[Senate Hearing 111-76]
[From the U.S. Government Publishing Office]



                                                         S. Hrg. 111-76

             HEARING ON PENDING HEALTH-RELATED LEGISLATION

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 22, 2009

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate




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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Johnny Isakson, Georgia
Bernard Sanders, (I) Vermont         Lindsey Graham, South Carolina
Sherrod Brown, Ohio                  Roger F. Wicker, Mississippi
Jim Webb, Virginia                   Mike Johanns, Nebraska
Jon Tester, Montana
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
                William E. Brew, Majority Staff Director
                 Lupe Wissel, Republican Staff Director









                            C O N T E N T S

                              ----------                              

                             April 22, 2009
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     2
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     4
Johanns, Hon. Mike, U.S. Senator from Nebraska...................     6
Tester, Hon. Jon, U.S. Senator from Montana......................     7
Burris, Hon. Roland W., U.S. Senator from Illinois...............     8
Begich, Hon. Mark, U.S. Senator from Alaska......................     9
Sanders, Hon. Bernard, U.S. Senator from Vermont.................    10
Murray, Hon. Patty, U.S. Senator from Washington.................    12

                               WITNESSES

Cross, Gerald M., M.D., FAAFP, Principal Deputy Under Secretary 
  for Health, U.S. Department of Veterans Affairs; accompanied by 
  Walter A. Hall, Assistant General Counsel, U.S. Department of 
  Veterans Affairs; and Joleen Clark, Chief Officer for Workforce 
  Management and Consulting, U.S. Department of Veterans Affairs.    13
    Prepared statement...........................................    14
    Written views for the record submitted by VA after the 
      hearing....................................................    39
    Response to written questions submitted by:
      Hon. Daniel K. Akaka.......................................    48
      Hon. Patty Murray..........................................    53
      Hon. Bernard Sanders.......................................    55
      Hon. Jon Tester............................................    57
        Map--Location of Veterans Rural Health Resource Centers..    62
        Appendix A--VRHRC Project Summaries......................    63
Atizado, Adrian, Assistant National Legislative Director, 
  Disabled American Veterans.....................................    81
    Prepared statement...........................................    82
    Response to requests arising during the hearing by Hon. 
      Daniel K. Akaka............................................   148
Hilsabeck, Ammie, R.N., Oscar G. Johnson VA Medical Center, Iron 
  Mountain, Michigan, on behalf of the American Federation of 
  Government Employees, AFL-CIO..................................    94
    Prepared statement...........................................    96
    Response to requests arising during the hearing by Hon. 
      Daniel K. Akaka............................................   144
Heady, Hilda R., MSW, Associate Vice President of Rural Health, 
  Robert C. Byrd Health Sciences Center, West Virginia 
  University, and Past President, National Rural Health 
  Association....................................................   102
    Prepared statement...........................................   104
Ibson, Ralph, Senior Fellow for Health Policy, Wounded Warrior 
  Project........................................................   107
    Prepared statement...........................................   109
        Attachment: Sustaining Family Caregiving for Wounded 
          Warriors: The Need for a Comprehensive Caregiver 
          Program................................................   113
Ortner, Blake C., Senior Associate Legislative Director, 
  Paralyzed Veterans of America..................................   132
    Prepared statement...........................................   133
    Response to requests arising during the hearing by Hon. 
      Daniel K. Akaka............................................   143

                                APPENDIX

Geer, Jerri, (Ret.) Coast Guard Lieutenant; prepared statement...   151
Brennan, Michael, M.D., President, American Academy of 
  Ophthalmology; prepared statement..............................   153
Campbell, Patrick, Chief Legislative Counsel, IAVA; prepared 
  statement......................................................   155
National Association of Veterans' Research and Education 
  Foundations (NAVREF); prepared statement.......................   157
Cohoon, Barbara, Deputy Director, Government Relations, The 
  National Military Family Association; prepared statement.......   160
Nurses Organization of Veterans Affairs (NOVA); prepared 
  statement......................................................   165
Holway, David J., National President, National Association of 
  Government Employees, SEIU/NAGE Local 5000; prepared statement.   168
Long, Luanne, RN, President, Hawai'i Nurses Association, United 
  American Nurses, AFL-CIO; prepared statement...................   170

 
             HEARING ON PENDING HEALTH-RELATED LEGISLATION

                              ----------                              


                       WEDNESDAY, APRIL 22, 2009

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:30 p.m., in 
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka, 
Chairman of the Committee, presiding.
    Present: Senators Akaka, Murray, Brown, Tester, Begich, 
Burris, Sanders, Burr, and Johanns.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Chairman Akaka. Thank you very much for being so patient. 
We had a vote call and decided to answer the call before we 
convened, so this is why we are starting late at this time.
    Aloha, good afternoon, and welcome to today's hearing. I 
call the Committee on Veterans' Affairs of the U.S. Senate to 
order.
    We have a lengthy agenda that reflects the work of many 
members on both sides of the aisle. The health care bills 
before us today address crucial issues and seek to improve 
services to veterans. I anticipate that today's hearing will 
allow us to develop another strong package of veterans health 
legislation. I will briefly highlight a few of the bills on our 
agenda.
    Severely injured servicemembers and their families face 
many challenges as they return home. The bipartisan caregivers' 
bill, S. 801, will give family members the support they need to 
care for the Nation's wounded warriors in the form of health 
care, counseling, respite, and financial support. It also will 
give them the training they need to provide the best care 
possible for their loved ones.
    I am joined by Senator Baucus and Senator Begich in 
supporting a bill, S. 734, which would provide much needed 
services for veterans returning to rural areas. The wars in 
Iraq and Afghanistan have placed extraordinary demands on the 
country's National Guard and Reserve, with multiple 
deployments. When they return home, it is often to a small 
town, far from a military base. This bill will improve VA's 
ability to recruit and retain health care providers and 
encourage VA to use volunteer counselors and telehealth 
services to reach more veterans. It also expands VA's ability 
to pay for travel when the only practical way for a veteran to 
reach a health care facility is by air.
    Many other bills on the agenda reflect the dedication and 
hard work of my colleagues in support of the Nation's veterans. 
There are bills that will eliminate certain copayments for the 
catastrophically disabled, authorize additional health care 
facilities, and ensure the availability of services for women 
veterans and homeless veterans.
    Senator Rockefeller has introduced a bill that would remove 
a limitation on VA employees' collective bargaining rights when 
employment actions are related to quality-of-care concerns. 
Many are working on this issue, including Luanne Long, who is a 
nurse from Hawai'i and president of the Hawai'i Nurses 
Association of the United American Nurses. Although she is not 
testifying before the Committee today she has submitted a 
statement for the record; and I appreciate her work on behalf 
of VA employees.
    I am confident that VA's new leadership will work with the 
Committee in our efforts to provide comprehensive health care 
to the country's wounded warriors. We recently held 
confirmation hearings for the Secretary, the Deputy Secretary, 
and the Assistant Secretary for Public Affairs, all of whom 
expressed their support for the VA health care system. We will 
be counting on their support as we address many of these 
issues.
    Dr. Cross, I believe you have been advised, VA will not be 
permitted to testify today. Indeed, in light of the very late 
submission of the Department's testimony--it was not received 
until 8:48 p.m. last night--I was inclined to exclude VA 
entirely, since the members have not had the opportunity to 
review the testimony. While I will submit my questions in 
writing, I am providing the opportunity for other members to 
ask questions of you directly if they wish.
    I do not suppose that you are directly responsible for the 
unacceptable lateness of the submission of the Department's 
statement, but as the designated witness, you have to be the 
one to hear the Committee's concerns and carry them back to the 
Secretary and his top managers. If the Department is to 
participate in the legislative process, there must be, at a 
minimum, timely submission of testimony on pending legislation.
    I realize that there are a significant number of bills on 
today's agenda, but other witnesses were able to review and 
comment on the pending legislation in testimony that was 
submitted by the Committee's deadline. I will communicate 
directly with Secretary Shinseki, both to learn exactly what 
happened with respect to today's hearing and to identify ways 
to keep this problem from occurring again.
    The record of today's hearing will remain open for 2 weeks 
so that witnesses can submit supplemental views on any 
legislative item. It is important that we have your input well 
in advance of our markup, tentatively scheduled for late May.
    I want to thank the witnesses for being here today.
    I would like to now call on Senator Burr, our Ranking 
Member, for his opening statement. Senator Burr?

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Thank you. Aloha, Mr. Chairman.
    Chairman Akaka. Aloha.
    Senator Burr. You have outdone yourself with the number of 
bills we are trying to cover in this hearing, but I will never 
complain to you about the volume of what we are trying to 
undertake in this Committee, I will assure you.
    Let me start by thanking you, Mr. Chairman, for working 
with me on legislation to provide assistance to the family 
caregivers of seriously injured veterans. I want to single out 
two special North Carolinians, Sarah and Ted Wade. 
Unfortunately, they are not here today, but they have spent 
many hours reviewing drafts of the bill before it was 
introduced. Their unique perspective on the needs of both 
family caregivers and seriously injured veterans needing full-
time care was absolutely essential in the crafting of this 
legislation.
    I am also proud to join you, Mr. Chairman, on legislation 
that would create a process under which the VA could be 
provided with a medical care budget 1 year ahead of time. It is 
very important and possible that we will have two 
appropriations for VA enacted this year, the first for 2010, 
the second for 2011. It will be nice to get the VA budget 
completed well ahead of time for a change.
    I am pleased to see that legislation I introduced to create 
a voluntary dental insurance benefit for all veterans and 
survivors of veterans enrolled for care at VA is on the agenda. 
The legislation is modeled after the popular TRICARE retiree 
dental program and simply gives veterans the option to pool 
together and get coverage that they might need.
    One of the bills on the agenda that I feel passionately 
about is S. 669, the Veterans' 2nd Amendment Protection Act. 
Three other Members of the Committee have joined me as 
cosponsors of the bill, along with 12 of my Senate colleagues. 
The Committee voted to approve this bill last Congress and I 
hope to see it enacted this year. As many of you know, if a 
veteran comes to the VA for help and is later determined to 
need assistance managing benefit payments, their name is sent 
to the National Instant Criminal Background Check System, known 
as NICS, which is a government database that is used to deny 
individuals their Second Amendment rights. Over 117,000 names 
have been sent by the VA to this government database since 
1998. In contrast, the Social Security Administration sends no 
names to this government database, despite having over five 
million beneficiaries who require assistance managing their 
finances.
    I have three problems with this policy. First, I believe 
our veterans are being unfairly targeted. Second, I believe it 
is inappropriate for a government employee to be able to make 
these types of decisions. And third, the current process 
doesn't even assess whether these individuals pose a danger to 
themselves or to others.
    S. 669 would prohibit VA from sending the names of veterans 
and others to the government database unless--and I stress 
``unless'' so it is clear to everyone--an appropriate judicial 
authority makes the determination that an individual poses a 
danger to themselves or to others, which is the same standard 
applied to every other American. By simply asking for due 
process, this bill respects protection of constitutional 
rights. We must provide our veterans with the due process 
granted to every other citizen.
    I wish I knew what the position of the Department of 
Justice was on this legislation, Mr. Chairman. You were nice 
enough to invite the Attorney General or his designee to come 
to testify, and as you can see, they are not here. I don't 
understand the reason for their absence here today. If the 
current practice is justified, then there should be no 
reluctance to have an administration official testify about 
this bill. In my view, this is the second time in less than 2 
weeks the Administration has tacitly endorsed an effort to 
unfairly target veterans.
    Just last week, the Department of Homeland Security 
released a report entitled ``Right-Wing Extremism,'' which 
states that, and I quote, ``Returning veterans possess combat 
skills and experience that are attractive to right-wing 
extremists.'' unquote, without any data to support such a vile 
claim against our Nation's veterans. The report suggests that 
those veterans who are, and I quote, ``. . . disgruntled, 
disillusioned, or suffering from the psychological effects of 
war,'' unquote, are more likely to join these groups. Again, 
without any data to substantiate such a claim, a Federal 
Government agency paints our veterans as extremists. This 
assessment of our veterans is not only misguided, it is an 
absolute insult to every one of them.
    In closing, I would like to submit testimony for the record 
sent to the Committee by Retired Coast Guard Lieutenant Jerri 
Geer. Lieutenant Geer came to VA for help in 2002 because she 
was having problems with her finances. Shortly thereafter, she 
received a letter telling her that she was placed on the 
government's criminal database used to prevent the purchase of 
firearms. What is ironic is that Lieutenant Geer doesn't even 
like guns. She was simply offended by the arbitrary manner in 
which her name was placed on a list with criminals and people 
who are threats to themselves and to others; and by how easily 
her rights as an American could be violated. I think all of us 
in this room would be offended if, in fact, we were placed on 
that list.
    I ask my colleagues for their support on S. 669 so that we 
can right what I think is a tremendous wrong.
    I thank the Chair.
    [The testimony of Lieutenant Geer is included in the 
Appendix.]
    Chairman Akaka. Thank you very much, Senator Burr.
    Let me call for your statements, Senator Brown, followed by 
Senator Johanns. Senator Brown?

               STATEMENT OF HON. SHERROD BROWN, 
                     U.S. SENATOR FROM OHIO

    Senator Brown. Thank you, Mr. Chairman.
    I would like to thank Deputy Under Secretary Cross for 
joining us today and being able to answer questions. I would 
like to thank Dr. Cross for his previous testimony at a field 
hearing in New Philadelphia, Ohio, 18 months or so ago about 
veterans in Appalachia which led to legislation that will 
particularly help rural hospitals and some of the issues we 
deal with.
    I want to thank the VSOs that are here and the 
representative from AFGE for your assistance.
    The legislation pending before the Committee, all of it is 
beneficial. In the interest of time, I will focus on two bills 
that are vitally important to my State. In Ohio, there are over 
one million veterans. That number is growing rapidly, as it is 
elsewhere, as men and women return from their service overseas 
in Iraq, Afghanistan, and deployments all over the world. In 
the last couple of years, I have held some 140 roundtables, at 
least one in each of Ohio's 88 counties, and several of them 
have been directly talking to groups of 15 or 20 veterans and 
listening to their ideas and concerns.
    Last year, Petty Officer Glenn Minney, USN (Ret.), an Iraq 
veteran from Chillicothe in South Central Ohio, shared his 
transition experience after surviving an IED blast. Glenn was 
treated for his headaches with ibuprofen, and for his eye 
discomfort he was given pink eye medication. It wasn't until 
nearly 8 months after he was injured that Glenn Minney was 
diagnosed with severe TBI. He advocated for increased attention 
to eye trauma in relation to TBI to prevent other veterans from 
suffering the months of uncertainty that he endured as his 
eyesight continued to deteriorate.
    TBI and PTSD are intimately related to vision problems as 
well as cognitive issues, memory lapses, anger, frustration, 
and other mental health issues. Glenn Minney is unfortunately 
not alone, as we know. As a result of the wars in Iraq and 
Afghanistan, there is an increasing number of head trauma and 
Traumatic Brain Injuries. Over one thousand servicemembers have 
been hospitalized with ocular or eye injuries.
    The VA has a critical shortfall in the number of blind 
rehabilitation outpatient specialists, with nearly one-third of 
those positions unfilled. As more servicemembers return from 
combat with eye injuries, we have a commitment to ensure they 
have access to rehab specialists.
    To address the gap in access to vision specialists, I 
introduced the Vision Scholars Act of 2009, which we will 
discuss today. The bill would improve VA recruitment of blind 
instructors while giving our Nation's veterans the 
comprehensive care they deserve.
    The second bill I would like to briefly discuss improves 
collective bargaining rights of VA employees. All VA employees 
have a proud tradition of faithful service, but they work side-
by-side in the same facility for our veterans but have unequal 
rights. Collective bargaining provides vital workplace 
protection for employees, helping to ensure higher safety 
standards, fair wages, and pension security.
    In 1991, Congress provided VA medical professionals with 
the same labor relations rights held by other Federal employees 
but carved out three exceptions that dealt with direct patient 
care. In the 1990s, labor and management entered into a 
partnership that set a process for resolving disputes, which 
worked well until the Bush administration abandoned the 
partnership. The narrow exceptions of the law now bar 
grievances over disputes that Congress never envisioned, such 
as scheduling and floating assignments for nurses. As a result, 
VA health care professionals are unable to negotiate for 
working conditions that are widely available to other 
clinicians at the VA and outside, too, for that matter.
    These workplace practices negatively affect recruitment and 
retention and morale and, ultimately, patient care. The 
veterans in my State and across the rest of this great country 
deserve the best health care and the best health care 
providers. Many of these providers, as we know--and we urge 
this more and more in the VA--are veterans themselves. That is 
why I have cosponsored this legislation with Senator Mikulski 
and my colleagues on this Committee: Senator Rockefeller, 
Senator Webb and Senator Sanders.
    So, I am looking forward to hearing testimony on these two 
bills and beyond. Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Brown.
    Senator Johanns?

