 51.210, VA permit a State home to 
provide services to the parents of Veterans if any of the parents' 
children died while serving in the armed forces.
    VA supports this bill. There should be no additional costs to VA.
Draft Legislation--Improve VA Outreach Act of 2010
    Section 2 of the draft outreach bill would require VA to establish 
and maintain procedures to effectively coordinate outreach activities 
of VA between internal departments, Federal, state and local agencies, 
and Veterans Service Organizations (VSOs). This bill would require VA 
to annually review the procedures in place to conduct these activities 
and modify them as needed. Section 3 would require VA to consult with 
the Department of Health and Human Services (HHS) regarding outreach to 
Veterans who receive medical care through HHS community health centers 
or facilities of the Indian Health Service (IHS). Section 4 would 
establish an advisory committee on outreach comprised of 
representatives from VSOs, individuals with expertise in Veterans' 
issues, marketing, branding, advertising, and communication, and 
representatives from State and county Veterans agencies. The Committee 
would also include representatives from the Center for Minority 
Veterans, Center for Women Veterans, VHA, Veterans Benefits 
Administration (VBA) and National Cemetery Administration (NCA) to 
serve as ex-officio members. Terms of service and pay for the Committee 
members would be decided by the Secretary. The Committee's 
responsibilities would include providing advice to the Secretary on 
outreach matters, reviewing the strategic plan for outreach, preparing 
biennial reports for the Secretary, and providing the Secretary with 
any other reports that the Committee considers appropriate. The Federal 
Advisory Committee Act would apply to this committee.
    Section 5 would require the Secretary to submit to Congress a 
biennial strategic plan for outreach activities, including plans to 
identify and inform Veterans and dependents of available benefits and 
services; plans to enroll or register eligible Veterans; and goals, 
objectives, tasks, and performance measures for the above-mentioned 
plans. The strategic plan would be sent to the Advisory Committee on 
Outreach for recommendations prior to being submitted to Congress.
    Because the bill would require duplication of existing programs, VA 
does not support it. We note that the requirements set forth in section 
2 are already being met. VA recently created the National Outreach 
Office in the Office of Intergovernmental Affairs, Office of Public and 
Intergovernmental Affairs. This new office is responsible for ensuring 
the effective coordination of the outreach activities of the Department 
between and among the Office of the Secretary, the Office of Public and 
Intergovernmental Affairs, VHA, VBA, NCA, staff offices, and external 
stakeholders. Further, VA already has a workgroup established to better 
coordinate services between IHS and VA and is working on a memorandum 
of agreement to improve collaboration.
    We believe Section 4, while well-intended, would be redundant. 
There are currently five advisory committees that provide outreach 
direction in their annual reports to the Secretary and Congress. These 
committees include the Advisory Committee on Homeless Veterans, the 
Advisory Committee on Minority Veterans, the Advisory Committee on the 
Readjustment of Veterans, the Veterans' Rural Health Advisory 
Committee, and the Advisory Committee on Women Veterans. Finally, 
pursuant to 38 U.S.C. 6302, VA is already required to develop a 
biennial plan on outreach activities.
    The annual discretionary cost of this bill would be approximately 
$400,000.
Draft Legislation--World War II Hearing Aid Treatment Act
    VA currently has authority to provide hearing aids to certain 
Veterans receiving VA health care. Specifically, 38 U.S.C section 
1717(c) authorizes VA to provide them to any Veteran who is profoundly 
deaf and is entitled to compensation on account of hearing impairment. 
This draft bill would extend eligibility for hearing aids to all 
Veterans of active-duty service in World War II, even if those Veterans 
are not otherwise entitled to compensation under title 38, United 
States Code.
    Hearing loss can be frustrating and dangerous, especially for older 
adults. Further, the added effects of hearing loss and aging can 
combine to create a significant communication handicap and negatively 
impact the ability to communicate effectively. The negative effect of 
stress and communication difficulties can contribute to poor quality of 
life. In addition, untreated hearing loss among the older adult 
population is linked to emotional and social consequences such as 
depression and social isolation. Use of hearing aids has been shown to 
be effective for hearing loss remediation and is an important element 
of life quality for all of our Veterans with hearing loss.
    VA does not support the draft legislation because we currently have 
authority to provide hearing aids to Veterans with service-connected 
hearing loss. In addition to the statutory authority found section 
1717(c), 38 USC 1707(b) authorizes the Secretary to provide sensori-
neural aids in accordance with guidelines prescribed by the Secretary. 
These guidelines are found in 38 CFR 17.149 and list a number of 
different categories of Veterans who are eligible for hearing aids, 
including Veterans with significant functional or cognitive impairment 
evidenced by deficiencies in activities of daily living and Veterans 
with hearing impairments resulting from the existence of another 
medical condition for which the Veteran is receiving VA care. VA also 
believes the legislation would cause inequitable treatments of non-
World War II Veterans with hearing loss. Furthermore, the legislation 
would create unequal benefits for hearing aids in relation to other 
prosthetic appliances that are also crucial to Veterans' well-being and 
quality of life.
    The discretionary cost of this legislation would be approximately 
$14.8 million in the first year, $350 million over 5-years and $509.7 
million over 10 years. This concludes my statement, Mr. Chairman. I 
would be happy to entertain any questions you or the other Members of 
the Committee may have.

                                 
 Statement of Adrian Atizado, Assistant National Legislative Director, 
                       Disabled American Veterans

    Mr. Chairman and Members of the Committee:
    Thank you for inviting the Disabled American Veterans (DAV) to 
submit our views for the record of this important hearing of the 
Subcommittee on Health. DAV is an organization of 1.2 million service-
disabled veterans, and devotes its energies to rebuilding the lives of 
disabled veterans and their families.
    Mr. Chairman, the DAV appreciates your leadership in enhancing 
Department of Veterans Affairs (VA) health care programs that many 
service-connected disabled veterans rely upon. At the Committee's 
request, the DAV is pleased to present our views on the bills pending 
before the Committee today.
        H.R. 4062, the Veterans Health and Radiation Safety Act
    Section 2 of this measure would require an annual report on low 
volume patient programs--specifically, programs with fewer than 100 
participants in a calendar year--at all VA medical facilities.
    Section 3 of the bill would require the VA to ensure that all 
health care employees, including contract employees, receive 
appropriate training related to the use of radioactive isotopes and on 
what constitutes a medical event and to whom it should be reported 
should such an event occur. Failure to provide such training would 
require the VA to stop the use of radioactive isotopes at a VA facility 
until such time the Department deems appropriate.
    Section 4 mandates VA to establish specific requirements such as 
independent peer review of such services, written evaluations by the 
manager of the employee providing such services and evaluation review 
prior to extension of any existing contracts with non-government 
entities.
    The genesis of this bill appears to be the recent finding by the VA 
Office of the Inspector General (OIG) related to application of 
prostate brachytherapy in the treatment of prostate cancer patients at 
the Philadelphia, Pennsylvania VA Medical Center, when the wrong 
strength of implanted radioactive seeds was discovered.
    The OIG made five recommendations, with all of which the Veteran 
Health Administration (VHA) Under Secretary for Health concurred:

    1.  VHA's National Director of Radiation Oncology Programs should 
have sufficient resources, to ensure that VHA provides one high quality 
standard of care for the prostate brachytherapy population. To achieve 
this end, VHA should standardize, to a practical extent, the 
privileging, delivery of care, and quality controls for the procedures 
required to provide this treatment.
    2.  VHA should take the steps required to ensure that patients who 
received low radiation doses in the course of brachytherapy be 
evaluated to ensure that their cancer treatment plan is appropriate.
    3.  VHA should review the controls that are in place to ensure that 
VA contracts for health care comply with applicable laws and 
regulations, and where necessary, make the required changes in 
organization and/or process to bring this contracting effort into 
compliance.
    4.  Senior VA leadership should meet with Senior U.S. Nuclear 
Regulatory Commission leadership to determine if there is a way forward 
that will ensure the goals of both organizations are achieved.
    5.  VHA should work with the OIG to develop a list of documents 
that should routinely be provided to the OIG when an outside agency is 
notified of a (possible) untoward medical event.