                STATEMENT OF HON. MIKE JOHANNS, 
                   U.S. SENATOR FROM NEBRASKA

    Senator Johanns. Mr. Chairman, thank you very much for the 
opportunity to say a few words.
    Let me, if I might, start out and, just for the record, 
join in the comments made by Ranking Member Burr. I also 
thought it was just completely inexcusable that the head of a 
Federal Department would make such statements about veterans in 
claiming that they pose a risk to our society. We bring them to 
military service to protect us, and then as they leave military 
service, to tag them with that kind of label is just enormously 
unfair.
    Let me talk about a recent experience that I had. I was 
back home in Nebraska for a recess and we had a veterans' 
roundtable where we brought veterans in and representatives of 
veterans organizations to really talk about whatever was on 
their mind. It wasn't very long before we turned to health care 
issues. One of the things about this roundtable is we had a 
spouse there whose husband was suffering from Post Traumatic 
Stress Disorder. We had a veteran there who was continuing to 
receive care through the system. So, we really got some great 
information. I got some great information as to some of the 
challenges that they are facing.
    The first thing I would like to say on Post Traumatic 
Stress Disorder--and it is hard to explain unless you have 
heard a family member speak of this--is how devastating it is, 
not only to the veteran but to the family members--the 
challenge that the veteran and family members face in terms of 
getting cured. It is something that I find just completely 
unacceptable. Anything we can do in this area is going to be a 
big improvement.
    I would offer this thought. When services are provided by 
the Veterans Administration, it appears to me that the services 
are good. The challenge is how to get those services and how to 
uncomplicate the process by which a veteran can access those 
services--a very, very important issue.
    The second issue that I wanted to visit is one which is a 
challenge for many of us on this panel. I come from a State 
that is a combination of large metropolitan communities like 
Lincoln and Omaha, Kearney, Grand Island, and very rural, small 
communities where we really, really struggle to provide 
services. We are facing that problem with medical services and 
mental health services. It is nearly impossible to get the 
trained personnel into those areas.
    So again, anything that we can do to help in these areas is 
going to find my support. These veterans want to return to 
where they came from, and sometimes that is ranching or farming 
or taking on the family business in a small community in 
Western Nebraska. We want to do everything we can to encourage 
that. That is very, very important to States like Nebraska. But 
if they need mental health services or medical services, we 
need to figure out ways to provide that to them. So, I am very 
anxious to hear the testimony today and very anxious to work 
with you in solving these problems.
    Mr. Chairman, I will wrap up just by saying, thank you for 
having this very important hearing. I hope to be a partner with 
you as we work on these issues. Thank you.
    Chairman Akaka. Thank you very much, Senator Johanns.
    Senator Tester?

                 STATEMENT BY HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman, and I want to 
thank all the distinguished witnesses who are here today to 
discuss pending health-related legislation before this 
Committee.
    Just last month, after hearing from and working with a lot 
of veterans in Montana, I introduced the Rural Veterans Health 
Care Improvement Act. This legislation would expand health care 
for thousands of Montanans and millions of other veterans who 
live in rural and frontier areas of this country. I want to 
thank Senator Thune and Senator Begich for their work on this 
legislation and I appreciate their interest in this issue.
    The obstacles faced by veterans and providers in rural 
areas are vastly different than those in urban areas. Rural 
veterans face a new combination of factors that create 
disparities in health care not found in larger cities and 
municipalities. Access, economic factors, cultural and social 
differences, educational shortcomings, a lack of provider and 
health care services, and the sheer isolation of living in 
remote rural areas all conspire to impede rural veterans in 
their struggle to obtain care and lead a normal, healthy life. 
Without question, our veterans have greater transportation 
difficulties reaching health care providers. They often travel 
great distances to reach a doctor or hospital. Sometimes, they 
just don't go at all.
    I want to share a few statistics from the National Rural 
Health Association to underscore this issue. Ten percent of 
physicians practice in rural America, despite the fact that 
one-fourth of the population lives in these areas. It puts us 
at a big disadvantage. It means it is harder to find a rural 
veteran a doctor, period.
    Twenty percent of the rural counties lack mental health 
services versus 5 percent of metropolitan counties. This means 
that our rural veterans are less likely to see or have access 
to mental health providers that can diagnose and treat things 
like PTSD and other combat-related mental conditions.
    The suicide rate among rural men is significantly higher 
than in urban areas, particularly among adult male veterans. 
Who is there to intervene, and do we transport them in cop cars 
for hours to get them to mental treatment facilities or a 
critical care bed?
    And finally, death and serious injury accidents account for 
60 percent of total rural accidents, compared to some 48 
percent in urban areas. One reason for this increased rate of 
morbidity and mortality is that in rural States, prolonged 
delays occur between the crash, the call for the EMT, and the 
EMT arriving. This means that veterans driving long distances 
to obtain care are more likely to die if involved in a serious 
motor vehicle accident.
    The statistics are sobering and highlight why we must 
improve health care for veterans who reside in rural areas. The 
Rural Veterans Health Care Improvement Act of 2009 does several 
things that will help. First, it locks in the current travel 
reimbursement for disabled veterans who travel for health care 
at 41.5 cents a mile. It authorizes the VA to award grants to 
Disabled American Veterans to transport veterans to their 
medical appointments, and it directs the VA to establish an 
Indian Health Coordinator in areas with high Native American 
veteran populations to improve the care given to Native 
veterans. It authorizes the VA to work with community health 
care centers and provide mental health services to Iraq and 
Afghan veterans in areas where the VA is unable to provide 
mental health care.
    It is just a start and we have a lot more to do, and I 
certainly appreciate the VSOs for bringing the issue forward 
and remaining focused on our rural veterans. I want to 
personally thank Chairman Akaka for introducing additional 
legislation that will complement this bill by improving the 
VA's hiring and employee compensation practices.
    With that, I conclude my remarks and I want to thank the 
panel members once again, the Committee, and Chairman Akaka.
    Chairman Akaka. Thank you very much, Senator Tester.
    Senator Burris?

              STATEMENT OF HON. ROLAND W. BURRIS, 
                   U.S. SENATOR FROM ILLINOIS

    Senator Burris. Thank you, Mr. Chairman.
    Members of the Committee, I hope I am around to get some 
answers to the questions, because during the recess I visited 
the Marion VA Hospital down in southern Illinois. My staff, Mr. 
Chairman, had a very difficult time with staff at the VA 
wanting to know why I was coming to Marion. Because Marion has 
had a few problems, they brought staff in from other locations. 
They brought staff in from Washington and they even brought the 
General Counsel in to be at the briefing that I was getting for 
visiting Marion Hospital, I assume because there have been 
problems there.
    My staff advised me that the staff at the VA were telling 
them that we didn't give them enough time, that we should have 
given them more time to prepare, and I found that very 
disconcerting--for a Senator to try to visit a veterans 
hospital just to get educated and get a fact-finding tour--that 
the VA was very defensive in that regard. But come to find out 
they were very accommodating and it turned out to be a decent 
meeting. But I just would like for someone to give me an 
explanation on why that type of treatment--as a Senator, I went 
to a North Chicago hospital and there was no problem. I visited 
Jesse Brown Hospital and there was no problem. But I wanted to 
go to Marion and they sent in people from Washington and 
brought in the General Counsel.
    Yes, there have been several veterans who died there as a 
result of incompetent medical care. So I just want to be on the 
record as having expressed my concern about that situation as I 
compliment what we are doing for our veterans.
    And second, this health care issue is very important. Just 
this Saturday, I had over 250 veterans at a town hall meeting I 
attended. It is called the Coalition of Veterans Organizations, 
and these individuals expressed their main concern is health 
care--health care for women veterans. Women are not the same as 
male veterans. There is special care that women need, and so we 
must be sensitive to those situations. Also, on the dental care 
issue, we must make sure that we move in that direction; and I 
hope that we will hear some testimony in that regard. Mr. 
Chairman, if I am not around because I have got two or three 
other stops to make on other committees, I would hope to be 
able to bring some questions in reference to some issues that I 
have.
    But I want to go on the record in terms of my commitment to 
those individuals--and this is my favorite expression, Mr. 
Chairman--that allow us to do what we do because they did what 
they did in protecting this country and fighting for us. And 
they are entitled to whatever we can give them as taxpayers for 
their commitment to allow us to be a free country. We cannot 
forget those individuals who put their lives on the line for 
us. I will reserve the rest of my time, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Burris.
    Senator Begich?

                STATEMENT OF HON. MARK BEGICH, 
                    U.S. SENATOR FROM ALASKA

    Senator Begich. Thank you very much, Mr. Chairman. Thank 
you for holding this hearing to provide an opportunity to hear 
responses to the legislation sponsored by several of us here 
including, obviously, the Chairman, who has spearheaded many of 
these pieces of legislation. I am a cosponsor on six of these 
pieces and a lot of it for me is to hone in on the obvious 
health care, and also rural health care.
    In Alaska, I think in the last Commerce Committee meeting, 
I coined the phrase ``extreme rural,'' which is what Alaska is. 
And so, we have very unique situations that I think are also an 
opportunity for some prototype and some experimentation--some 
new ways to deliver health care that could be a model for other 
States around the country, especially those that have kind of 
mixed urban and rural geography--Montana, Nebraska, and others. 
So, I am going to be interested in your responses, especially 
on rural health care.
    On another issue, reimbursement, not only vehicle miles and 
plane tickets for individuals, but one more step. We have a 
very unique program in Alaska, and during the questions I will 
ask a few more details about your thoughts on it. We have one 
program that actually has three or four, if I am not mistaken, 
maybe as many as five pilots that actually fly out on their own 
dime with their own plane to go help veterans out in rural 
communities which the VA will never get to; no commercial 
airline will ever get to. And so, the reimbursement for them is 
zero.
    An idea I want to float to see how you would respond is one 
of the issues they asked for--not that they are asking for 
reimbursement of their time or their effort or their plane--but 
just some of the fuel costs as they reach rural areas, because 
if the VA had to fly these individuals out or pay for that, it 
would be very, very expensive. Uniquely so, there is a twist on 
it, because in Alaska we have the highest per capita amount of 
small planes per person in the country. We are in a very unique 
situation. The plane and bush pilot, is the cab driver, and so 
I want to explore that with you.
    Another issue in Alaska is that we have about 600 homeless 
veterans. I know in a bigger sense, that may be small compared 
to other communities, but we have very unique climate 
conditions that homeless veterans live in. So, I would be 
curious--in your expansion, in your opportunities--of what you 
see down the road in regards to homeless veterans. I believe 
that number is going to grow because one of the common 
denominators among the homeless population is mental illness or 
issues with mental health. We are going to see, I think, a 
growing percentage and number.
    And then the last question is, what efforts will you make 
in regards to new technologies? Telemedicine is a powerful 
technology in Alaska. I know the VA is experimenting with that 
and utilizing it. I think Alaska, again, is a great test ground 
for that and I would be interested in your commentary on that.
    But again, Mr. Chairman, thank you for hosting this 
hearing. I am looking forward to the panel's comments in 
regards to the legislation. I do believe, based on all the 
legislation that is in front of us, there are opportunities 
to--I don't know what the process is. I am new to the Senate, 
but it seems like we could meld some of these pieces of 
legislation into one to really focus in and hone in on 
delivering additional and more supportive rural health care to 
our veterans. And the larger percentage of veterans--from some 
of the data that I have seen in Alaska, at least, and it may be 
occurring around the country--more and more veterans are living 
in rural areas than urban areas. They are growing to that, not 
necessarily raw numbers, but in percentage growth. So, again, I 
think rural health care and rural delivery of health care is 
going to be a huge piece of the equation.
    I will end there and say thank you very much, Mr. Chairman, 
for this opportunity.
    Chairman Akaka. Thank you very much, Senator Begich.
    Let me call on Senator Sanders.

              STATEMENT OF HON. BERNARD SANDERS, 
                   U.S. SENATOR FROM VERMONT

    Senator Sanders. Thank you, Mr. Chairman.
    Before I comment on the legislation before us, let me say a 
word about this so-called political controversy regarding the 
Secretary of Homeland Security. Of course, the Secretary of 
Homeland Security did not say anything disparaging about 
veterans. This is just politics that are the same old, same 
old. What she was reporting is that there has been a 
significant rise in right-wing extremism in this country, 
including some groups who advocate violence, and that they are 
targeting veterans as well as other groups. That is what she 
said, and I think she is right. We have to be concerned about 
that.
    But Mr. Chairman, in terms of what we are talking about 
today, let me thank you for holding this important hearing. I 
am also delighted to have the witnesses with us today from the 
VA and other organizations.
    I also want to congratulate the Chairman for his advanced 
appropriations legislation and to announce what everybody 
knows, is that we finally have a President of the United States 
who is in support of advanced appropriations. This is a big 
deal and I think is going to make the appropriations process 
for our veterans a lot more secure, a lot more predictable, and 
it is a huge step forward. I congratulate you, Mr. Chairman, 
and President Obama for taking that step.
    In addition, I want to thank Chairman Akaka for including a 
version of Senator Feingold's and my legislation, S. 315, the 
Veterans Outreach Improvement Act of 2009, in his omnibus 
health care bill, S. 252, that is on the agenda today. This 
provision would create a VA pilot grant program funded by the 
Department of Veterans Affairs to give resources to eligible 
community-based organizations and local and State entities, 
including Veterans Service Organizations, to conduct outreach 
programs to inform veterans and their families about VA 
benefits.
    The bottom line is, we could have the best programs in the 
world for our veterans, but if they don't know about them, it 
is not going to do anybody any good. In Vermont, we have 
developed an outreach program which is working. I think this 
concept will help. We want veterans to know what they are 
entitled to. If they want to take advantage of it, fine. If 
not, fine, but they should know about it.
    Mr. Chairman, one of the bills included on today's agenda 
is another piece of legislation I have introduced, S. 821, a 
bill to prohibit the VA from collecting certain copayments from 
veterans who are catastrophically disabled. This Committee 
approved a version of this legislation last year and it also 
was passed in the House by the very close vote of 421 to 
nothing. Unfortunately, it was not signed into law and I hope 
we have better luck this year. I want to thank the Paralyzed 
Veterans of America, the Blinded Veterans Association, the DAV, 
and the American Federation of Government Employees, who all 
support this legislation.
    In short, this legislation would eliminate copayments paid 
by catastrophically disabled veterans who are currently 
considered Priority Group 4 veterans, yet are charged fees and 
copayments as if they were in Priority Group 7 or 8. As the 
Paralyzed Veterans of America note in their prepared testimony, 
``In 1985, Congress passed legislation opening the VA health 
system to all veterans. In 1996, Congress revised the law and 
created a set of rankings or priority groups. When this was 
done, PVA worked to ensure that those veterans with 
catastrophic disabilities would be placed in a higher 
enrollment category known as Priority Group 4. However, unlike 
other Category 4 veterans, if they would otherwise have been in 
Category 7 or 8 due to their incomes, they are required to pay 
all fees and copayments . . .'' I think clearly that is a 
miscarriage--a disservice to those veterans who are suffering 
from major physical problems.
    So, Mr. Chairman, I hope very much that we can pass those 
pieces of legislation as well as the others that are before us 
today and I thank you very much.
    Chairman Akaka. Thank you very much, Senator Sanders.
    Senator Murray?