    DAV has no specific resolution with respect to H.R. 4062, the 
Veterans Health and Radiation Safety Act; however, we concur with the 
OIG that proper training, oversight and following all mandates and 
established procedures for radiation therapies are necessary for VA and 
non-VA contracted health personnel to ensure patient safety. We ask the 
Committee to provide oversight to ensure VA carries out all of the 
recommendations made by the OIG in this case and we have no objection 
to passage of H.R. 4062 to ensure Congress is properly informed about 
smaller, ``low volume'' VA treatment programs and that proper training 
of health personnel administering radioactive isotope treatment is 
mandated along with appropriate training for identifying and reporting 
a medical event that could be harmful to veteran patients.
   H.R. 4505--To enable State homes to furnish nursing home care to 
  parents any of whose children died while serving in the Armed Forces
    Mr. Chairman, H.R. 4505 would empower State Veterans homes to 
furnish nursing home care to parents, any of whose children died while 
serving in the armed forces. Parents who lose a child to a military 
death are normally and generally referred to as ``Gold Star Parents.'' 
In this instance, nevertheless, their losing fewer than ``all'' of 
their children to military deaths serves as a bar to their admissions 
to State Veterans homes under the non-veteran eligibility standards 
both in the law and in the regulations.
    This bill would require the Secretary of Veterans Affairs to amend 
existing regulations (title 38, Code of Federal Regulations, Chapter 1, 
Part 51, Paragraph 51.210(c), with the following policy:
    ``In administering section 51.210(d) of title 38, Code of Federal 
Regulations, the Secretary of Veterans Affairs shall permit a State 
home to provide services to, in addition to non-veterans described in 
such subsection, a non-veteran any of whose children died while serving 
in the Armed Forces.''
    Mr. Chairman, DAV does not have a national resolution from our 
membership on the specific matter entertained by this bill; however, we 
believe the current statutory eligibility limitation on non-veteran 
admissions to State Veterans homes (not to exceed 25 percent of 
operating bed capacity, or 50 percent of that capacity in the case of a 
home that was constructed by a State without federal matching funds) is 
a sufficient guard to ensure that veterans receive proper priority for 
admission to State home residence. Therefore, while DAV would offer no 
objection to the passage of this bill in its current form, we ask the 
Committee to consider amending the bill further to subject this non-
veteran population to the same limitation that applies to other non-
veterans who are eligible for admission to State Veterans homes.
              Draft Bill--Improve VA Outreach Act of 2010
    Section 2 of this bill would require VA to establish, maintain, and 
annually review procedures for ensuring the effective coordination of 
the outreach activities within VA, state and county veterans agencies, 
veterans service organizations, Department of Labor, National Guard 
Bureau, and each of the reserve components of the Armed Forces.
    Section 3 would amend title 38, United States Code, Sec. 6306 to 
require VA to consult with the Department of Health and Human Services 
to seek to better serve veterans who receive medical care through 
community health centers or through facilities of the Indian Health 
Service.
    Section 4 would establish an 11-member VA Advisory Committee on 
Outreach with ex officio members from the Department's Centers for 
Minority Veterans and Women Veterans, VHA, the Veterans Benefits 
Administration and the National Cemeteries Administration. The 
Committee would be required to provide a report to Congress with an 
analysis of and recommendations to improve VA's strategic plan for 
outreach.
    Section 5 of this measure would amend title 38, United States Code, 
Sec. 6302 by changing the required biennial plan to a strategic plan 
for outreach activities and for such plan to be reported to Congress. 
Rather than a summary of outreach plans VA is undertaking, the 
strategic plan would be a single outreach plan that includes the goals, 
objectives, tasks and performance measures for implementation. In 
addition, the strategic plan is to identify and inform eligible 
veterans and dependents not enrolled for benefits and services provided 
by the Department, and to enroll or register veterans eligible for VA 
benefits and services. Consultation by VA with outside entities for the 
purposes of developing the biennial plan would be substituted with the 
Department's consideration of the Advisory Committee on Outreach's 
analysis and recommendations of the strategic plan required under 
Section 4 of this draft bill.
    As this Subcommittee is aware, VA has a statutory mandate to 
perform outreach activities to certain categories of veterans. For 
example, title 38, United States Code, Sec. 2022 requires VA's Mental 
Health and Readjustment Counseling Service to conduct joint outreach 
efforts to veterans at risk of homelessness. Title 38, United States 
Code, Sec. Sec. 7722 and 7727 require the Veterans Benefits 
Administration to conduct outreach activities, which include sending 
letters to separating servicemembers, distributing full information 
about veterans' benefits to veterans and their dependents, and outreach 
to assist claimants with the preparation and presentation of claims for 
benefits.
    Public Law 108-454, the Veterans Benefits Improvement Act of 2004, 
requires VA to prepare and submit to Congress a report containing a 
detailed description of the Department's outreach efforts to inform 
members of the uniformed services and veterans (and their family 
members and survivors) of the benefits and services to which they are 
entitled and the current level of awareness of those benefits and 
services. The report is also to include the results of a national 
survey to ascertain servicemembers' and veterans' level of awareness of 
VA benefits and services and whether they know how to access those 
benefits and services.
    While this law did not address the lack of an annual strategic plan 
from VA to conduct its outreach activities, Public Law 109-233 added 
Chapter 63 to Part IV of title 38 to ensure all veterans, especially 
those who have been recently discharged or released from active 
military service, are provided timely and appropriate assistance to aid 
and encourage them in applying for and obtaining such benefits and 
services in order that they may achieve a rapid social and economic 
readjustment to civilian life and obtain a higher standard of living 
for themselves and their dependents. In addition, the outreach services 
program authorized in Chapter 63 is for the purpose of charging the 
Department with the affirmative duty of seeking out eligible veterans 
and eligible dependents and providing them with such services.
    This law requires a biennial plan for outreach activities by VA to 
identify and notify eligible veterans and dependents not enrolled for 
benefits and services provided by the Department. In addition, a 
biennial report to Congress is required that includes implementation of 
the biennial plan, recommendations for the improvement of VA outreach 
activities, and incorporation of the recommendations of the report 
mandated by Public Law 108-454.
    DAV has had the opportunity to review the December 1, 2008, VA 
biennial outreach activities report to Congress. Clearly VA is 
conducting numerous outreach activities to veterans of all eras and has 
a special emphasis on veterans of Operations Enduring and Iraqi 
Freedom. However, we note the report lacks an overarching plan as well 
as any parameters or statistical evidence to determine whether outreach 
efforts, individually or collectively, are achieving the desired 
results. Strategic planning is essential for successful business 
operations and a full understanding of the veteran population is an 
important element in providing education and outreach.
    The mission of VA would be incomplete and its programs would be 
ineffective if it only passively received applications from those who 
may by chance learn of benefits available to them. When veterans and 
their programs are brought together, utilization is optimized, 
economies of scale are attained, program goals are achieved, and 
program outcomes are improved. An essential part of VA's mission is 
therefore to seek out and educate veterans about the special programs 
created for their benefit, and incidentally, the ultimate benefit of 
society. Thus, VA must maintain, and adjust based on experience, an 
active, ongoing, and systematic project to create awareness among 
potentially eligible veterans of the special benefits and services 
provided for them. This bill would reinforce the authority and 
congressional mandate for VA outreach and would benefit veterans 
suffering from service-related disabilities who may be unaware of the 
range of benefits and services available to them. DAV has no resolution 
from our membership to support this draft bill; however, its purpose 
appears beneficial, and we have no objection to the Committee's 
favorable consideration.
 Draft Bill--To provide hearing aid devices to veterans of World War II
    Section 2 of this draft bill would allow the VA to provide a 
hearing aid device to any World War II era veteran diagnosed with a 
hearing impairment regardless of whether the veteran is entitled to VA 
compensation benefits.
    Prior to enactment of the Veterans' Health Care Eligibility Reform 
Act of 1996, Public Law 104-262, VA's authority to furnish prosthetic 
devices and appliances to veterans on an outpatient basis was very 
limited. The law significantly changed the eligibility of veterans to 
receive hospital care and outpatient medical services, including 
prosthetics, medical equipment, and supplies to any veteran otherwise 
receiving health care services from VA. Unfortunately, sensori-neural 
aids, which are a type of prosthetic device including eye glasses and 
hearing aids, were not included when providing prosthetic devices and 
appliances by VA was expanded.
    Section 103(a) of Public Law 104-262 provides that VA could furnish 
needed sensori-neural aids only in accordance with guidelines 
promulgated by the Secretary.\1\ Subsequently, the Department published 
regulations (38 CFR Sec. 17.149) in the Federal Register establishing 
such guidelines. In 2002, the VHA issued Directive 2002-039 to 
establish uniform policy for the provision of hearing aids and 
eyeglasses. This directive was revised on October 28, 2008 as VHA 
Directive 2008-070.
---------------------------------------------------------------------------
    \1\ 38 U.S.C. 1707(b).
---------------------------------------------------------------------------
    Current VHA policy on the prescription and provision of hearing 
aids (and eyeglasses) is to furnish such sensori-neural aids to the 
following veterans:

    1.  Those with a compensable service-connected disability;
    2.  Those who are former prisoners of war;
    3.  Those awarded a Purple Heart;
    4.  Those in receipt of benefits under title 38, United States Code 
1151;
    5.  Those in receipt of increased pension based on the need for 
regular aid and attendance or by reason of being permanently 
housebound;
    6.  Those who have a visual or hearing impairment that resulted 
from the existence of another medical condition for which the veteran 
is receiving VA care, or which resulted from treatment of that medical 
condition;
    7.  Those with a significant functional or cognitive impairment 
evidenced by deficiencies in activities of daily living, but not 
including normally occurring visual or hearing impairments; and
    8.  Those visually or hearing impaired so severely that the 
provision of sensori-neural aids is necessary to permit active 
participation in their own medical treatment.

    Moreover, VA will furnish needed hearing aids to those veterans who 
have service-connected hearing disabilities rated 0 percent if there is 
organic conductive, mixed, or sensory hearing impairment, and loss of 
pure tone hearing sensitivity in the low, mid, or high-frequency range 
or a combination of frequency ranges which contribute to a loss of 
communication ability; however, hearing aids are to be provided only as 
needed for the service-connected hearing disability.
    Clearly, veterans in Priority Groups 1-5 are eligible for hearing 
aids. Nonservice-connected veterans (Priority Groups 6, 7, and 8) must 
receive a hearing aid evaluation prior to determining eligibility for 
hearing aids to establish medical justification for provision of these 
devices. These veterans must be enrolled or exempt from enrollment for 
VA health care and the device must be determined to be necessary to 
permit the veteran's active participation in their own medical 
treatment
    Hearing impairment is the most common body system disability in 
veterans. It is apparent that section 103(a) of Public Law 104-262 is 
aimed at reducing the cost of providing sensori-neural aids. Top-of-
the-line hearing aids are costly, but that is always true of the newest 
technology. Conversely, the cost of hearing aids employing older 
technology has actually decreased over the years. For example, in 1996 
when Public Law 104-262 was enacted, a top of the line two-channel 
digital aid cost $2,500. The equivalent two-channel behind the ear 
hearing aid today can be purchased for $495. For VA in 2008 (using six 
companies on contract for different technology), the average cost for 
hearing aid devices it has furnished was $355, whereas in the private 
sector, the cost per aid was $1,500 to $2,500.
    In 2008, there were nearly 520,000 veterans that had a VA 
disability for hearing loss. While changes in eligibility for hearing 
aid services, along with the aging population, contributed to a greater 
than 300 percent increase in the number of hearing aids dispensed from 
1996 to 2006, the cost of hearing aid devices has decreased. DAV has no 
resolution from our membership to support this draft bill; however, its 
purpose appears beneficial.
    Mr. Chairman, this concludes my statement. Thank you for allowing 
the DAV to present its views before the Subcommittee today.