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Thank you very much, Mr. Chairman. I thank 
you and Senator Burr for holding this hearing and thank you to 
all the witnesses who are before us today.
    I think everyone on this Committee knows that the health 
care needs of our American veterans are shifting and 
diversifying and health care technologies and techniques are 
changing, too. So when it comes to providing care for our 
veterans, this really is a time of challenge and opportunities. 
And, of course, with our troops now fighting in Iraq and 
Afghanistan, it is very important that Congress use its 
legislative powers to make sure that the VA is prepared to meet 
the health care needs of our veterans tomorrow as well as 
today.
    One of the best ways that I believe we can address the 
needs on the horizon is to pass the Women Veterans Health Care 
Improvement Act of 2009, which expands and improves health care 
services for our women veterans in the VA system. Women have 
always played a very important role in our military, going back 
to the founding of our country. However, as we all know, in 
today's conflicts, women are playing a far different and a far 
greater role. Women now make up about 15 percent of current 
active duty, Guard, and Reserve forces, and because today's 
conflicts don't have the clear front lines of past wars, women, 
like all of our servicemembers today, are on the front lines--
riding on dangerous routes, guarding key checkpoints, and 
seeing the horrors of war firsthand.
    Women have historically remained a very small portion of 
veterans and a small minority at the VA. That is changing. 
According to the VA, there are now 1.8 million women veterans 
who make up more than 7 percent of the total veteran population 
in the United States. And the number of women veterans who are 
enrolled in the VA system is expected to double in the next 5 
years. That makes female veterans one of the fastest-growing 
demographics of veterans today.
    So, we cannot overlook the growing number of women veterans 
or their unique needs any longer. We have to make sure that the 
VA is prepared to take care of the needs of these honorable 
veterans, and that is why Senator Hutchison and I have 
introduced the Women Veterans Health Care Improvement Act of 
2009. This is legislation that will encourage female veterans 
to access care at the VA by increasing the VA's understanding 
of the needs of women veterans and the practices that will help 
them best.
    I know that the VA recognizes they need to improve services 
for our women veterans, and the Department has taken some steps 
to do that. All VA medical centers are now supposed to have 
full-time women veterans program managers to make sure that 
women veterans' needs are taken care of. But a lot more needs 
to be done if we are going to ensure that women are able to 
access care at the VA and get the services they need, and that 
these services are tailored to women's needs.
    So I believe that planning for the new wave of women 
veterans is going to be difficult and complex, but it is a task 
that needs to be addressed and I hope that this Committee can 
pass this legislation this year and move it to the President's 
desk.
    I also want to mention another bill on the docket today 
that authorizes the construction of an outpatient clinic at the 
VA medical center in Walla Walla in the southeast corner of my 
home State. Not long ago, the VA came before us and recommended 
shutting down that facility. And I have been very proud to 
fight alongside the veterans in the three-State region served 
by the Walla Walla VA, to save Walla Walla VA and ensure that 
it has a future. This has been a battle very close to my 
heart--I know the VA knows that--because it is critical to 
70,000 veterans who are served by that facility.
    Since 2003, when this issue first arose, I have used every 
tool at my disposal to make sure that Walla Walla veterans are 
taken care of. I sent letters to the VA Secretary. I contacted 
President Bush. This Committee held a hearing out in Walla 
Walla to solicit the thoughts and concerns of local veterans. 
And I think all of our veterans in that area sent a loud, clear 
message that was heard, that southeastern Washington needs the 
existing VA facilities and it deserves a new, modern VA 
facility, as well.
    So back in November, the VA announced that the Walla Walla 
VA is going to get more than $71 million for the design and 
construction of a new outpatient clinic to serve those local 
veterans; and I truly want to thank the VA for all of their 
work on this. I was thrilled by that development and it is a 
major victory for our veterans.
    Now, since that money has already been approved, this 
legislation that is before us today simply authorizes the 
construction of a new multiple-specialty outpatient facility at 
the Walla Walla VA. So after 5 years of uncertainty and a whole 
lot of veterans speaking out, we are almost there. This 
legislation is key and I really thank the Committee for 
considering it today. I hope we can approve it soon and move it 
forward.
    Thank you very much.
    Chairman Akaka. Thank you very much, Senator Murray.
    Now let me introduce the first panel. Dr. Gerald Cross, 
Principal Deputy Under Secretary for Health, will be answering 
questions. He is accompanied by Walter Hall, Assistant General 
Counsel, and by Joleen Clark, Chief Officer for Workforce 
Management and Consulting at VHA.
    I thank all of you for being here today. VA's full 
testimony will appear in the record.

  STATEMENT OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY 
    UNDER SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS 
   AFFAIRS; ACCOMPANIED BY WALTER A. HALL, ASSISTANT GENERAL 
COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND JOLEEN CLARK, 
  CHIEF OFFICER FOR WORKFORCE MANAGEMENT AND CONSULTING, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    [The prepared statement of Dr. Cross follows:]
 Prepared Statement of Gerald M. Cross, M.D., FAAFP, Principal Deputy 
       Under Secretary for Health, Department of Veterans Affairs
    Good Afternoon Mr. Chairman and Members of the Committee: Thank you 
for inviting me here today to present the Administration's views on a 
number of bills that would affect Department of Veterans Affairs (VA) 
programs of benefits and services. With me today are Walter A. Hall, 
Assistant General Counsel and Joleen Clark, Chief Workforce Management 
and Consulting Officer for VHA. Unfortunately, we do not yet have views 
and estimates on several bills including S. 239, S. 498, S. 699, S. 
772, S. 793, subsection (f) of S. 252 and S. 821. We will forward those 
as soon as they are available. Our support for the bill provisions 
discussed below is contingent upon VA's ability to fund such activities 
within the President's 2010 budget.
      s. 226 ``renaming of the havre, montana outpatient clinic''
    Mr. Chairman, the first bill on the agenda is S. 226, a bill to 
rename the Havre, Montana VA Outpatient Clinic the Merril Lundman 
Department of Veterans Affairs Outpatient Clinic. VA defers to Congress 
concerning this matter.
        s. 246 ``veterans health care quality improvement act''
    S. 246 is intended to encourage highly qualified doctors to serve 
in hard-to-fill positions. Section 2(a) would establish additional 
standards for appointment and practice as a VA physician. We note that 
S. 252, Section 104, has substantially similar provisions. Section 2(a) 
would require physicians, both before and following appointment, to 
disclose lawsuits, civil actions, other claims (whether open or closed) 
that result in payment and settlement payments and judgments that are 
based on the physician's medical malpractice or negligence, each 
investigation or disciplinary action taken relating to the individual's 
performance as a physician, and written notification from a State of a 
potential termination of license for cause or otherwise. It also would 
require a physician before appointment and at the time of biennial 
review of performance to authorize the State licensing board in each 
State in which the physician holds or has held a license to disclose 
anything in State records concerning such matters. Other provisions of 
this section would mandate enrollment of any privileged physician in 
the National Practitioners Data Bank (NPDB) Proactive Disclosure 
Service and encourage the hiring of board-certified physicians. VA has 
no objection to these requirements. However, legislation is 
unnecessary. VA already requires physicians to disclose anything that 
would adversely affect or otherwise limit their appointment and/or 
clinical privileges. Following appointment and at the biennial review 
of performance, VA also requires physicians to authorize the relevant 
State licensing boards to disclose information. Failure to disclose or 
provide authorization may be grounds for denial of appointment or 
termination from employment. Mandatory enrollment of VA physicians in 
the NPDB Proactive Disclosure Service has been required since November 
2008. VA has long recognized board certification as important evidence 
of professional attainment and has given it significant consideration 
in recruiting and hiring physicians.
    VA has no objection to the majority of the provisions in Section 2 
relating to standards for appointment and practice of physicians in VA 
medical facilities and has already implemented most in agency policy. 
However, VA strongly opposes the requirement in Section 2 for Network 
Directors to approve physician appointments. This will introduce 
unacceptable and unnecessary delays into the process for appointing 
physicians. It is unnecessary since significant safeguards have been 
implemented to strengthen the process of medical staff appointments. 
Also it is important to recognize that granting clinical privileges 
requires local knowledge, including clinical performance and peer-
review information, which is not readily accessed at the VISN level.
    Section 3 would require the appointment of board-certified 
physicians as Quality Assurance Officers (QAO) at the national, VISN, 
and facility level. It would also mandate a comprehensive review of all 
quality and safety programs and policies, including a detailed review 
of the National Surgical Quality Improvement Program (NSQIP). A report 
to Congress of the results of this review would be due within 60 days 
of enactment. VA does not oppose Section 3, and has already taken steps 
to increase the involvement of qualified physicians in quality 
leadership throughout the health care system. We note that the needs of 
smaller facilities can often be met by a part-time QAO, who may also 
have other clinical or administrative duties.
    Under Section 4(a), VA would provide certain incentives, including 
student loan repayment, to physicians for service in hard-to-fill 
positions. Since we do not believe another loan repayment program is 
necessary, VA does not support this provision. VA can currently 
authorize educational loan repayment incentives to physicians in hard-
to-fill positions through the Education Debt Reduction Program (EDRP). 
The provisions of S. 246 would establish a second debt repayment 
program operating under separate legal authority and regulatory 
guidelines, increasing complexity and potential confusion. In addition, 
the legislation creates a loan repayment program only for physicians 
and excludes all other occupations, regardless of the hiring needs and 
priorities of the Department. Current law provides comprehensive 
incentives available to more than 32 health care professional 
occupations. We estimate that the cost of the loan repayment incentive 
program described in Section 4(a) would be $4.6 million in the first 
year, $54.9 million over five years, and approximately $186.5 million 
over ten years.
    We are opposed to another incentive program in Section 4(a) that 
would require VA to institute a program of tuition reimbursement for a 
course of education leading to board certification for physicians who 
agree to serve as physicians in VA. We cannot support this provision 
for several reasons. The time between the granting of tuition 
reimbursement and when the physician would become board certified is 
too long. Medical school and internship together can take seven years 
or longer to complete, depending on the specialty. Hard-to-fill 
specialties would likely have longer education requirements. During 
that time, VA's priorities and hard-to-fill positions can change 
significantly. Signing a contract today for services and obligations 
that will not begin for several years is subject to many risk factors 
that cannot be foreseen. Undoubtedly the personal circumstances and 
career objectives of many physicians would change, administering the 
contracts and monitoring the program would be complex, and the 
opportunities and occasions for civil court actions could also require 
substantial resources. Further, many students may fulfill their 
contract obligations but for one reason or another may not be an 
appropriate hire for VA at the time they are eligible. For example, 
certification may be beyond the capabilities of the graduating students 
in the tuition reimbursement program. There could be many circumstances 
under which VA's investment would not pay off but there would be 
insufficient grounds for seeking repayment. Assuming a student would 
receive the full reimbursement each year, as well as the annual 
stipend, over an eight-year period taxpayers will have invested 
$280,000 in the student before he or she begins working for VA. If upon 
graduation the doctor does not or cannot fulfill his or her employment 
obligation to VA, such a sizable investment would be very difficult to 
recoup. Considering the amount of the reimbursement and stipend per 
student and the cost of administration, we estimate that the program 
cost to be $283,000 in the startup year, $51.7 million over five years, 
and $174.7 million over ten years.
    Section 4(b) would require VA medical facilities to seek to 
establish an affiliation with a medical school within reasonable 
proximity of such facility. Mr. Chairman, VA strongly supports the 
concept of affiliations and we are actively engaged in their expansion. 
In 2008, more than 100,000 medical and associated health students, 
residents, and fellows received some or all of their clinical training 
in VA facilities through affiliations with more than 1,200 educational 
institutions, including 107 medical schools. Many of these trainees 
have their health profession degrees and contribute substantially to 
VA's ability to deliver cost-effective and high-quality patient care 
during their advanced VA clinical training. As the Nation's health care 
system evolves, VA continues to be on the leading edge with innovative 
education and training programs. Therefore, we believe that the 
statutory requirement to pursue affiliations is unnecessary.
       s. 252 ``veterans health care authorization act of 2009''
    S. 252 contains seven separate titles addressing a wide range of 
issues including personnel matters, homeless veterans, nonprofit 
research and education corporations and many health care matters 
including provisions specific to mental health and women veterans 
health care. Title I contains several provisions intended to enhance 
VA's ability to recruit and retain nurses and other health-care 
professionals and set certain standards for appointment and practice of 
physicians. These provisions are virtually identical to those reported 
in S. 2969 from the 110th Congress. We appreciated the opportunity to 
work with Committee staff on the prior bill and to provide technical 
comments and operational observations. We note that the reported bill 
and now Title I of S. 252 address many of our concerns and comments. 
However, there are several provisions we cannot support.
    Section 101 contains provisions for the enhancement of authorities 
for retention of medical professionals.
Secretarial Authority to Extend Hybrid Status to Additional Occupations
    Subsection (a) would provide the Secretary authority to extend 
hybrid status to additional occupations. It would add ``nurse 
assistants'' to the list of so-called hybrid occupations for which the 
Secretary is authorized to appoint and to determine qualifications and 
rates of pay under title 38. In addition, it would authorize the 
Secretary to extend hybrid status to ``such other classes of health 
care occupations as the Secretary considers necessary for the 
recruitment and retention needs of the Department'' subject to a 
requirement to provide 45 days' advance notice to the Veterans' Affairs 
Committees and OMB. Before providing such notice, VA would be required 
to solicit comments from unions representing employees in such 
occupations.
    VA favors such a provision. Nursing Assistants are critical to the 
Veterans Health Administration's (VHA) ability to provide care for a 
growing population of older veterans, who are high-acuity patients and/
or frail elderly requiring 24-hour nursing care. Turnover data, 11.1 
percent for 2007 and 10.96 percent for 2008, illustrate the great 
difficulty VA experiences in retaining this occupation. It is 
increasingly critical for VHA to be able to quickly and easily employ 
these nurse extenders. The same holds true for other hard-to-recruit 
health care occupations. This bill would give the Secretary the ability 
to react quickly when it is determined that these authorities would be 
useful to help recruit and retain a critical occupation without seeking 
additional legislative authority. However, the bill language should be 
modified to specifically apply to occupations that clearly involve the 
delivery of health care. In addition, because this authority involves 
the conversion of title 5 occupations to title 38 hybrids, the 45-day 
notice requirement should be modified to add OPM. Thus, we recommend 
modifying subsection 2(a) of the bill to read:

        (a) Secretarial Authority to Extend Title 38 Status to 
        Additional Positions.
        (1) In general.--Paragraph (3) of section 7401 of title 38, 
        United States Code, is amended by striking ``and blind 
        rehabilitation outpatient specialists.'' and inserting in its 
        place the following: ``blind rehabilitation outpatient 
        specialists, and such other classes of health care occupations 
        who
        (A) are employed in the Administration (other than 
        administrative, clerical, and physical plant maintenance and 
        protective services employees);
        (B) are paid under the General Schedule pursuant to section 
        5332 of title 5;
        (C) are determined by the Secretary to be providing either 
        direct patient care services or services incident to direct 
        patient-care services; and
        (D) would not otherwise be available to provide medical care 
        and treatment for veterans;
        (E) as the Secretary considers necessary for the recruitment 
        and retention needs of the Department.
        (2) Notwithstanding chapter 71 of title 5, United States Code, 
        the Secretary's authority provided in paragraph (1) is subject 
        to the following requirements:
        ``(A) Not later than 45 days before the Secretary appoints any 
        personnel for a class of health care occupations that is not 
        specifically listed in this paragraph, the Secretary shall 
        submit to the Committee on Veterans' Affairs of the Senate, the 
        Committee on Veterans' Affairs of the House of Representatives, 
        the Office of Personnel Management, and the Office of 
        Management and Budget notice of such appointment.
        ``(B) Before submitting notice under subparagraph (A), the 
        Secretary shall solicit comments from any labor organization 
        representing employees in such class and include such comments 
        in such notice.''
Probationary Periods for Part-Time Nurses
    Subsection (b) provides for probationary periods for part-time (PT) 
Registered Nurses (RN) and revises the probationary period for RNs, 
both full-time (FT) and PT, from 2 years to a maximum of its 
equivalency in hours, 4180. It also provides that a PT appointee who 
previously served on a FT basis in a ``pure'' title 38 position 
(7401(1)), and completed a probationary period in the FT position, 
would not have to serve a probationary period in the PT ``pure'' title 
38 position. VA opposes this provision. We believe this provision is 
technically flawed and would not be helpful.
    Part-time title 38 employees, including RNs, do not serve 
probationary periods. Probationary periods apply to full-time, 
permanent employees. We see no benefit to creating a probationary 
period for part-time nurses as these positions are temporary.
Prohibition on Temporary Part-Time Nurse Appointments in Excess of 
        4,180 Hours
    Subsection (c) would add a new section 7405(g) that would provide 
that part-time appointments of RNs are no longer temporary after no 
more than 4180 hours. After completion of the 4180 hours, the RN in 
essence would be converted to a permanent employee under section 
7403(a) who has completed the probationary period. VA opposes this 
provision because it would impair our ability to adapt to changing 
demands in patient need and resource allocations. VA currently has the 
authority to create temporary appointments for up to three years. If 
this proposal is enacted, VA would lose this valuable flexibility. VA 
uses this flexibility to manage positions during periods of changing 
patient care needs and budgets. Without this current flexibility, VA's 
ability to make adjustments in the size of our temporary workforce 
would be limited. VA and its employees would be put into an untenable 
dilemma of either preemptively dismissing employees just prior to the 
expiration of the their probationary periods when patient demand 
justifies their continued employment or allowing a nurse to convert and 
retain employment, even if patient demand no longer justifies that 
position. In either scenario, patient care would be placed in 
competition with organizational flexibility, while the current system 
allows VA to achieve and maintain both.
Reemployed Annuitant Offset Waiver
    Subsection (d) generally provides that annuitants may be 
temporarily reemployed in a title 38 position without being subject to 
having their salary offset by the amount of their annuity. VA opposes 
this provision as 5 U.S.C. 8344 and 8468 provide the agency access to 
retired title 38 health care providers.
Rate of Basic Pay for Section 7306 Appointees Set to Rate of Basic Pay 
        for SES
    Subsection (e) would amend section 7404(a) to add a provision 
setting the basic pay of non-physician/dentist section 7306 employees 
in accordance with the rate of basic pay for the Senior Executive 
Service (SES). This amendment would be effective the first pay period 
that is 180 days after enactment.
    VA supports the principle of pay equity with SES rates for its 
section 7306 non-physician/dentist executives as a tool needed to meet 
the challenge of recruitment and retention. Equity in pay for executive 
level managers and consultants is essential to attracting and retaining 
candidates for key positions. The pay schedule for 38 U.S.C. Sec. 7306 
appointees is capped at the pay rate for Level V of the Executive 
Schedule (currently $143,500). Locality pay is paid up to the rate for 
Level III (currently $162,900).
    Individuals appointed under 38 U.S.C. Sec. 7306 serve in executive 
level positions that are equivalent in scope and responsibility to 
positions in the SES. By comparison, employees in the SES receive a 
significantly higher rate of basic pay. The maximum SES pay limitation 
is the rate for Level II (currently $177,200) pending OPM certification 
that the agency meets all regulatory criteria for certified performance 
appraisal systems, including that the employing agency makes meaningful 
distinctions based on performance. We estimate the costs of this 
provision to be $343,917 in FY 2010 and $3,765,786 over a 10-year 
period.
    As noted, the SES pay system conditions pay up to EX Level II on 
OPM certification that an agency's SES rating system meets all 
regulatory criteria for certified performance appraisal systems. In 
this regard we note that VHA uses the same rating system for its 
section 7306 executives as it uses for its SES members. OPM has 
certified this system in the past, and just last year recertified VA 
through July 2010. For consistency, we recommend that the bill be 
modified to require that the Secretary make the same certification for 
the rating system covering section 7306 employees. Thus, we suggest 
that section 101(e)(3) be modified to read as follows:

        (3) Positions to which an Executive order applies under 
        paragraph (1) and are not described by paragraph (2) shall be 
        paid basic rates of pay in accordance with section 5382 of 
        title 5 for Senior Executive Service positions and not greater 
        than the rate of basic pay payable for level III of the 
        Executive Schedule; or if the Secretary certifies that the 
        employees are covered by a performance appraisal system meeting 
        the certification criteria establishedby regulation under 
        section 5307(d), level II of the Executive Schedule.
Comparability Pay Program for Section 7306 and SES Appointees
    Subsection (f) would amend section 7410 to add a new subsection to 
establish ``comparability pay'' for VHA non-physician/dentist section 
7306 employees and SES employees of not more than $100,000 per employee 
in order to achieve annual pay levels comparable to the private sector. 
Similar to provisions for RN Executive Pay in section 7452(g), it would 
provide that ``comparability pay'' would be in addition to other pay, 
awards and bonuses; would be considered base pay for retirement 
purposes; would not be base pay for adverse action purposes; and could 
not result in aggregate pay exceeding the annual pay of the President.
    VA supports the concept of comparability pay for its non-physician/
dentist executives. However, we recommend that the new administration 
be given an opportunity to review this matter. Public sector executive 
pay is dramatically below the private sector for comparable positions, 
particularly in the health care sector. This proposal would allow VA 
executives to receive salaries far exceeding executives in other 
agencies which also must compete with the private sector. It would be a 
potentially precedent-setting departure from the unitary approach to 
governmentwide SES pay.
Special Incentive Pay for Department Pharmacist Executives
    Subsection (g) would further amend section 7410 to authorize 
recruitment and retention special incentive pay for pharmacist 
executives of up to $40,000. VA's determination of whether to provide 
and the amount of such incentive pay would be based on: grade and step, 
scope and complexity of the position, personal qualifications, 
characteristics of the labor market concerned, and such other factors 
as the Secretary considers appropriate. As with RN Executive Pay and 
comparability pay proposed by subsection (f), this subsection would 
provide that ``comparability pay'' would be in addition to other pay, 
awards and bonuses; would be considered base pay for retirement 
purposes; would not be base pay for adverse action purposes; and could 
not result in aggregate pay exceeding the annual pay of the President.
    This provision will provide a retention incentive to about 40 
positions: pharmacy benefit managers (PBM), consolidated mail 
outpatient pharmacy (CMOP) directors and VISN formulary leaders (VFL). 
VA supports this provision. Long-standing, severe and worsening pay 
compression exists within the ranks of senior pharmacy program managers 
in VHA. A national survey performed yearly by the American Society of 
Health System Pharmacists provides evidence that a similar trend exists 
in the private sector. Currently VHA has had extreme difficulty in 
recruiting pharmacists for leadership positions. Some examples include: 
the VA Medical Center in Bay Pines has not had a permanent Pharmacy 
Manager for two years; the VA Medical Center, Portland, OR, position 
has been vacant for one year; the VA Medical Center, Asheville, NC, has 
been vacant over one year; and numerous other facilities are 
experiencing the same recruiting difficulties. Several other facilities 
with extended vacancies that were recently filled include: the VA 
Medical Center, Omaha, NE, for two years; VA Medical Center Dayton, OH, 
for two years; and VA Medical Center, Las Vegas, NV, vacant for one 
year. The current pay rate that we are able to pay executives varies 
minimally from staff pharmacist positions and therefore is not an 
incentive to recruit pharmacy executive/those in leadership roles to 
VA. This provision will provide a mechanism to alleviate this 
compression. VA is still developing costs for this proposal and will 
submit them for the record when they are available.
Physician/Dentist Pay
    Subsection (h) concerns physician/dentist pay. VA supports this 
provision. Paragraph (1) would provide that the title 5 non-foreign 
cost of living adjustment allowance for physicians and dentists would 
be determined as a percentage of base pay only. This would clarify the 
application of the title 5 non-foreign cost of living adjustment 
allowance to VHA physicians and dentists. The VA physician/dentist pay 
statute, 38 U.S.C. Sec. 7431, does not address how the allowance is 
determined for physicians and dentists. We recommend that this 
provision be amended to clarify that it is applicable only to these 
physicians and dentists employed at Department facilities in Alaska, 
Guam, Hawaii, and Puerto Rico. These are the only Department facilities 
to which the title 5 non-foreign cost of living adjustment allowance is 
applicable.
    Paragraph (2) would amend section 7431(c)(4)(B)(i) to exempt 
physicians and dentists in administrative or executive leadership 
provisions from the panel process in determining the amount of market 
pay and pay tiers for such physicians and dentists. In situations where 
physicians or dentists occupy these leadership positions as chief 
officers, network directors, and medical center directors, the 
consultation of a panel has some limitations. The small number of 
physicians and dentists who would qualify as peers for these leaders 
results in their serving on each other's compensation panels and, in 
some cases, on their supervisor's panel. Providing the Secretary with 
discretion to identify administrative or executive physician/dentist 
positions that may be excluded from the panel process would resolve 
these issues.
    Paragraph (3) would provide an exception to the prohibition on the 
reduction of market pay for changes in board certification or reduction 
of privileges correcting an oversight in the recent revision of the 
physician/dentist pay statute. This modification would allow VA to 
address situations where there is a loss of board certification or an 
adverse reduction in clinical privileges. No costs are associated with 
this provision.
RN and CRNA Pay
    Subsections (i) and (j) relate to RN and Certified Registered Nurse 
Anesthetist (CRNA) Pay. Subsection (i) would amend the current cap for 
registered nurse from EL V to EL IV. VA supports this provision. This 
would increase the cap from level V to level IV for both RNs and CRNAs, 
consistent with the pay cap that applies to the GS locality pay system. 
We note that subsection (i) would obviate the need for subsection (j) 
as the two pay scales affected are already tied to each other. We 
estimate the cost of this provision to be $6.16 million for FY 2010 and 
$72.31 million over a 10-year period.
    Subsection (k) would make amendments to the RN locality pay system 
(LPS). These provisions are not helpful and are unnecessary. No costs 
are associated with this provision.
    Paragraph (1) would require the Under Secretary for Health to 
provide education, training, and support to VAMC directors in the 
``conduct and use'' of LPS surveys, including third party surveys. 
Paragraph (2) would require the annual report VAMCs must provide to VA 
Central Office to include the methodology for every schedule 
adjustment. These reports form the basis for the annual VA report to 
Congress. We are concerned that this provision, especially in 
conjunction with proposed paragraph 3, could result in the 
inappropriate disclosure of confidential salary survey data, contrary 
to current section 7451(d)(5). It also would impose an onerous burden 
inasmuch as VHA has nearly 800 nurse locality pay schedules. We do note 
that VA policy does provide for how these surveys are to be obtained or 
conducted. Paragraph (3) would require the most recent VAMC report on 
nurse staffing to be provided to any covered employee or employee's 
union representative upon request. This provision should be modified to 
specify at what point the report must be provided. It would not be 
appropriate to provide an individual a copy of the VAMC report before 
Congress receives the VA report.
    Subsection (l) would increase the maximum payable for nurse 
executive special pay to $100,000. This provision would make the amount 
of nurse executive pay consistent with the Executive Comparability Pay 
proposed in section 2(f) of this bill. However, special pay of this 
amount would allow VA nurse executives to receive salaries far 
exceeding executives in other agencies that also must compete with the 
private section and there is no evidence that such levels of pay are 
necessary. Thus, VA opposes this provision.
    The caption for subsection (m) suggests it provides for eligibility 
of part-time nurses for certain nurse premium pay. However, many of the 
substantive amendments are not limited to part-time nurses, or to all 
registered nurses. VA opposes subsection (m) as it has serious 
technical flaws, is unnecessary, and is costly.
    Subparagraph (1)(A) would amend section 7453(a) to make part-time 
nurses eligible for premium pay under that section. However, part-time 
nurses already are eligible for section 7453 premium pay where they 
meet the criteria for such pay.
    Subparagraphs (1)(B) and (1)(C) would require evening tour 
differential to be paid to all nurses performing any service between 6 
PM and 6 am, and any service on a weekend, instead of just those 
performing service on a tour of duty established for those times to 
meet on-going patient care needs. Under current law, these 
differentials are limited to the RN's normal tour of duty and any 
additional time worked on an established tour.
    The ``tour of duty'' requirement in the current law is intended to 
ensure adequate professional care and treatment to patients during off 
and undesirable tours. The limitation of tour differential and weekend 
pay only for service on a ``tour of duty'' rewards those employees who 
are subject to regular and recurring night and weekend work 
requirements. If that is changed to ``period of service'', any 
employees performing night or weekend work on an occasional or ad-hoc 
basis would also be entitled to this premium pay in addition to 
overtime pay, providing an inappropriate windfall for performing 
occasional work.
    Subparagraph (2) would authorize title 5 VHA employees to receive 
25 percent premium pay for performing weekend work on Saturday and 
Sunday. We understand the purpose of this provision is to limit the 
expansion of weekend premium pay to non-tour hours to registered 
nurses. However, it does not fully achieve that purpose. Pursuant to 
section 7454(a) and (b)(2), physician assistants, expanded-function 
dental auxiliaries, and hybrids are also entitled to weekend pay under 
section 7453. The expansion of weekend pay proposed in this 
subparagraph would apply to them as well. In addition, because 
physician assistants and expanded-function dental auxiliaries are 
entitled to all forms of registered nurse premium pay under section 
7453, the expansion of the night differential premium pay also would 
apply to them. Furthermore, where VA has authorized section 7453 night 
differential for hybrids, the expansion of the night differential 
premium pay would apply to them as well.
    Subsection (n) would add additional occupations to the exemption to 
the 28th step cap on title 38 special salary rates: LPNs, LVNs, and 
unspecified ``other nursing positions otherwise covered by title 5''. 
Notwithstanding the exemption, under current statute, title 38 special 
salary rates cannot exceed the rate for EL V. It is not clear what 
positions ``nursing positions otherwise covered by title 5'' would 
include. RNs are appointed under title 38, LPNs/LVNs are hybrids, and 
section 101(a)(2) of the bill would convert nursing assistants to 
hybrid. Moreover, it is not apparent why only these positions and not 
all positions authorized title 38 special rates would be exempted. 
Using the same formula for the cap on title 5 special rates would 
afford VA the most flexibility in establishing maximum rates for title 
38 special rates. We also note that adopting the title 5 fixed-
percentage formula would render unnecessary the section 7455(c)(2) 
report for exceeding 94 percent of the grade maximum and, so, propose 
deleting it.
    Thus we recommend amending section 7455 to read as follows:

        (a)(1) Subject to subsections (b), (c), and (d), when the 
        Secretary determines it to be necessary in order to obtain or 
        retain the services of persons described in paragraph (2), the 
        Secretary may increase the minimum rates of basic pay 
        authorized under applicable statutes and regulations, and may 
        make corresponding increases in all rates of the pay range for 
        each grade. Any increase in such rates of basic pay----
          * * * * * * *
        (c) The amount of any increase under subsection (a) in the 
        minimum rate for any grade may not exceed the maximum rate of 
        basic pay (excluding any locality-based comparability payment 
        under section 5304 of title 5 or similar provision of law) for 
        the grade or level by more than 30 percent, and no rate may be 
        established under this section in excess of the rate of basic 
        pay payable for level IV of the Executive Schedule.

    VA's concerns that pay setting authorized by this provision may be 
subject to collective bargaining are discussed in conjunction with S. 
362.
    Section 102(a)(1) would add new section 7459, imposing restrictions 
on nurse overtime. Section 7459 generally would prohibit mandatory 
overtime for nurses (RNs, LPNs, LVNs, nursing assistants, and any other 
nurse position designated by the Secretary). It would permit mandatory 
overtime by nurses under certain conditions: an emergency that could 
not have been reasonably anticipated; the emergency is non-recurring 
and not due to inattention or lack of reasonable contingency planning; 
VA exhausted all good faith, reasonable attempts to obtain voluntary 
workers; the affected nurses have critical skills and expertise; and 
the patient work requires continuity of care through completion of a 
case, treatment, or procedure. VA could not penalize nurses for 
refusing to work prohibited mandatory overtime. Section 7459 provides 
that nurses may work overtime hours on a voluntary basis.
    VA favors this mandatory overtime restriction with the caveat that 
first and foremost, VA needs to be able to mandate overtime where 
issues of patient safety are identified by facility leadership. We note 
VAMCs currently have policies preventing RNs from working more than 12 
consecutive hours and 60 hours in a 7-day period pursuant to section 
4(b) of Pub. L. 108-445.
    Section 102(b) would amend 38 U.S.C. 7456 (the ``Baylor Plan''), 
which authorizes VA to allow nurses who perform two 12-hour regularly 
scheduled tours of duty on a weekend to be paid for 40 hours. This 
work-scheduling practice typically would be used when facilities 
encounter significant staffing difficulties caused by similar work 
scheduling practices in the local community. It would delete current 
section 7456(c), the current Baylor Plan requirement, which provides 
for a 5-hour leave charge for each 3 hours of absence that reflects the 
relative value of the truncated Baylor tour, in effect increasing the 
value of leave for affected employees. Currently, VA has only one 
employee working on the Baylor Plan. VA opposes this provision as 
providing an unwarranted windfall.
    Section 102(c) would amend section 7456A to change the 36/40 
alternate work schedule to a 72/80 alternate work schedule, so that 
under the schedule six 12-hour ``periods of service'' anytime in a pay 
period would substitute for three ``12-hour tours of duty'' in each 
week of the pay period. Similar changes would be made to section 
7456A's overtime, premium pay and leave provisions.
    VA is experiencing planning problems with the use of the current 
36/40 schedule. The problem stems from the 36/40 language requiring 
three 12-hour tours in a work week and because VA defines ``work week'' 
as Sunday to Saturday. The problem occurs because the work week 
requirement prevents scheduling one of the 12-hour tours over two 
different weeks, e.g., 6PM Saturday to 6AM Sunday. Changing ``work 
week'' to ``pay period'' only makes the problem occur every 2 weeks 
instead of every week, so we do not view that as helpful. We do support 
changing the 36/40 alternate work schedule to a 72/80 alternate work 
schedule, so that the six 12-hour tours can occur anytime in a pay 
period, providing more work scheduling/planning flexibility. We would 
be glad to provide appropriate bill language.
    Section 103 would make amendments to VA's Education Assistance 
Programs. VA supports these proposals. Section 103(a) would amend 
section 7618 to reinstate the Health Professionals Educational 
Assistance Scholarship Program through the end of 2014. The program 
expired in 1998. The Health Professional Scholarship Program would help 
reduce the nursing shortage in VA by obligating scholarship recipients 
to work for 2 years at a VA health care facility after graduation and 
licensure. This proposal would also expand eligibility for the 
scholarship program to all hybrid occupations. This would be helpful in 
recruiting and retaining employees in the several hard-to-fill hybrid 
occupations. We are still determining costs for this provision and will 
forward them to the Committee as soon as they are available.
    Section 103(b) would make certain amendments to the Education Debt 
Reduction Program. It would amend section 7681(a)(2) to add retention 
as a purpose of the program and amend section 7682(a)(1) to make it 
available to ``an'' employee, in lieu of ``recently appointed.'' It 
would also increase the authorized statutory amounts in section 7683 to 
$60,000 and $12,000, respectively.
    The ``recently appointed'' requirement limits eligibility to 
employees who have been appointed within six months. VA's experience 
has been that this is not a sufficient period. In several instances, 
employees applying just missed the six-month deadline. In many cases it 
takes more than six months for employees to become aware of this very 
helpful recruitment and retention program. This proposal offers greater 
flexibility to VA in applying the program. VA also supports the 
increased amounts in light of increased education costs since the 
program was enacted. We note this program can be implemented in a cost-
neutral fashion.
    Section 103(c) would authorize VA researchers from ``disadvantaged 
backgrounds'' to participate in a loan repayment program that the VA 
may establish using the Public Health Service Act authorities for the 
NIH Loan Repayment Program. We agree that loan repayment incentives 
would be helpful to clinicians with medical specialization and research 
interests who might consider career clinical care or clinical research 
opportunities relating to the work of VHA.
    Section 104 is nearly identical to S. 246, Section 2(a), which I 
have previously discussed.
    Section 201 would eliminate two reporting requirements: the Nurse 
Pay Report and the Long-Term Planning Report. VA supports this 
provision. There would be no discernible cost savings associated with 
this provision. Similarly, VA supports Section 202 to amend the Persian 
Gulf War Veterans' Health Status Act to change the due date of the 
annual report to Congress from March 1 to July 1. This change would 
have no impact on cost.
    VA also supports Section 203. Section 203 will provide 
clarification of the legal authority beyond the existing regulations 
that will prevent providers from collecting from the beneficiary any 
amounts in excess of the CHAMPVA determined allowable amount. VA favors 
this provision. There would be no significant cost to VA.
    Section 204, relating to payer provisions for care furnished to 
certain children of Vietnam Veterans, has been made moot by the passage 
of Pub. L. 110-387, Section 408, ``Spina Bifida Comprehensive Health 
Care.''
    VA strongly supports Section 205 of S. 252, which would permit VA 
health care practitioners to disclose the relevant portions of VA 
records of the treatment of drug abuse, alcoholism and alcohol abuse, 
infection with the human immunodeficiency virus, and sickle cell anemia 
to surrogate decisionmakers who are authorized to make decisions on 
behalf of patients who lack decisionmaking capacity, but to whom the 
patient had not specifically authorized release of that legally 
protected information prior to losing decisionmaking capacity. This 
provision would only permit such a disclosure when the practitioner 
deems the content necessary for the representative to make an informed 
decision regarding the patient's treatment. This provision is critical 
to ensure that a patient's surrogate has all the clinically relevant 
information needed to provide full and informed consent with respect to 
the treatment decisions that the surrogate is being asked to make.
    Section 206 would authorize VA to require that applicants for, and 
recipients of, VA medical care and services provide their health-plan 
contract information and social security numbers to the Secretary upon 
request. It would also authorize VA to require applicants for, or 
recipients of, VA medical care or services to provide their social 
security numbers and those of dependents or VA beneficiaries upon whom 
the applicant or recipient's eligibility is based. Recognizing that 
some individuals do not have social security numbers, the provision 
would not require an applicant or recipient to furnish the social 
security number of an individual for whom a social security number has 
not been issued. Under this provision, VA would deny the application 
for medical care or services, or terminate the provision of, medical 
care or services, to individuals who fail to provide the information 
requested under this section. However, the legislation authorizes the 
Secretary to reconsider the application for, or reinstate the provision 
of, care or services once the information requested under this section 
has been provided. Of note, this provision makes clear that its terms 
may not be construed to deny medical care and treatment to an 
individual in a medical emergency.
    Given the significant privacy concerns related to this provision, 
we defer views until further analysis can be made and the new 
administration is given an opportunity to review this matter.
    Section 207 addresses quality management in VA facilities and 
establishes quality management officer positions at the national, VISN 
and facility level. Section 207 is similar to S. 246, Section 3, 
although the position established is termed ``Quality Management 
Officer'' (QMO), and there is no stipulation that the position be 
filled by a board-certified physician. Section 207 would require the 
QMO to be responsible for and undertake specific actions to carry out 
VHA's quality management program. Section 207 additionally would 
require the National QMO to assess quality of care by developing an 
aggregate quality metric from existing data sources, monitoring and 
analyzing existing measures of quality, and encouraging research and 
development in the area of quality metrics. Section 207 would authorize 
appropriations necessary to carry out the quality management program, 
including $25,000,000 for the quality metric provisions during the 2 
fiscal year period following enactment. Mr. Chairman, we support the 
intent of these provisions, that is enhancing VA's quality management 
programs, and have already undertaken actions to achieve many of the 
same goals. We would welcome the opportunity to meet with the Committee 
to discuss recent actions we have undertaken to improve the quality of 
care across the system, including program oversight related measures.
    Section 208 requires submission of an annual report to Congress 
describing progress toward implementing provisions of Sections 104 and 
207. VA has no objection to this requirement and, in fact, supports the 
concept of transparency in health care. We note that a comprehensive 
Hospital Quality Report was prepared by the Department in 2008 and is 
updated annually.
    We estimate that the requirement that the VISN Director review all 
information needed for physician appointment would require an 
additional FTEE (GS 14) at the VISN level. We also estimate that the 
appointment of a board-certified physician to serve as QAO at the 
facility and network levels would require 162 physicians for 141 
medical staffs and 21 networks. We estimate salary and benefits costs 
for each QAO to be approximately $200,000 (actual will vary according 
to specialty, time commitment, and local market factors). We estimate 
total costs for a FTE MD QAO and FTE VISN coordinator to be $35.10 
million in the first year, $188.05 million over five years, and 
approximately $413.22 million over ten years. We estimate that salaries 
plus benefits for the new positions will include a 4% increase in costs 
for each subsequent year.
    Section 209 would require the Secretary to conduct a pilot program, 
in collaboration with the Secretary of Defense, to assess the 
feasibility of training and certifying family caregivers to be personal 
care attendants for veterans and members of the of the Armed Forces 
suffering from TBI. The pilot program would be conducted at three VA 
medical centers and, if determined appropriate, at one DOD medical 
center. VA would be required to determine the eligibility of a family 
member to participate in the pilot programs, and such a determination 
would have to be based on the needs of the veteran or servicemember as 
determined by the patient's physician. The training curricula would be 
developed by VA and include applicable standards and protocols used by 
certification programs of national brain injury care specialist 
organizations and best practices recognized by caregiver organizations. 
Training costs would be borne by VA, with DOD required to reimburse VA 
for the costs of training family members of servicemembers. Family 
caregivers certified under this program would be eligible for VA 
compensation and may receive assessments of their needs in the role of 
caregiver and referrals to community resources to obtain needed 
services.
    VA does not support section 209. Currently, we are able to contract 
for caregiver services with home health and similar public and private 
agencies. The contractor trains and pays them, affords them liability 
protection, and oversees the quality of their care. This remains the 
preferable arrangement as it does not divert VA from its primary 
mission of treating veterans and training clinicians. Moreover, it does 
not put VA in the position of having to tell family members how, at the 
risk of losing their caregiver compensation, they have to care for 
their loved ones. If enacted, we estimate the cost of the three-year 
pilot to be $178.4 million.
    Section 210 would require VA, in collaboration with DOD, to carry 
out a pilot program to assess the feasibility of providing respite care 
to family caregivers of servicemembers and veterans diagnosed with TBI, 
through the use of students enrolled in graduate education programs in 
the fields of mental health or rehabilitation. Students participating 
in the program would provide respite relief to the servicemember's or 
veteran's family caregiver, while also providing socialization and 
cognitive skill development to the servicemember or veteran. VA would 
be required to recruit these students, train them in the provision of 
respite care, and work with the heads of their graduate programs to 
determine the amount of training and experience needed to participate 
in the pilot program.
    VA does not support section 210. Individuals providing respite care 
do not require advanced degrees, only appropriate training. Respite 
care does not require specialized skills, and its functions are not 
applicable to curricula objectives in the graduate degree programs 
related to mental health or rehabilitation that we are aware of. 
Further, section 210 would require VA to use graduate students in roles 
that are not permissible under academic affiliation agreements, and we 
have serious doubts this proposal would be acceptable to graduate 
schools.
    Moreover, VA has a comprehensive respite care program. We also have 
specialized initiatives underway for TBI patients to reduce the strain 
on their caregivers, which overlap with this bill. We also provide 
respite care by placing the veteran in a local VA facility for the 
duration of the respite period. Veterans may receive up to 30 days of 
respite care per year. We estimate the costs of conducting the pilot 
program to be $3.5 million in the first year and approximately $11.4 
million over five years.
    Section 211 would require the Secretary to carry out a two-year 
pilot grant program (at five locations selected by the Secretary) to 
assess the feasibility of using community-based organizations and local 
and State government entities to increase the coordination of VA 
benefits and services to veterans transitioning from military service 
to civilian life, to increase the availability of medical services 
available to these veterans, and to provide their families with their 
own readjustment services. Grantees could use grant funds for purposes 
prescribed by the Secretary.
    VA opposes section 211 because it is duplicative of the 
Department's on-going efforts. Vet Centers are already providing many 
of the services contemplated by this provision. Additionally, VA case 
managers and Federal recovery coordinators already coordinate the 
delivery of health care and other VA services available to veterans 
transitioning from military service to civilian life, including 
supportive services for their families. VA is committing ever 
increasing resources to these ends. The duplicated efforts required by 
the bill would likely create significant confusion for the beneficiary.
    To the extent the Secretary determines external resources are 
necessary to provide the services described in the bill, VA already has 
the necessary authority to contract for them. We favor using contracts 
instead of grants, as the former allow VA to respond to changing local 
needs and assure the quality of services provided. That approach also 
gives us an accurate way to project the cost of the services. This 
provision, on the other hand, would not. It would also not be cost-
effective as it is likely that a grant awarded under the program would 
be for an amount significantly less than the cost VA incurs in 
administering the grant. We also note the bill would not include 
authority for VA to recapture unused grant funds in the event a grantee 
fails to provide the services described in the grant.
    Although the proposed pilot project is limited to five locations, 
the bill does not specify the number and amount of the grants to be 
awarded. We are unable to estimate the cost of this provision due to 
the lack of specificity.
    Section 212 would authorize VA to contract for specialized 
residential care and rehabilitation services for veterans of Operation 
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) who: (1) suffer 
from Traumatic Brain Injury, (2) have an accumulation of deficits in 
activities of daily living and instrumental activities of daily living 
that affects their ability to care for themselves, and (3) would 
otherwise receive their care and rehabilitation in a nursing home. 
These veterans do not require nursing home care, but they generally 
lack the resources to remain at home and live independently; this 
represents an extremely small subset of the OEF/OIF population. In 
fact, for FY 2010, VA estimates only 10 veterans would qualify and 
participate in this program. Age appropriate day health and other 
community programs, VA's home based primary care, and medical foster 
homes will be expanded to provide these Veterans with long-term 
specialized rehabilitation services. VA supports this legislation as it 
would enable us to provide these veterans with long-term rehabilitation 
services in a far more appropriate treatment setting than we are 
currently authorized to provide. VA estimates the discretionary cost of 
section 212 to be $923,000 for the first year, $12.2 million over five 
years, and $76.8 over ten years.
    Section 213 would amend sections 5701 and 7332 of title 38, United 
States Code. The amendments would authorize VA to disclose 
individually-identifiable patient medical information without the prior 
written consent of a patient to a third-party health plan to collect 
reasonable charges under VA collections authority for care or services 
provided for a non-service-connected disability. The section 5701 
amendment would specifically authorize disclosure of a patient's name 
and address information for this purpose. The section 7332 amendment 
would authorize disclosure of both individual identifier information 
and medical information for purposes of carrying out the Department's 
collection responsibilities.
    Given the significant privacy concerns related to this provision, 
we defer views on this section until further analysis can be made and 
the new administration is given an opportunity to review this matter.
    Section 214 would require VA to enter into a contract with the 
Institute of Medicine of the National Academies to conduct an expanded 
study on the health impact of Project Shipboard Hazard and Defense 
(Project SHAD). VA opposes this proposal. The 2007 four-year, $3.8 
million, VA-sponsored study by the National Academies of Sciences (NAS) 
``Long-Term Health Effects of Participation in Project SHAD'' 
represented an exhaustive effort to locate and evaluate the health of 
every living or deceased SHAD veteran. That study found little or no 
long-term health effects linked to SHAD participation, and spending 
additional resources with the hope that possibly tracking down a small 
number of additional SHAD veterans might significantly change those 
results is unrealistic. We have been assured by the NAS group who 
conducted the original study that they have spared no effort in 
tracking down every SHAD participant as part of their study. We 
estimate that such a study would cost $2.5 million.
    When VA is providing inpatient or outpatient care for a patient 
with Traumatic Brain Injury, VA is required to develop an individual 
plan for the veteran or servicemember. In implementing such plans, 38 
U.S.C. Sec. 1710E authorizes the Secretary to provide hospital care and 
medical services through cooperative agreements with appropriate public 
or private entities that have established long-term neurobehavioral 
rehabilitation and recovery programs. Section 215 would amend this 
authority by defining covered individuals as servicemembers or veterans 
receiving inpatient or outpatient rehabilitative hospital care or 
medical services for Traumatic Brain Injury to whom the Secretary is 
unable to provide treatment or services at the frequency or for the 
duration described in the plan, or for whom the Secretary determines 
such care is optimal. This provision would also require that facilities 
participating in such cooperative agreements maintain standards for the 
provision of treatment or services that have been established by an 
independent, peer-reviewed organization that accredits specialized 
rehabilitation programs for adults with Traumatic Brain Injury.
    VA supports this provision but recommends that the plan referenced 
in this provision be described as the VA Individualized Rehabilitation 
and Reintegration Plan developed in accordance with section 1710C. 
Further, the bill as currently drafted states that the Secretary may 
not provide treatment or services at the non-VA facility unless the 
facility ``maintains standards for the provision of such treatment or 
services established by an independent, peer-reviewed organization that 
accredits specialized rehabilitation programs for adults with Traumatic 
Brain Injury.''
    Section 216 would include federally recognized tribal organizations 
in certain State home programs. Specifically, section 216(a) would 
authorize VA to treat a health facility or certain beds in a health 
facility of a tribal organization as a State nursing home for veterans. 
This would allow VA to pay per diem to the organization for the nursing 
home care of veterans in the home. The home would be required to meet 
the existing standards for State homes and such other standards as VA 
requires. In addition, the organization would have to demonstrate that, 
but for treatment in the home, a substantial number of veterans 
residing in the area would not have access to nursing home care, and 
the Secretary would have to determine that treatment of the facility or 
beds as a State home would best meet the needs of veterans for nursing 
home care in the area. Finally, tribal organizations would be subject 
to limitations on the number of beds that could receive per diem under 
this provision.
    VA opposes Section 216(a). It would be very difficult to maintain a 
critical mass of staff with expertise in the care of frail, elderly 
patients in such a setting. Moreover, this would duplicate the function 
of the existing Community Nursing Home Program under which VA can pay 
for the care of Veterans placed in nursing homes in the private sector. 
VA contracts with more than 4,500 community nursing homes nationally 
and can add more as needed to assure Veterans' access to care.
    Section 216(b) would authorize VA to award grants to tribal 
organizations for the construction or acquisition of state homes in the 
same manner and under the same conditions as grants awarded to States 
subject to exceptions prescribed by VA to take into account the unique 
circumstances of tribal organizations. This provision would require VA 
to give priority to grant applications from tribal organizations that 
had not previously applied for a grant even if the State in which the 
tribal organization was located had previously applied for (or 
received) a grant.
    VA also opposes Section 216(b). The proposal would disenfranchise 
the states for which the construction grant program was expressly 
established since priority for awarding of grants is prescribed in 
statute and regulation. The first priority is for renovations necessary 
to protect the lives and safety of Veterans residing in the home. The 
second priority is for grants to states, or under this provision, 
tribal entities, that have never previously received a grant from this 
program. Since every state has received a grant and no tribal entity 
ever has, all construction and renovation applications from tribes 
would take precedence over all applications from states, except for 
life safety grants, until all tribal entities that wished to submit 
applications had done so. Since there are more 500 recognized tribal 
entities, it could be years before states are again able to receive 
grants other than life safety grants, and even then they would have to 
compete with more than 500 eligible applicants instead of the 50 states 
and a few territories now eligible for the grants. The radical change 
being proposed would be detrimental to the states for which this 
program was specifically established.
    VA estimates the cost of Section 216 to be $2.6 million for the 
first year, $14.2 million over five years, and $31.5 million over ten 
years.
    Section 217 would require the Secretary to carry out a pilot 
program to assess the feasibility and advisability of providing a 
dental insurance plan to veterans enrolled for VA health care pursuant 
to section 1705 of title 38 and survivors or dependants enrolled for 
care under section 1781 of title 38 (CHAMPVA). Under this plan, VA 
would manage and administer a group dental plan. VA opposes section 217 
as this provision would establish an entirely new and dramatically 
different role for VA.
    Section 301 of this bill corresponds to section 101 of S. 597, 
another bill on today's agenda. This section would require VA to 
contract with a qualified independent entity or organization to carry 
out a comprehensive assessment of the barriers encountered by women 
veterans seeking comprehensive health care from VA, building on the 
VA's own ``National Survey of Women Veterans in Fiscal Year 2007-2008'' 
(National Survey). Many requirements related to sample size and the 
scope of the survey would apply to the conduct of the assessment. 
Section 301 would also require the contractor-entity to conduct 
research on the effects of the following concerns on the study 
participants:

     The perceived stigma associated with seeking mental health 
care services.
     The effect of driving distance or availability of other 
forms of transportation to the nearest appropriate VA facility on 
access to care.
     The availability of child care.
     The acceptability of integrated primary care, or with 
women's health clinics, or both.
     The comprehension of eligibility requirements for, and the 
scope of services available under, such health care.
     The perception of personal safety and comfort of women 
veterans in inpatient, outpatient, and behavioral health facilities of 
the Department.
     The gender sensitivity of health care providers and staff 
to issues that particularly affect women.
     The effectiveness of outreach for health care services 
available to women veterans.
     The location and operating hours of health care facilities 
that provide services to women veterans.
     Such other significant barriers identified by the 
Secretary.