                                 
               Statement of Paralyzed Veterans of America
    Chairman Michaud and Members of the Subcommittee, Paralyzed 
Veterans of America (PVA) would like to thank you for the opportunity 
to present our views concerning pending legislation. PVA appreciates 
the effort and cooperation this Subcommittee demonstrates as they 
address the problems of today's veterans and the veterans of tomorrow.
      H.R. 4062, the ``Veterans' Health and Radiation Safety Act''
    PVA supports H.R. 4062, the ``Veterans' Health and Radiation Safety 
Act,'' which would require an annual report on low volume programs at 
the Department of Veterans Affairs (VA) medical facilities and 
establish a requirement for training of employees and contractors 
wherever radioactive isotopes are used.
    Under the provisions of this legislation, the Department of 
Veterans Affairs (VA) will be required to ensure training is provided 
in the proper handling and use of radioactive isotopes in VA 
facilities. While PVA does not believe Congress should be in the 
business of legislating good medical practice, the incidents at VA 
facilities demonstrate that there sometimes is a need for directed 
guidance. Radioactive materials can never be taken for granted and 
ensuring VA employees, and more specifically their contractors, are 
required to have adequate and appropriate training is clearly 
necessary. PVA also thinks it is wise to have contracting officers 
review contracts prior to extension or renewal to ensure these 
requirements are met. The dangerous nature of radioactive materials 
makes this critical for both the safety and health of the employees and 
the veterans they serve.
  H.R. 4465, a bill to properly determine a veteran's financial status
    PVA supports H.R. 4465 to properly account for a veteran's children 
when determining financial status. While this may seem like a minor 
issue, it can have a tremendous impact on those that this legislation 
will affect.
    In today's society, more and more extended families are taking 
responsibility for children. Grandparents and sometimes great 
grandparents are taking care of the children of their children. 
Invariably these ``new'' parents are older, often with much lower 
income, and are gaining custody of these children and providing for a 
family.
    While the Internal Revenue Service (IRS) recognizes the financial 
challenge custody of these children can create when determining 
financial status, VA does not. The IRS considers someone a dependent 
when a person has custody of the child. Social Security includes 
grandchildren in its definition of a child, making them eligible for 
dependent benefits. But for VA, a dependent is identified as the 
biological, adopted, or step-child of a veteran only. If a veteran has 
sole custody of a child and is enrolled in the VA, PVA believes that 
the child should be considered when calculating the financial status of 
the veteran. While the veteran could go through the burdensome adoption 
process, this expense will create only greater challenges for the 
custodial parents and it should not be necessary. The challenge of a 
grandparent or great grandparent taking on the care of a child is 
significantly difficult already and VA should not add to that burden. 
Additionally, PVA supports consistency across Federal Agencies when 
considering similar benefit calculations.
 H.R. 4505, a bill to furnish nursing home care to parents of children 
                  who died serving in the armed forces
    PVA supports H.R. 4505 to furnish nursing home care to parents of 
children who died serving in the armed forces. This legislation 
corrects an injustice that requires parents to lose all their children 
before being eligible for State Veterans Home residency. While this may 
have made sense in the past when children often remained home with 
their parents to tend the farm or family business, it does not make 
sense in today's mobile economy.
                The ``Improve VA Outreach Act of 2010''
    PVA welcomes legislation to improve outreach to our Nation's 
veterans. There are still many veterans who may not realize they are 
eligible for VA benefits. This particularly includes women veterans who 
are traditionally underserved, and those veterans that may erroneously 
believe that because they did not serve in combat that they are not 
eligible for VA benefits. The Secretary should make every effort to 
reach out to these veterans, especially homeless veterans and those 
suffering in poverty who may be significantly helped by VA services. 
However, this outreach cannot simply be an empty slogan or program that 
allows VA to proclaim how much they are doing to reach veterans.
    PVA is concerned that this legislation may be headed in that 
direction. It is unfortunate that Congress must direct VA to 
``establish and maintain procedures for ensuring the effective 
coordination of outreach activities of the Department between and 
among'' Federal agencies. This is a basic task that VA should be doing 
and should have been doing since its inception, and while PVA welcomes 
the creation of the Advisory Committee on Outreach, establishing a 
committee is often a way to demonstrate action when no actual action is 
taking place. This committee is meant to advise the Secretary on 
outreach matters, but this advisory process is already available 
through meetings the Secretary has with various congressionally 
chartered Veterans Service Organizations (VSO). We are not sure that a 
formal committee will improve this function.
    Formalizing this process may provide a stronger voice to the 
Advisory Committee and its membership. The requirement that the 
Advisory Committee conduct ``an analysis of the strategic plan'' and 
make recommendations ``for improving the plan'' is welcome, but if the 
Secretary chooses to ignore these recommendations, he can. The 
Secretary is only required to submit a ``summary of all reports and 
recommendations of the Committee'' to Congress and this summary can be 
slanted in any way the Secretary sees fit. If Congress truly wishes the 
Secretary to consider recommendations of the Advisory Committee, this 
committee should request testimony from the Advisory Committee itself 
or the members represented on the Committee, at the time of the 
Secretary's report. It can be expected that Congressional Committees 
may request testimony in the event of significant disagreements with 
the Secretary, but by compelling testimony in the legislation it sends 
the message that the Advisory Committee should be heeded and not simply 
serve as a sounding board or one more empty gesture.
    PVA supports all efforts of VA to reach out to its constituents. 
With the ever increasing number of veterans from the wars in 
Afghanistan and Iraq, and the increasing age of veterans from previous 
conflicts, greater needs are being created. It is the hope of PVA that 
this outreach program can be an effort that will truly reach those who 
are in need. But this will not happen if sufficient resources are not 
committed to the effort. Simply establishing an Advisory Committee will 
not do it and PVA implores the Secretary to do more.
 Draft Legislation to ``authorize the Secretary to provide hearing aid 
                 devices to veterans of World War II''
    PVA does not support the legislation to authorize the Secretary to 
provide hearing aid devices to veterans of World War II as currently 
written. PVA believes that if a veteran is enrolled in the VA health 
system that they should be eligible for a hearing aid. This would 
simply be another service provided to enrollees. However, PVA does not 
believe that a World War II veteran should be able to bring in a 
hearing aid prescription from their private doctor and have VA supply 
the device. PVA expressed similar objections in the past to non-VA 
prescriptions being filled by a VA pharmacist. PVA would support the 
legislation if it were clarified to clearly state its intent to provide 
for those who are enrolled in the VA health care system. In addition, 
PVA is concerned that the costs associated with this new benefit be 
supported with newly appropriated funds. The VA should not be expected 
to supply this new service with current appropriations which could have 
detrimental effects on care provided to other veterans.

                                 
    Statement of Vivianne Cisneros Wersel, Au.D. Chair, Government 
         Relations Committee, Gold Star Wives of America, Inc.