    Additionally, section 301 would require the Secretary to ensure 
that the heads of the Center for Women Veterans and the Advisory 
Committee on Women Veterans review the results of the comprehensive 
assessment and submit their own findings with respect to it to the 
Under Secretary for Health and other VA offices that administer health 
care benefits to women veterans.
    The results of our National Survey will not be available until 
later in the fiscal year. Consequently, we do not think it feasible to 
enter into a contract for the mandated assessment and research until we 
have first had a chance to complete and fully analyze the results of 
the National Survey. Only in this way can the assessment and research 
adequately build on the National Survey and reliably augment, rather 
than duplicate, VA's efforts in this area. We estimate the cost of 
section 101 to be $3.5 million.
    The next section, section 302, corresponds to section 201 of S. 597 
and requires VA to develop a plan to improve the provision of health 
care services to women veterans. VA fully supports the evaluation and 
enhancement of care to women veterans and initiated a planning and 
implementation program in September 2008. Consequently, this provision 
is unnecessary as the initiative is already underway.
    Section 303 of S. 252 corresponds to section 102 of S. 597. This 
section would require VA to enter into a contract with an entity or 
organization to conduct a very detailed and comprehensive assessment of 
all VA health care services and programs provided to women veterans at 
each VA facility. The assessment would have to include VA's specialized 
programs for women with PTSD, homeless women, women requiring care for 
substance abuse or mental illnesses, and those requiring obstetric and 
gynecologic care. It would also need to address whether effective 
health care programs (including health promotion and disease prevention 
programs) are readily available to, and easily accessed by, women 
veterans based on a number of specified factors.
    After the assessment is performed, the bill would require VA to 
develop an extremely detailed plan to improve the provision of health 
care services to women veterans, taking into account, among other 
things, projected health care needs of women veterans in the future and 
the types of services available for women veterans at each VA medical 
center. VA would then be required to report to Congress on the 
assessment and plan, including any administrative or legislative 
recommendations VA deems appropriate. What is unclear in the bill is 
whether the contractor-entity conducting the assessment would also be 
required to develop the follow-up ``plan,'' as the terms of section 303 
refer to the contractor's conduct of ``studies and research'' required 
by that section. VA supports section 303 only if the development of the 
mandated plan would be conducted by a contractor-entity. We estimate 
the total costs of this section to be $4,354,000 during the period of 
Fiscal Year 2010 through Fiscal Year 2012.
    Section 304 corresponds to section 202 of S. 597. This provision 
would require the Secretary to establish a program for education, 
training, certification and continuing medical education for VA mental 
health professionals furnishing care and counseling services for 
military sexual trauma (MST). VA would also be required to determine 
the minimum qualifications necessary for mental health professionals 
certified under the program to provide evidence-based treatment. The 
provision would establish extremely detailed reporting requirements. VA 
would also have to establish education, training, certification, and 
staffing standards for VA health care facilities for full-time 
equivalent employees who are trained to provide MST services.
    We do not support the training-related requirements of section 304 
because they are duplicative of existing programs. In FY 2007, VA 
funded a Military Sexual Trauma Support Team, whose mission is, in 
part, to enhance and expand MST-related training and education 
opportunities nationwide. VA also hosts an annual four-day long 
training session for 30 clinicians in conjunction with the National 
Center for PTSD, which focuses on treatment of the after-effects of 
MST. VA also conducts training through monthly teleconferences that 
attract 130 to 170 attendees each month. VA has recently unveiled the 
MST Resource Homepage, a Web page that serves as a clearinghouse for 
MST-related resources such as patient education materials, sample power 
point trainings, provider educational opportunities, reports of MST 
screening rates by facility, and descriptions of VA policies and 
benefits related to MST. It also hosts discussion forums for providers. 
In addition, VA primary care providers screen their veteran-patients, 
particularly recently returning veterans, for MST, using a screening 
tool developed by the Department. We are currently revising our 
training program to further underscore the importance of effective 
screening by primary care providers who provide clinical care for MST 
within primary care settings.
    We object strongly to section 304's requirement for staffing 
standards. Staffing-related determinations must be made at the local 
level based on the identified needs of the facility's patient 
population, workload, staffing, and other capacity issues. Retaining 
this flexibility is essential to permit VA and individual facilities to 
respond to changing needs and available resources. Imposition of 
national staffing standards would be an inefficient and ineffective way 
to manage a health care system that is dynamic and experiences 
continual changes in workload, utilization rates, etc.
    Section 305 would require VA, not later than six months after the 
date of enactment, to conduct a pilot program to evaluate the 
feasibility of providing reintegration and readjustment services in a 
group retreat setting to women veterans recently separated from service 
after a prolonged deployment. Participation in the pilot would be at 
the election of the veteran. Services provided under the pilot would 
include, for instance, traditional VA readjustment counseling services, 
financial counseling, information on stress reduction, and information 
and counseling on conflict resolution.
    We are unclear as to the purpose of and need for this provision. 
The term ``group retreat setting'' is not defined, but we assume it 
could not include VA medical facilities or Vet Centers, as we could not 
limit Vet Center access to any one group of veterans. Moreover, it is 
important to note that many Vet Centers are already well designed to 
meet the individual and group needs of women veterans. We estimate that 
the cost of the pilot would be around $300,000.
    Section 306 mandates a report to Congress to ensure that health 
care needs of women are met and to assess whether there is at least one 
full-time Women Veterans Program Manager employed at each VAMC. This 
section is substantially similar to section 103 of S. 597. The report 
shall include an assessment of whether there is at least one full-time 
employee at each VA medical center who is a full-time women veterans 
program manager. VA does not oppose this provision but we believe it is 
unnecessary. VA is already reporting regularly on the employment of 
Women Veteran Program Managers. To date, 137 of the 144 positions have 
been filled as full-time employees. No additional funds would be 
required to submit this report.
    Next, section 307 (and the corresponding provision in S. 597, 
section 204) would require the Department's Advisory Committee on Women 
Veterans, created by statute, to include women veterans who are 
recently separated veterans. It would also require the Department's 
Advisory Committee on Minority Veterans to include recently separated 
veterans who are minority group members. These requirements would apply 
to committee appointments made on or after the bill's enactment. We 
fully support section 307. These amendments would help both Committees 
to better identify and address the needs of their respective veteran-
populations.
    Section 308 would require the Secretary, commencing not later than 
six months after the date of enactment, to carry out a two-year pilot 
program, at no fewer than three VISN sites, to pay veterans the costs 
of childcare they incur to travel to and from VA facilities for regular 
mental health services, intensive mental health services, or other 
intensive health care services specified by the Secretary. The 
provision is gender-neutral. Any veteran who is a child's primary 
caretaker and who is receiving covered health care services would be 
eligible to participate in the pilot program. The corresponding 
provision is in section 205 of S. 597.
    VA is very cognizant of the veterans' needs for convenient access 
to health care; however, we oppose section 308 as this expansion would 
divert resources from direct medical care.
    We support section 309, which would authorize VA to furnish health 
care services up to seven days after birth to a newborn child of a 
female veteran who is receiving maternity care furnished by VA if the 
veteran delivered the child in a VA facility or in another facility 
pursuant to contract for service related to such delivery. This 
provision corresponds to section 206 of S. 597. We estimate that the 
cost would be $55.3 million the first year, $293.6 million over five 
years, and approximately $589.4 over ten years.
    VA supports Section 401, which would make members of the Armed 
Forces who serve in Operation Enduring Freedom or Operation Iraqi 
Freedom eligible for counseling and services through Readjustment 
Counseling Service, but we are concerned with the precedent that would 
be established by providing disparate eligibility to veterans of 
different conflicts. Under this provision active duty combat veterans 
of OEF/OIF would have access to Vet Centers for counseling and related 
mental health services and behavioral health services, including 
substance abuse assessment, counseling, and referral. Active duty 
veterans of the Persian Gulf War or other prior or subsequent combat 
would not have access to those services. Providing these services to 
active duty OEF/OIF personnel would cost approximately $3.7 million in 
the first year, $19.8 over five years, and $44.1 million over ten 
years. DOD has reimbursed VA for services provided to active duty 
members; however, we have not yet discussed the funding of this 
provision or possible reimbursement rates with DOD for readjustment 
counseling services.
    Until 1996, VA had specific statutory authority to refer ineligible 
veterans to non-VA resources and to advise such individuals of the 
right to apply for review of the individual's discharge or release. VA 
supports Section 402, which would reinstate these provisions. 
Reinstatement of these provisions would give the Vet Centers the 
latitude to help Veterans with problematic discharges with problems 
deemed by Vet Center staff to be related to war trauma, through 
referral to services outside the VA and/or referral for assistance with 
discharge upgrades when appropriate. The total number of Veterans this 
provision would affect is assumed to be small so the costs of this 
provision would be negligible.
    VA opposes Section 403, requiring VA to conduct a study to 
determine the number of Veterans who have committed suicide between 
January 1, 1997, and the date of the bill's enactment. VA opposes 
conducting the study because other information, more valuable in 
guiding VA's strategy for suicide prevention, is already available and 
is continually being refined through other research and data collection 
efforts. Moreover, we do not believe that the new requirement would 
yield any additional information of significant value.
    Rates and counts of deaths from suicide are available from 2000 
onward for Veterans who utilized the VHA Health Care System. In 
addition, they are available on specific cohorts of Veterans including 
those who served in OEF/OIF and in the first Persian Gulf War, whether 
or not they utilize VHA health care services. Finally, they are 
available on all individuals identified at the times of their deaths as 
Veterans by their families in the sixteen states that participate in 
the Centers for Disease Control and Prevention's National Violent Death 
Reporting System. VA estimates that the overall cost for conducting 
such a study would be $2,356,000 in FY 2010 and $7,224,000 over five 
years.
    VA is opposed to Section 404, which would transfer $5 million from 
VA to the Department of Health and Human Services (HHS) by the end of 
FY 2010 for a graduate psychology education (GPE) program. This 
transfer of funds to the GPE Program would reduce funding available for 
VA programs or services without any clear benefit to VA in exchange for 
those services. VA much prefers to target these funds to increasing 
internship and post-doctoral training positions within VA facilities. 
VA already supports 435 Psychology internship positions in 90 different 
programs and 200 postdoctoral fellowship programs in 54 programs. Thus 
we already provide the ``training of psychologists in the treatment of 
Veterans with Post Traumatic Stress Disorder, Traumatic Brain Injury, 
and other combat-related disorders'' that this legislation aims to 
achieve. Assuming that this $5 million would become a recurring 
transfer of funds, the estimate over ten years is $50 million.
    Sections 501 and 502 of S. 252 would authorize VA to conduct two 
five-year pilot grant programs under which public and non-profit 
organizations (including faith-based and community organizations) would 
receive funds for coordinating the provision of local supportive 
services for very low income, formerly homeless veterans who reside in 
permanent housing. Under one of the pilot programs, VA would provide 
grants to organizations assisting veterans residing in permanent 
housing located on military property that the Secretary of Defense 
closed or slated for closure as part of the 2005 Base Realignment and 
Closure program and ultimately designated for use in assisting the 
homeless. The other pilot program would provide grants to organizations 
assisting veterans residing in permanent housing on any property across 
the country. Both pilot programs would require the Secretary to 
promulgate regulations establishing criteria for receiving grants and 
the scope of supportive services covered by the grant program.
    The 2005 Base Realignment and Closure process has been completed 
and local plans have already been developed. Therefore the new 
authority as proposed in section 501 would be ineffective. Further, the 
Veterans Mental Health and Other Care Improvement Act of 2008, Public 
Law 110-387, Title VI, Section 604 provided authorization for VA to 
facilitate the provision of supportive services for very low income 
veterans for veteran families in permanent housing. VA is in the 
process of writing regulations and hopes to offer funding later this 
year. Section 604 allows VA to effectively aid veterans better than 
either of the two pilots. We respectfully suggest that the two pilots 
are no longer needed and believe that the supportive services grants 
under Pub. L. 110-387 which this Committee approved last year to be a 
more effective way to assist veterans.
    Section 503 of S. 252 would require that VA establish a pilot 
program for financial support of entities that provide outreach to 
inform certain veterans about pension benefits. To this end, the bill 
would provide VA with additional authority to make grants to public and 
non-profit organizations (including faith-based and community 
organizations) for purposes of providing outreach to inform low-income 
and elderly veterans and their spouses residing in rural areas about 
potential eligibility for VA pension. The bill authorized the 
expenditure of $1,275,000 from General Operating Expenses (GOE) in each 
of fiscal years 2010 through 2014. Although VA supports the intent of 
Section 503 of S. 252, we oppose the bill because it duplicates ongoing 
outreach efforts by VBA to conduct outreach to low income and elderly 
veterans and their spouses and dependents. If this legislation is 
enacted, VA would need additional GOE to administer the pilot program 
and to train the public and non-profit organizations to accurately 
discuss VA benefit programs.
    VA's outreach efforts to elderly veterans and their survivors 
include several approaches. We have provided the Social Security 
Administration with our pamphlet ``Federal Benefits for Veterans and 
Dependents.'' Additionally, we have participated and will continue to 
participate in the annual conference of the American Association of 
Retired Persons (AARP). This year VA will participate in the National 
Convention of the Association of Directors of Assisted Living 
Facilities. From January 2008 to January 2009 the number of veterans 
receiving disability pension declined about two percent or less than 
7,000 veterans. That decline can be almost entirely accounted for by 
the decline in the number of World War II veterans receiving pension. 
The decline in this population accounted for 85 percent of the decline. 
The Vietnam Era veteran population is only now reaching age 65 where 
entitlement exists based on age. We expect their participation in the 
pension program to rise. With respect to survivor pension, the number 
of widow(ers) on the rules has increased 5,924 or 7.2 percent over the 
same January to January period. In light of the significantly lower 
allowable income limits for survivors, this rise is primarily 
attributable to entitlement being established as a result of high 
medical expenses. The rise is reflective of our work with social 
security and AARP and soon with the assisted living organizations.
    Section 504 of the bill would authorize a 3-year pilot program to 
assess the feasibility of providing grants to public or nonprofit 
organizations as a means of providing expanded services to veterans 
participating in vocational rehabilitation programs under chapter 31 of 
title 38, United States Code. Under this program, VA would provide 
financial assistance through grants to public or nonprofit 
organizations that would then establish new programs or activities, or 
expand or modify existing programs or activities, to provide assistance 
to veterans participating in vocational rehabilitation programs under 
chapter 31. The type of assistance to be provided includes 
transportation, childcare, and clothing to facilitate participation in 
a vocational rehabilitation program or related activity. The pilot 
program would be used to assess the feasibility of providing such 
expanded services to veterans through these types of grants.
    VA supports efforts to facilitate successful completion of 
vocational rehabilitation programs under chapter 31. However, VA does 
not support the use of grant programs to achieve this objective. The 
administrative burden associated with creating and administering such a 
grant program would be prohibitive, particularly since VA must continue 
to monitor grantee's activities to ensure alignment with VA program 
objectives and each program participant's individual rehabilitation 
plan. VA personnel already use existing systems to process direct 
reimbursements to veterans for authorized, necessary costs associated 
with participation in their specific vocational rehabilitation 
programs. VA believes that, subject to the availability of funding for 
the purpose, any incentive programs to facilitate completion of 
vocational rehabilitation programs should be built onto existing VA 
reimbursement authorities.
    The Department would be authorized $5 million from the amounts 
available in VA's GOE account in each of fiscal years 2010 through 2012 
to carry out section 504 of this bill.
    Section 505 would require that not less than one year before the 
expiration of the authority to carry out the pilot programs established 
under section 501 through 504, VA would submit a report to Congress 
including the following: lessons learned, recommendations on whether to 
continue such pilot program, the number of veterans and dependents 
served by such pilot program, an assessment of the quality of service 
provided to veterans and dependents, the amount of funds provided to 
grant recipients, and the names of organizations that have received 
grants.
    VA supports sections 601 to section 606 of Title VI, which would 
update and clarify provisions of Public Law 100-322 authorizing VA-
affiliated Nonprofit Research Corporations (NPCs). Title VI promulgates 
revisions that will allow the NPCs to better serve VA research and 
education programs while maintaining the high degree of oversight 
applied to these nonprofits. There are no added costs associated with 
Title VI. VA supports Title VI.
    Subsection (a)(1) of section 701 of the bill would amend section 
902(a) of title 38, U.S.C., so as to permit VA police officers to: (1) 
carry VA-issued weapons, including firearms, while off VA property in 
an official capacity or while in official travel status; (2) conduct 
investigations, on and off VA property, of offenses that may have been 
committed on VA property, consistent with agreements with affected 
local, state, or Federal law enforcement agencies; (3) carry out, as 
needed and appropriate, any of the duties described in section 
902(a)(1), as revised, when engaged in such duties pursuant to other 
Federal statutes; and (4) execute any arrest warrant issued by a 
competent judicial authority. Subsection (a)(2) of section 701 would 
further amend section 902 of title 38 to specify that the powers 
granted to VA police officers be exercised in accordance with 
guidelines approved by the Secretary and the Attorney General of the 
United States. VA will work with the Department Justice to formulate 
our views on this proposed legislation. We will submit our views at a 
later date.
    Section 702 of the Committee bill would amend section 903(b) of 
title 38, U.S.C., which governs the uniform allowance for VA police 
officers, to limit the allowable amount to the lesser of: (1) the 
amount prescribed by the OPM; or (2) the estimated or actual costs as 
determined by periodic surveys conducted by VA. The provision would 
also amend section 903(c) of title 38 to provide that the allowance 
established under subsection (b) of section 902 of title 38, as 
modified by the Committee bill, shall be paid at the beginning of an 
officer's appointment for those appointed on or after October 1, 2008, 
and for other officers at the request of the officer, subject to the 
fiscal year limitations established in subsection (b), as modified by 
the Committee bill.
    VA supports these provisions. Under current section 903, uniformed 
Department of Veteran Affairs Police are paid $400 for an initial 
uniform allowance, and then $200 annually throughout their careers. 
This is a marginal amount and does not cover the actual costs of 
uniforms and equipment required by the Department for our officers. VA 
Police officer uniforms are required by the Department and purchased by 
the officers using the statutorily authorized allowance. These amounts 
were last updated in 1991. Our Police Officers generally have to reach 
into their own pockets to supplement both the initial purchases and 
annual upkeep.
    The Office of Personnel Management (OPM) published new regulations 
in the Federal Register that increase the authorized uniform allowance 
amount up to $800 initially and $800 annually. Section 702 would allow 
the Department to occasionally review and increase initial allowances 
up to the OPM-authorized maximum, if that is necessary.
    The Department requires that all VA police officers present an 
image of professionalism and authority. Authorizing an updated uniform 
allowance will help to achieve that. We also note that uniform 
allowances are a recruiting tool. We estimate costs at $1.58 million 
for one year, $6.5 million for five years, and $16.82 million for ten 
years.
   s. 362 ``repeal of exceptions to rights of certain department of 
    veterans affairs employees to engage in collective bargaining''
    S. 362 would make matters relating to direct patient care and the 
clinical competence of clinical health care providers subject to 
collective bargaining. More specifically, it would repeal the current 
restriction on collective bargaining, arbitrations, and grievances over 
matters that the Secretary determines concern the professional conduct 
or competence, peer review, or compensation of Title 38 employees. 
Last, the bill imposes an unrealistic and unworkable time limit on 
certain grievance appeals. VA strongly opposes this provision.
    Our concern with this bill is its potential to adversely impact 
VA's ability to deliver quality patient care. While we appreciate the 
many positive contributions collective bargaining and labor-management 
partnership make to VA's mission, VA strongly opposes S. 362, which, if 
enacted, would imperil VA's ability to furnish timely and quality care 
for veterans. S. 362 would transfer VA's Title 38 specific authorities, 
namely the right to make direct patient care and clinical competency 
decisions, assess Title 38 professionals' clinical skills, and 
determine discretionary compensation for Title 38 professionals, to 
independent third-party arbitrators and other non-VA, non-clinical 
labor third parties who lack the clinical training and health care 
management expertise to make such determinations. While S. 362 would 
result in a host of untenable situations, we limit our comments here to 
the most significant problems raised by the legislation.
    First, the rules for collective bargaining often lead to protracted 
negotiations and third-party proceedings. On average, it takes 60 days 
to negotiate national MOUs with AFGE, which does not include local-
level bargaining which can take as long as 30 to 60 days. While this is 
acceptable for most workplace matters, it is not when it comes to 
providing quality patient care. If this bill were enacted, critical 
changes in patient care (e.g. new, mandated training on care of 
Traumatic Brain Injury or extended hours for mental health facilities) 
could not be implemented until after national and local bargaining had 
been completed. This would very likely result in veterans' experiencing 
delays or gaps in their receipt of needed clinical care or services. 
Indeed, we foresee the situation where a VA facility is not able to 
change the standards requiring 24-hour assessments of patients without 
first engaging in collective bargaining, even though immediate patient 
care concerns are the cause for the change. Such delays and the very 
practice of negotiating clinical matters would be an anathema to 
patient-centered medicine.
    Second, S. 362 would allow Title 38 professionals to grieve matters 
or file Unfair Labor Practice grievances on clinical matters currently 
exempted from collective bargaining. If a grievance were not resolved 
at the informal stage, it would go to a third-party arbitrator for 
decision. Labor grievance arbitrators and the Federal Service Impasses 
Panel would have considerable discretion to impose a clinical or 
patient care resolution on the parties. VA would have limited, if any, 
recourse if such an external party erred in its consideration of the 
clinical or patient care issue. VA would be bound by that third-party's 
decision. As a provider, this is wholly unacceptable. VA clinicians 
need to make the clinical decisions involving their patients to ensure 
care is furnished in compliance with VA and prevailing medical practice 
standards.
    Moreover, these decisions should not be made by a non-clinical 
third party who is not accountable for ensuring the health and safety 
of the veterans receiving their care through the Department. If the 
Secretary and the Under Secretary for Health are going to be held 
responsible and accountable for the quality of care provided to 
veterans, it is they who must be able to determine which matters affect 
that care. They must be able to establish standards of professional 
conduct for, and competency of, our clinical providers based on what is 
best for Veterans from a medical perspective rather than what is the 
best that can be negotiated through collective bargaining or based on 
what a non-clinical arbitrator or FLRA judge decides is appropriate. At 
the least, because the third party's final decision on a clinical 
matter would be imposed on VA, the relevant union should be held 
accountable and liable, along with the Department, for any adverse 
patient outcomes resulting from the decision.
    Additionally, S. 362 would adversely affect patient care and safety 
by permitting Title 38 providers to file grievances based on changes 
made in their shifts (e.g., whether or not to utilize compressed work 
schedules) that are needed to maximize providers' skills and best meet 
patient care needs. VA needs the ability to quickly change shift 
assignments to meet patient needs that cannot be anticipated. Shift 
changes may also be necessitated by a medical emergency. However, S. 
362 would permit the union to submit a proposal to define what 
constitutes emergency situations, limiting situations when VHA could 
schedule staff, such as RNs, to work longer than 12-hour shifts. In 
such a case, the impact on patient care would be four-fold:

     By imposing a collectively bargained-for definition of 
``emergency,'' the proposal would open to grievance and arbitration any 
management determination that a nurse should work beyond 12 hours to 
meet emergent patient care needs;
     It would effectively prohibit management from determining 
that an emergency exists when the specific limitations of the 
bargained-for definition are not met;
     It could delay adequate nurse staffing for the affected 
unit, leave the unit under-staffed for the entire tour, or force VA 
into procuring expensive contract care that may not equal that of VA 
employees; and,
     It would place limitations on management's ability to 
mandate a particular nurse, with personal professional qualifications 
that render him/her the preferable or necessary patient care provider 
under the circumstances, to work in an emergency, directly impacting 
patient care.

    It is even foreseeable that the union could submit a proposal 
empowering RNs to be able to refuse mandatory overtime in excess of 12 
hours, even if based on critical patient needs. This would effectively 
prohibit VA from taking any disciplinary action against an RN who 
refused to work more than 12 consecutive hours. If no RN agreed to work 
longer than 12 hours on a particular unit, then the unit would be left 
short-staffed, or VA would need to procure expensive contract care that 
may not equal that of VA employees, either of which would adversely 
impact patient care. This is not to say, however, that any changes in 
shift assignments at the facility level are invariably clinical care 
matters excepted from collective bargaining. We are committed to 
ensuring that changes in staffing are not the result of any facility's 
failure to make adequate staffing plans to meet their foreseeable, 
projected, and routine patient workloads.
    We cannot underscore enough that veterans would find little solace 
in learning that their care was delayed or denied because of our 
statutory obligation to first participate in collective bargaining with 
the unions on a clinical matter related to their care (including 
staffing), particularly if their medical situation leads to grave 
consequences. Nor could our veteran-patients be expected to understand 
why their VA providers--a coterie of highly qualified, trained, and 
trusted professionals--have no option but to follow the decisions of 
third-parties with whom they disagree. This would be particularly hard 
for them to accept when the final arbiter is a stranger to patient and 
provider alike and otherwise completely uninvolved in the patient's 
care.
    S. 362 would also thwart VA's ability to immediately re-assign 
staff from direct patient care duties to administrative duties based on 
an allegation that the staff committed patient abuse or posed some 
other danger to patient safety. Until such serious allegations can be 
properly investigated, the only reasonable action VA can take to 
protect patients is to immediately remove that staff member from direct 
patient care duties. Under the bill, however, such staff reassignments 
would be subject to negotiations, as staff would be able to grieve 
them. Such decisions should not be left to arbitrators, who lack any 
clinical training and who have no responsibility for providing health 
care.
    Another example of the problems raised by this legislation concerns 
VA's Peer Review process, which VA uses to assess the clinical skills 
of our Title 38 professionals and also to assess whether our patients 
received the high-standard of care they deserve. The Peer Review 
program is now expressly exempted from collective bargaining under 
section 7422. S. 362 would change that, permitting non-VA, non-clinical 
third-parties to assess the clinical skills of our Title 38 
professionals and determine whether they are clinically competent in 
their area of practice. This would be an absurdity were it not such a 
serious threat to our patients' welfare.
    In addition to clinical-care issues, S. 362 would also result in 
unprecedented changes in how the Federal Government operates. It would 
permit unions to bargain over, grieve, and arbitrate subjects that are 
even exempted from collective bargaining under Title 5, including the 
determination of the amount of an employee's compensation. Permitting 
Title 38 staff to negotiate the discretionary aspects of their 
compensation would simply be at odds with how other Federal employees 
are treated. Such inequitable treatment among Federal employees cannot 
be justified.
    By significantly changing VA's collective bargaining obligations, 
S. 362 would also adversely impact VA's budget and management rights. 
It would also skew toward a slippery slope the current balance 
maintained between providing beneficial working conditions for Title 38 
professionals and providing quality patient care services that are 
timely and that meet, if not exceed, the diverse, and often complex, 
medical needs of our veterans.
    Congress purposefully left it to the Secretary's discretion to 
decide which matters would be excluded from collective bargaining. In 
so doing, Congress implicitly acknowledged that our large, dynamic 
health care system should not permit real-time clinical decisions and 
clinical management decisions to be decided through the collective 
bargaining process. The Under Secretary for Health has been delegated 
the authority to make these discretionary determinations. Since 1992, 
there have been no more than 17 decisions issued by the Under Secretary 
in a one-year period. This means that very few section 7422 grievances 
have been filed and pursued by employees up to the Under Secretary 
level. This is particularly striking given the number of VA health care 
facilities and bargaining unit employees at those facilities.
    In fact, our data reflect that, on the whole, our efforts to 
recruit and retain health care professionals (particularly nurses) have 
been widely successful notwithstanding the exceptions from collective 
bargaining now provided for by section 7422. We are glad to share our 
data with the Committee and brief the members on our continuing efforts 
in this area.
    In view of the foregoing, we strongly oppose this legislation. 
Although we appreciate the valuable role the unions can play on behalf 
of their members, this bill would give them bargaining rights on 
clinical care matters that would clearly and foreseeably endanger the 
well-being of our veteran-patients.
    In addition, section 2 of the bill, a proposed new section 
7463(f)(1), would impose a requirement for VA to decide grievance 
appeals no later than 60 days after the grievance is filed. In many 
cases however, the grievance examiner's review could take most or all 
of those 60 days, leaving no time for a review of, and decision on, the 
examiner's findings and recommendations called for in section 
7463(d)(3). If the Committee does not forebear in its consideration of 
S. 362, we suggest that provision of the bill be modified to (1) amend 
section 7463(d)(2) to impose a 120-day time limit for the examiner's 
review and recommendations, and (2) to amend 7463(d)(3) to impose a 60-
day time limit for that section's review and decision on the examiner's 
findings and recommendations.
    Finally, section 3 of the bill would amend the Disciplinary Appeals 
Board statute to require the provision of a transcript to the employee 
three weeks before the submission of post-hearing briefs. We think this 
unnecessarily constrains the time for DABs to consider their decisions, 
which must be rendered within 45 days of the DAB hearing and no later 
than 120 days after commencement of the appeal. In fact, there may be 
instances where it will be impossible to provide the three weeks and 
meet the 120-day time limit.
    In sum, VA's ability to manage its health care facilities and to 
monitor the professional conduct and competence of its employees are 
management actions that must be reserved for the VA professionals 
responsible for delivering quality patient care.
        s. 404 ``veterans' emergency care fairness act of 2009''
    VA supports S. 404, the ``Veterans' Emergency Care Fairness Act.'' 
This bill would expand Veteran eligibility for reimbursement by VA for 
emergency treatment furnished in a non-VA facility. Under current law, 
VA is a payer of last resort. Consequently, a Veteran who would 
otherwise be eligible for reimbursement or payment of private emergency 
medical expenses is ineligible for the benefit because a third party 
makes partial payment toward the Veteran's emergency treatment expenses 
pursuant to other contractual or legal recourse available to the 
Veteran. In these cases, Veterans are often left with sizable medical 
debts for which they are personally liable. VA payment as secondary 
payer would fully extinguish the Veteran's liability to the private 
provider who furnished the emergency treatment.
    It is difficult to cost this proposal without extensive data on 
Veterans' personal liability for non-VA emergency care expenses. We 
have estimated the cost based on the average payment made by VA for 
unauthorized non-VA emergency treatment of Veterans' non-service-
connected disabilities. We estimate the cost of implementing this draft 
bill to be $500,000 for FY 2010, $3 million over a 5-year period, and 
$7.8 million over a 10-year period.
           s. 423 ``veterans health care budget reform act''
    S. 423 would authorize advance appropriations for certain medical 
accounts of the Department by providing two-fiscal year budget 
authority. Mr. Chairman, we know that Congress and the Administration 
share the same objective--to ensure VA delivers timely, accessible, and 
high-quality care that Veterans expect and deserve. On April 9, 2009, 
the President emphasized that care for Veterans should never be 
hindered by budget delays and expressed support for advanced funding 
for Veterans' medical care. We believe that advanced funding will 
ensure that sufficient resources are available from the first day of 
the fiscal year so that the health care needs of Veterans can be 
provided on a timely basis. We look forward to working with Congress to 
make advanced funding for VA health care a reality.
 s. 509 ``authorize a major medical facility project at the department 
     of veterans affairs medical center, walla walla, washington.''
    S. 509 would authorize a major medical facility project at the VA 
Medical Center in Walla Walla, Washington, in an amount not to exceed 
$71,400,000. The project includes construction of a new multi-specialty 
outpatient clinic, campus renovations and upgrades, as well as 
additional parking. Mr. Chairman, funds for this project were 
appropriated last year in Pub. L. 110-329. We support this bill.
  s. 543 ``veteran and service-member caregiver support act of 2009''
    Mr. Chairman, S. 543 describes a pilot program to train, certify 
and pay family caregivers for care provided to an eligible veteran or 
servicemember. There are similarities between this provision and the 
previously described section 209 of S. 252, which would also establish 
a pilot program for family caregivers, but there are also some 
significant differences. While S. 252 pertains specifically to veterans 
or servicemembers with Traumatic Brain Injury, the eligibility criteria 
set forth in S. 543 would authorize a much larger and less well-defined 
population. In addition, S. 543 differs in the duration and location of 
the pilot programs and also authorizes the inclusion of private 
facilities in the pilot. S. 543 provides more specificity concerning 
eligibility of family members, veterans and servicemembers, and is more 
proscriptive in describing the development of the curriculum. It also 
sets forth a detailed mechanism for determining amounts paid to family 
caregivers. Another provision in the bill directs the Secretary to 
review VA respite care programs, identify options for enhancing respite 
care and enhance the availability of such care. The bill also directs 
the Secretary to collaborate with the Secretary of Defense to develop a 
pilot program to make certain counseling and social services available 
to each eligible family caregiver participating in the pilot program.
    The concerns we identified with section 209 of S. 252 also apply to 
this pilot program. VA currently contracts for caregiver services with 
home health and similar public and private agencies. The contractor 
trains and pays the family member, affords them liability protection, 
and oversees the quality of their care. As previously noted, this 
arrangement is preferable because it does not divert VA from its 
primary mission of treating veterans and training clinicians.
    VA does not oppose the intent of the subsection of this bill 
addressing respite care but believes that it is unnecessary. VA already 
has a comprehensive respite care program that provides Veterans with 
short-term services to give the caregiver a period of relief from the 
demands of daily care for the chronically ill or disabled Veteran or 
active duty servicemember. Respite care services are planned in advance 
for the benefit of the caregiver in conjunction with the necessary 
medical care of the patient. As noted earlier with regard to section 
210 of S. 252, Veterans are entitled to 30 days of respite care a year 
in inpatient, community, or other settings.
    VA has two pilot programs underway to expand respite services. VA 
Voluntary Services (VAVS) is establishing and operating a community-
based volunteer home respite program to benefit Veterans and their 
primary caregivers. Respite services provided through VAVS are in 
addition to the 30 days of respite care per year. This program is 
underway at ten VA medical centers. A caregiver assistance pilot 
program is also underway to provide 24-hour in-home respite care at two 
VA medical centers. Additionally, every Veteran and caregiver has 
access to a VA social worker who provides an assessment of 
individualized needs of the family caregiver with respect to the family 
member's role as a caregiver, assistance with the development of a plan 
for long-term care of the Veteran, and implementation of a treatment 
plan.
         s. 597 ``women veterans health care improvement act''
    S. 597, is nearly identical to sections 301 through 309 of S. 252. 
The views expressed regarding those sections are also applicable to the 
provisions in S. 597.
     s. 658 ``rural veterans health care improvement act of 2009''
    S. 658 contains several sections. I will address each section 
separately.
    Section 2 would establish the beneficiary travel allowance for 
mileage at a rate of 41.5 cents per mile. It would also require the 
Secretary amend the VHA Handbook to clarify that the allowance for 
mileage may exceed the cost of public transportation. VA does not 
oppose this provision but believes that it is unnecessary. VA currently 
reimburses beneficiary travel mileage at 41.5 cents per mile. Public 
Law 110-387 gave the VA Secretary authority, based on availability of 
funds, to prescribe a rate higher than the Federal employee rate and, 
using this authority, the Secretary raised the mileage reimbursement 
rate to 41.5 cents per mile effective November 17, 2008. S. 658 would 
also remove the Secretary's authority to adjust the mileage 
reimbursement rate when it is determined that such change is 
appropriate.
    Section 3 directs VA to establish at least one and no more than 