    The members of Gold Star Wives of America are the widows\1\ of 
military servicemembers who served during World War II, the Korean War, 
the Vietnam War, the Gulf War, the wars in Iraq and Afghanistan and in 
the periods between these wars. Our husbands died on active duty and/or 
as the result of a service connected cause.
---------------------------------------------------------------------------
    \1\ Although widowers are more than welcome in GSW, GSW's 
membership is primarily widows. Use of the word widows or other gender 
specific language is meant to include widowers.
---------------------------------------------------------------------------
    We are those to whom Abraham Lincoln referred when he made the 
government's commitment ``. . . to care for him who shall have borne 
the battle, and for his widow, and his orphan.''
                               H.R. 4505
    H.R. 4505 would grant nursing home care in state veterans' homes to 
the parents of those who died while serving the Armed Forces of the 
United States.
    Gold Star Wives of America (GSW) believes that this legislation 
needs to be amended to include:

      The widows of those who died while serving in the Armed 
Forces
      The parents and widows of those who died of a service 
connected cause

    Many of these parents, wives and widows have spent or will spend 
much of their lives as the caregivers of severely disabled veterans. If 
anyone deserves nursing home care in a Department of Veterans Affairs 
(VA) or VA subsidized nursing home, it is the parents, wives and widows 
who have provided care to severely disabled servicemembers and 
veterans.
    The recent bill which provides for benefits to caregivers included 
only the caregivers of those who were injured in Iraq and Afghanistan. 
The caregivers of veterans from previous war eras were not included in 
these benefits.
    Survivor benefits during earlier war eras were less than adequate. 
Many of the widows from the World War II and Korean War eras receive 
Dependency and Indemnity Compensation (DIC) and $200-$300 in Social 
Security. Many of these widows live on $1500 a month or less and are 
financially challenged.
    Some of the widows of the Vietnam era receive only DIC and are not 
entitled to Social Security Widows' Pension because their husbands died 
very young and had not accumulated enough quarterly work credits for 
them to receive a Social Security Widows' Pension. (This oversight also 
needs to be fixed.)
    Congress has not been able to fund H.R. 2243, the bill to increase 
DIC or H.R. 775, the bill to repeal the DIC offset to SBP for widows 
who have not remarried.
    As a result of this lack of funding many of our widows are in 
significant financial need now and they would have no means to pay for 
nursing home care should the need arise.
    As an alternative to providing care for parents, wives, and widows 
in a VA or VA subsidized nursing home, Congress should consider 
providing subsidized long term care insurance. Long term care insurance 
would be far less expensive and would allow these proposed 
beneficiaries to obtain nursing home care while remaining in their own 
communities close to friends and family. An exception might be made so 
that if a veteran is already in a nursing home, his family members 
would be eligible for care in the same VA or VA subsidized nursing 
home.
    Subsidized long term care insurance would also relieve the burden 
to the VA of providing care to additional family members when the VA is 
already staggering under the current burden of caring for veterans.
    ``Taking care of survivors is as essential as taking care of our 
Veterans and military personnel. By taking care of survivors, we are 
honoring a commitment made to our Veterans and military members.''--
Secretary of Veterans Affairs Eric Shinseki
                   MATERIAL SUBMITTED FOR THE RECORD

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 14, 2010

Hon. Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20240

Dear Secretary Shinseki:

    Thank you for the testimony of Dr. Robert Jesse, Acting Principal 
Deputy Under Secretary for Health and Walter A. Hall, Assistant General 
Counsel, at the U.S. House of Representatives Committee on Veterans' 
Affairs Subcommittee on Health Legislative Hearing on H.R. 4062, H.R. 
4505, H.R. 4465, and Draft Legislation entitled, the ``Improve VA 
Outreach Act of 2010,'' and the ``World War II Hearing Aid Treatment 
Act,'' which took place on June 9, 2010.
    Please provide answers to the following questions by Monday, July 
26, 2010, to Jeff Burdette, Legislative Assistant to the Subcommittee 
on Health.

    1.  Dr. Jesse testified that the definition of a low volume 
``program'' in H.R. 4062 is unclear so that it can be narrowly defined 
to include all facilities or no facility. Please explain further by 
providing some specific examples of how VA can potentially define a 
``program''.
    2.  VA's testimony requested clarification on H.R. 4465. It is my 
understanding that the goal of H.R. 4465 is to help veterans who 
receive pension for non-service connected disability and are in 
priority group 5. For this sub-group of veterans, their medical co-
payments are reduced by the number of dependents they have. The current 
law narrowly defines dependents to include biological, step, and 
adopted children. This bill would newly include children who are under 
the guardianship of the veteran. This means that the veteran can have a 
higher income level and not exceed the VA national income threshold, 
which means free VA prescriptions and travel benefits, as well as free 
VA health care for the veteran. In light of this information, are you 
able to share VA's position on this bill?
    3.  The Gold Star Wives of America submitted a statement for the 
record recommending that H.R. 4505 be amended to make eligible for 
state nursing home care widows of individuals who died while serving in 
the Armed Forces, as well as parents and widows of those who died of a 
service-connected cause. Would VA continue to support this bill if it 
were amended to include the Gold Star Wives' recommendations? Please 
explain.
    4.  VA states that the draft legislation on outreach is largely 
duplicative of existing efforts. We've also heard our VSO panel testify 
about the need to greatly improve VA's current outreach efforts. Given 
this clear need and if the draft legislation is duplicative, what other 
legislative authorities can help VA be more successful in outreaching 
to our veterans?
    5.  VA estimates the cost of the draft hearing aid bill as $350 
million over 5 years and $510 million over 10 years. Please explain the 
underlying assumptions that you used to develop this cost estimate. In 
other words, how many beneficiaries and cost per hearing aid did VA 
assume in this estimate?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by Monday, July 26, 
2010.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________
                     Committee on Veterans' Affairs
                     U.S. House of Representatives
 Post-Hearing Questions for the Honorable Robert A. Petzel, M.D., Ph.D.
    Under Secretary for Health, U.S. Department of Veterans Affairs
                 From the Honorable Michael H. Michaud
    H.R. 4062, H.R. 4505, H.R. 4465, and Draft Legislation entitled,
     the ``Improve VA Outreach Act of 2010'' and the ``World War II
                      Hearing Aid Treatment Act''
                              May 27, 2010

    Question 1: Dr. Jesse testified that the definition of a low volume 
``program'' in H.R. 4062 is unclear so that it can be narrowly defined 
to include all facilities or no facility. Please explain further by 
providing some specific examples of how VA can potentially define a 
``program.''

    Response: H.R. 4062 defined a low volume program as a program that 
treats 100 patients or fewer during a calendar year. Clinical programs 
within the Veterans Health Administration (VHA) provide a wide range of 
services comprised of clinical assessments, treatments, and procedures. 
In most cases this is aligned around a medical specialty or a 
subspecialty provider that has received training to provide a variety 
of assessments, treatments or procedures based upon his or her training 
and education. As Dr. Jesse stated, this can be a clinical offering 
that is within a single VA Medical Center, a Veterans Integrated 
Service Network (VISN), or at the national level. VA believes a better 
approach is to use a definition to be ``a group of practitioners who 
collaborate closely to perform a procedure or collection of procedures 
that require the same skill sets.''
    VA does however, believe it best to address the concern presented 
in H.R. 4062 through VA's existing credentialing and privileging 
process. After initial credentialing, which focuses on the identified 
clinician's training and experience, each individual medical center is 
required to complete privileging of the provider. The privileging 
process includes both experience in performing an identified procedure 
and a review of the clinical outcomes. This process requires a review 
every 2 years for cause. The overall number of procedures performed 
within VA may not be the best predictor of competency, as many VA 
providers also perform procedures within community and academic 
settings, which may be included in the re-privileging process. The 
overall number of procedures performed may be extended to the person's 
overall performance at various clinical sites.
    The overall review of the quality of care provided by an individual 
clinician requires both evidence of continued experience and the 
overall results of his or her clinical outcomes. Defining the overall 
competency of the individual and outcomes of a system-wide performance 
of procedures or treatments requires much more than volume triggers; VA 
must and does take into consideration quality outcomes and risk-
adjusted factors.
    The following are examples:

        An Imaging Program consists of general and specialty 
        procedures, including neuroradiology, interventional 
        procedures, and nuclear medicine. At the facility level, each 
        individual clinical service may be a separate program (nuclear 
        medicine and radiology, for example).

        Radiation Oncology Program may include a variety of treatment 
        and services such as external beam treatments, prostate 
        brachytherapy seed implant services, and other brachytherapy 
        treatments.

        Cardiology Program may include outpatient evaluations, 
        procedures clinics, cardiac invasive procedures 
        (catherization), and open heart surgery.

    Question 2: VA's testimony requested clarification on H.R. 4465. It 
is my understanding that the goal of H.R. 4465 is to help Veterans who 
receive pension for non-service connected disability and are in 
priority group 5. For this sub-group of Veterans, their medical co-
payments are reduced by the number of dependents they have. The current 
law narrowly defines dependents to include biological and adopted 
children, and stepchildren. This bill would newly include children who 
are under the guardianship of the Veteran. This means that the Veteran 
can have a higher income level and not exceed the VA national income 
threshold, which means free VA prescriptions and travel benefits, as 
well as free VA health care for the Veteran. In light of this 
information, are you able to share VA's position on this bill?

    Response: The effect of the bill would be that persons placed in 
the legal custody of a Veteran by a court would be considered children 
under more generous criteria than the Veteran's natural children; the 
purpose of this differentiation is unclear. If the intention is to 
extend the broader criteria (the age 21 cut-off) to all children of 
Veterans, we suggest clarifying the language. In addition, all 
conditions in the bill as drafted are conjunctive and could be 
interpreted to read that only persons placed in the custody of a 
Veteran by a court shall be treated as a child. VA is available to work 
with Committee Staff to provide clarity and technical assistance.

    Question 3: The Gold Star Wives of America submitted a statement 
for the record recommending that H.R. 4505 be amended to make eligible 
for state nursing home care widows of individuals who died while 
serving in the Armed Forces, as well as parents and widows of those who 
died of a service-connected cause. Would VA continue to support this 
bill if it were amended to include the Gold Star Wives' recommendation? 
Please explain.

    Response: Current law limits state home beds to spouses and parents 
if all of their children have died while serving in the Armed Forces of 
the United States. Historically, the reason for permitting spouses was 
to make it possible for the Veteran to continue to live with the spouse 
if both required nursing home care. Spouses living in a state home at 
the time of death of a Veteran may continue to live in the home. The 
proposal by the Gold Star Wives to make widows of individuals who died 
while serving in the Armed Forces eligible for admission to State 
Veterans Homes would treat those spouses more equitably. Since VA does 
not pay a per diem to the state for any non-Veteran residents of State 
Veterans Homes, this proposal would not have any effect on VA's costs. 
Accordingly, VA has no objection to the proposal.

    Question 4: VA states that the draft legislation on outreach is 
largely duplicative of existing efforts. We've also heard our VSO panel 
testify about the need to greatly improve VA's current outreach 
efforts. Given this clear need and if the draft legislation is 
duplicative, what other legislative authorities can help VA be more 
successful in outreaching to our Veterans?

    Response: VA already has adequate legislative authority to conduct 
outreach to all Veterans and is aggressively working towards that end. 
VA is taking steps to align and synchronize its outreach efforts across 
VA business lines to ensure outreach activities employ clear, accurate, 
consistent, and targeted messages to inform Veterans and their families 
of the benefits and services available to them.
    VA has established an outreach office within the Office of Public 
and Intergovernmental Affairs (OPIA) and is in the process of hiring 
staff. The office will promote uniform messaging across the Department, 
reduce cost, and share the fiscal responsibility of researching, 
analyzing, and measuring our efforts. The three Administrations and 
Staff Offices will continue to execute outreach activities, but the 
overall Department outreach strategy will be coordinated across all 
organizations by OPIA.
    As a result, OPIA will ensure necessary and valuable information is 
delivered timely to Veterans and their families; will leverage 
technology and partnerships with our stakeholders; will unify outreach 
messages and measure tangible outcomes nationwide. VA will report the 
success of these activities to Veterans, Congress, stakeholders, and 
the American public. The outreach office is expected to be fully 
functional by the end of the year.

    Question 5: VA estimates the cost of the draft hearing aid bill as 
$350 million over 5 years and $510 million over 10 years. Please 
explain the underlying assumptions that you used to develop this cost 
estimate. In other words, how many beneficiaries and cost per hearing 
aid did VA assume in the estimate?

    Response: VA's earlier estimate of the draft bill included baseline 
costs for the WWII veterans who are already eligible under current law. 
Excluding these baseline costs, the draft bill would cost $40 million 
over 5 years and $56 million over 10 years. Under the draft bill, VA 
estimates that 13,260 additional World War II (WWII) Veterans will 
utilize hearing aids at the end of 5 years, and 2,508 additional WWII 
Veterans will utilize hearing aids at the end of 10 years. The cost 
assumed for hearing aids was $729 (per pair) at the end of 5 years, and 
$757 (per pair) at the end of 10 years.
    These projections are based on historical facts that VA has 
provided hearing aids to more than 700,000 WWII Veterans who were 
eligible for hearing aids in accordance with VA policy. This Veteran 
population will decrease over time, and more than half will have 
hearing loss based on published epidemiological studies. Not all WWII 
Veterans with hearing loss will seek VA hearing aid services.
    The following assumptions are based on VA data and Veteran health 
utilization information:

      Average Veteran receives 2 hearing aids at a time 
(current average contract cost is $349 each = $700 rounded);
      Hearing aids are replaced on average every 4 years;
      First 2 years hearing aids are under warranty with no 
repair or replacement cost;
      One repair per 4 year life span of hearing aids; average 
repair cost is $102 in 2010 (per VA Remote Order Entry System data);
      Consumer Price Index inflation factors for repairs and 
hearing aid cost;
      710,000 WWII Veterans currently are in receipt of hearing 
aids;
      Half of WWII Veterans have sufficient hearing loss 
requiring hearing aids;
      20 percent of eligible WWII Veterans meeting hearing aid 
loss criteria and not in receipt of VA hearing aids will request VA 
hearing aids at some time;
      Half of the 20 percent of eligible WWII Veterans who 
request hearing aids will do so within the first year; and
      New requests in outlying years will be 50 percent of the 
new requests for the previous year.


                                 Table 1. 10-year cost projections based on current VA data and WWII Veteran population
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                   New       Hearing
               FY                  WWII Veteran   Hearing Aid    Hearing    Aid Cost/    Hearing Aid     Average #    Repair   Repair Cost   Total Cost
                                    Population       Users      Aid Users     Pair        Total Cost    of Repairs     Cost       Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
2011                              1,517,404       567,900      21,200      $700            $14,840,000  0           $102                $0   $14,840,000
--------------------------------------------------------------------------------------------------------------------------------------------------------
2012                              1,294,133       493,315      10,600      $700             $7,420,000  0           $102                $0    $7,420,000
--------------------------------------------------------------------------------------------------------------------------------------------------------
2013                              1,091,800       419,685       5,300      $700             $3,710,000  0           $102                 0    $3,710,000
--------------------------------------------------------------------------------------------------------------------------------------------------------
2014                              1,034,727       401,351       2,650      $729             $1,931,850  14,380      $106        $1,524,280    $3,456,130
--------------------------------------------------------------------------------------------------------------------------------------------------------
2015                                855,070       334,446      13,260      $729             $9,666,540   7,021      $106          $744,226   $10,410,766
--------------------------------------------------------------------------------------------------------------------------------------------------------
5-YR                              ..............  ...........  ..........  ..........      $37,568,390  ..........  .........   $2,268,506   $39,836,896
--------------------------------------------------------------------------------------------------------------------------------------------------------
2016                                697,806       274,909       6,420      $729             $4,680,180   3,427      $106          $363,262    $5,043,442
--------------------------------------------------------------------------------------------------------------------------------------------------------
2017                                562,022       223,007       3,107      $729             $2,265,003   1,461      $106          $154,866    $2,419,869
--------------------------------------------------------------------------------------------------------------------------------------------------------
2018                                446,469       176,342       1,320      $757               $999,240   6,958      $110          $765,380    $1,764,620
--------------------------------------------------------------------------------------------------------------------------------------------------------
2019                                349,623       137,630       5,510      $757             $4,171,070   3,204      $110          $352,440    $4,523,510
--------------------------------------------------------------------------------------------------------------------------------------------------------
2020                                269,721       106,016       2,508      $757             $1,898,556   1,474      $110          $162,140    $2,060,696
--------------------------------------------------------------------------------------------------------------------------------------------------------
10-YR                             ..............  ...........  ..........  ..........      $51,582,439  ..........  .........   $4,066,594   $55,649,033
--------------------------------------------------------------------------------------------------------------------------------------------------------

                                 