five, geographically dispersed centers of excellence for rural health 
research, education, and clinical activities. VA opposes this 
legislation because proposed centers of excellence are duplicative of 
the Veterans Rural Health Resource Centers (VRHRCs) that were 
established to improve care and services for veterans residing in 
geographically isolated areas. Provisions within this section are also 
duplicative of efforts of VA's Veterans Rural Health Advisory Committee 
which was established to examine ways to enhance VA health care 
services for Veterans in rural areas by evaluating current programs and 
identifying barriers to health care. We estimate the cost of Section 3 
to be $2 million in the first year, $10.8 over five years, and $23.8 
million over ten years.
    Section 4 would require the Secretary to establish a grant program 
for State veterans' service agencies and Veterans Service Organizations 
to provide innovative transportation options to veterans in rural 
areas. VA supports this provision. Section 4 authorizes appropriations 
of $3,000,000 annually for fiscal years 2009-2013.
    Section 5 would require the Secretary to create demonstration 
projects through partnerships with the Department of Health and Human 
Services and the Indian Health Service to examine the feasibility and 
advisability of alternatives for expanding care for Veterans in rural 
areas. VA does not support this provision as it is duplicative of pilot 
programs that are required under Section 107 and Section 403 of Public 
Law 110-387. Section 107 of that law requires VA to establish pilot 
programs in rural areas to use contracted community health centers, the 
Indian Health Service, or other appropriate entities to provide peer 
outreach, peer-to-peer counseling, readjustment counseling, and other 
mental health services to Operation Enduring Freedom and Operation 
Iraqi Freedom Veterans. The enactment of section 403 requires VA to 
establish a pilot program under which VA provides health services to 
highly rural Veterans through qualifying non-VA health care providers. 
Overall, we estimate that the demonstration projects outlined in 
Section 5 would cost $4.4 billion over three years.
    Section 6 directs the Secretary to establish a program to provide 
peer outreach services, peer support services, readjustment counseling 
services, and mental health services to Veterans of Operation Enduring 
Freedom and Operation Iraqi Freedom, particularly those who served 
while in the National Guard and Reserves. This section would also 
provide the Secretary the authority to contract with community mental 
health centers and other entities to provide services in areas not 
adequately served by Department facilities. VA opposes this section as 
it would blur the fundamental distinction between the readjustment 
counseling services and mental health services currently provided by 
the Department. These services are authorized by separate authorities 
and employ different eligibility criteria. Moreover, they should not be 
combined as they are conceptually and operationally very distinct areas 
of treatment.
    Readjustment counseling is a special community-based counseling 
service that goes beyond medical care to provide combat veterans 
services needed to facilitate a successful readjustment to civilian 
life. VA's authority to furnish readjustment counseling services 
already includes the authority to furnish limited mental health 
services necessary for effective treatment of the veteran's 
readjustment issues. Vet Centers, for example, provide professional 
treatment for combat-related PTSD, depression, and substance abuse and, 
if necessary, refer the veteran to VA facilities for treatment of 
additional or more complex mental health needs. In contrast, 
comprehensive mental health services are furnished as medically needed 
to all enrolled Veterans, regardless of combat status, as part of VA's 
standard medical benefits package.
    VA currently contracts for readjustment counseling and related 
readjustment services with private sector community mental health 
agencies and other professional entities. Most of these contract 
providers are located in rural areas. Similarly, VA has authority to 
contract for mental health services for enrolled Veterans if VA cannot 
provide needed services in a timely manner. In this regard, section 6 
is duplicative of existing contract authorities and ongoing activities.
    Vet Centers also provide veteran-peer outreach and counseling. In 
2004, VA began an aggressive outreach effort, which included hiring 
theater of combat OEF/OIF Veterans to provide outreach services and 
peer counseling to their fellow veterans. To date, the Vet Center 
program has hired 100 OEF/OIF outreach workers. In addition, the 
program has seen a significant expansion of its resources. Starting 
from a total of 206 Vet Centers in fiscal year (FY) 2006, there are now 
232 Vet Centers, and another 39 planned to be operational by the end of 
FY 2009. Funding to support all of the Vet Center program initiatives 
is included in the program's annual operating budget.
    Section 7 would establish an ``Indian Veterans Health Care 
Coordinator'' at the 10 medical centers which serve the greatest number 
of Indian veterans to improve outreach to tribal communities, 
coordinate medical needs with the Indian Health Service, expand access 
and participation in the Veterans Affairs Tribal Veterans 
Representative program, and advocate on behalf of Indian veterans. This 
section would also require the integration of electronic health records 
between VA and the Indian Health Service and would permit the Secretary 
to transfer medical and IT equipment to the Indian Health Service.
    VA does not support Section 7 because the agency is already 
providing support to American Indian Veterans, primarily through our 
rural health initiatives. VA encourages cooperation and resource 
sharing between the Indian Health Service and VHA to deliver quality 
health care services and enhance the health status of American Indian 
and Alaska Native (AI/AN) veterans. VA also maintains the VISN Tribal 
Veterans Representative (TVR) Program, which provides outreach and open 
communication to veterans in extremely rural and underserved areas, 
especially the 
AI/AN and Hawaiian Native (HN) populations. The VISN TVR program trains 
individuals on outreach techniques to assist, facilitate and encourage 
veterans to access their full range of earned VA benefits. Multiple 
agencies use VA's VISN TVR outreach services including the Indian 
Health Service, Tribal Health Services, Community Health Centers and 
veterans' service organizations. VA estimates the cost of the 
provisions in Section 7 at $985,000 in the first year, $5.3 million 
over five years, and $11.6 million over ten years.
    Section 8 would require the Secretary to provide an annual report 
to Congress on matters related to care for Veterans who live in rural 
areas. VA is not opposed to this reporting but we believe it is 
unnecessary. VA already provides a number of periodic reports to 
Congress on the status of rural and highly rural Veterans. For example, 
Public Law 110-329 requires that the Secretary of the Department of 
Veterans Affairs report quarterly to the Congress on new rural health 
initiatives implemented through appropriations funding. The Office of 
Rural Health also provides regularly recurring reports to the SVAC and 
HVAC.
            s. 669 ``veterans 2nd amendment protection act''
    S. 669 would clarify the conditions under which certain persons may 
be treated as adjudicated mentally incompetent for certain purposes. 
Pursuant to section 103(e)(1) of the Brady Handgun Violence Prevention 
Act (Pub. L. 103-159), VA is required to provide the Department of 
Justice (DOJ) with information concerning individuals who, due to a 
determination by VA, are prohibited from purchasing or possessing 
firearms under the standards imposed by 18 U.S.C. Sec. 922(d)(4) and 
(g)(4), which prohibits the purchase or possession of firearms by any 
person ``adjudicated as a mental defective.'' Under existing DOJ 
regulations, the phrase ``adjudicated as a mental defective'' includes 
persons found to be a danger to themselves or others and persons found 
to lack the mental capacity to manage their own affairs. Pursuant to 
those requirements, VA's Veterans Benefits Administration (VBA) 
currently provides DOJ with information on persons adjudicated by VA 
under 38 CFR Sec. 3.353, as lacking the mental capacity to contract or 
manage their own affairs. This information is then included in 
databases managed by DOJ's Federal Bureau of Investigation and Bureau 
of Alcohol Tobacco and Firearms, and serves to prevent, through the 
National Instant Criminal Background Check System, prohibited 
individuals from purchasing firearms.
    S. 669 would provide that a person VA finds to be mentally 
incapacitated, mentally incompetent, or experiencing an extended loss 
of consciousness ``shall not be considered adjudicated as a mental 
defective'' for purposes of 18 U.S.C. Sec. 922(d)(4) and (g)(4), unless 
a ``judge, magistrate, or other judicial authority of competent 
jurisdiction'' concludes that ``the individual is a danger to himself 
or herself or to others.'' This amendment would revise the reporting 
requirements contained in title 18 of the United States Code, by adding 
additional prerequisites to the reporting by VA to DOJ, of information 
pertaining to persons VA adjudicates as incompetent. VA takes no 
position on this bill at this point as the Administration is still 
working with the Department of Justice to formulate views.

 s. 734 ``rural veterans' health care access and quality act of 2009''
    I will address individually the several sections of S. 734.
    VA opposes Section 2, which would remove the current cap for the 
Education Debt Reduction Program (EDRP) and would cover the full cost 
of the principal and interest owed by participants. This section could 
result in significantly higher awards, but would mean significantly 
fewer people could participate. Moreover, EDRP is a reimbursement 
program, meaning that VA provides awards to employees at the end of the 
year covering their out-of-pocket payments on their loans. In many 
situations, employees would be unable to bear the cost of higher per 
year awards. For example, an individual with a $150,000 loan would have 
to pay $30,000 on their own before VA could reimburse them at the end 
of the year. We also note by removing the cap on loan repayment awards, 
VA's programs would be inconsistent with other student loan repayment 
or reimbursement programs in the Federal Government. Moreover, this 
bill does not eliminate the six-month eligibility requirement and thus 
does not improve the retention value of EDRP. VA estimates Section 2 
would cost $9.7 million in FY 2010, with a five-year total of $145.9 
million and a ten-year total of $389.2 million.
    Section 3 proposes to transfer $20 million to the Department of 
Health and Human Services to include VA among the list of facilities 
eligible for assignment of participants in the National Health Service 
Corps Scholarship Program. VA believes that participation in this 
program would help attract high caliber research-focused candidates to 
VA; however, we believe that VA funding would be better spent 
supporting our current recruitment and retention initiatives, such as 
the Employee Debt Reduction Program, the Employee Incentive Scholarship 
Program, or the Health Professionals Educational Assistance Scholarship 
Program, which would be resumed under section 103 of S. 252.
    Section 4 of S. 734 would require the Director of the Office of 
Rural Health (ORH) to develop a five-year strategic plan. VA does not 
oppose this provision but believes it is unnecessary. The ORH is 
already developing a national strategic plan and has informed Congress 
of its planning process. The plan under development will exceed the 
requirements of the bill by enabling ORH to focus on six key areas: 
access, technology, quality, education and training, collaborations, 
and workforce recruitment and retention. Additionally, the national ORH 
strategic plan will meet ORH's mission requirements, which are to 
promulgate policies, best practices and innovations to improve health 
care services to Veterans who reside in rural and highly rural areas, 
while undertaking ongoing initiatives to find better health care 
solutions and improving overall access. This national strategic plan 
will include specific goals for timely and quality access and 
incremental milestones for measuring the achievement of these 
objectives. Telehealth and telemedicine are important elements of these 
objectives and ORH will work in close collaboration with VHA's Office 
of Care Coordination Services to appropriately include this method of 
health care delivery. VA estimates there would be no significant costs 
associated with Section 4.
    Section 5 of S. 734 would permit VA to use paraprofessional 
volunteers and eligible volunteer counselors to support the mission of 
Vet Centers and outreach efforts. VA does not oppose section but 
believes it is unnecessary as VA already has the authority under 38 
U.S.C. 513, 38 U.S.C. 7405, and VHA Directive 1620 (September 28, 2005) 
to use volunteers for these services to supplement, rather than 
replace, VA compensated staff. Additionally, these authorities permit 
volunteer assistance by physicians, dentists, nurses and other 
professionally licensed persons to assume full responsibility for 
professional services in their respective fields with the approval of 
the facility Chief of Staff, provided the volunteer is properly 
privileged and credentialed to perform such service and that any 
activities in which they engage are under the supervision of VA-
compensated clinical staff. VA estimates there would be no significant 
costs associated with Section 5.
    Because they are either unnecessary or redundant of current 
activities, VA does not support a number of the provisions in Section 
6. This section would require VA to: (1) carry out a program of 
teleconsultation for the provision of remote mental health and 
Traumatic Brain Injury (TBI) assessments; (2) carry out a program of 
teleretinal imaging in each VISN, expanding the number of patients 
enrolled in such a program by five percent annually through FY 2015; 
(3) develop in cooperation with affiliated universities an elective 
rotation in telemedicine for medical residents; and (4) modify the 
Veterans Equitable Resource Allocation (VERA) system to provide 
incentives for utilizing telehealth and to incorporate such 
consultations in facility workload data.
    Regarding the first provision, VA has already implemented a 
national program to provide teleconsultation for remote mental health 
assessments. VA is currently undertaking a pilot of the remote 
assessment of TBI via teleconsultation in Denver. There are also 
clinical, technological, and business processes that need to be 
formalized before national implementation. We are working within VA and 
with external partners to establish technical and clinical care 
standards. The costs that would result from this proposal are 
insignificant.
    VA similarly does not support the second provision concerning 
teleretinal imaging. VA has already instituted teleretinal imaging 
programs in each of the 21 VISNs. While VA's teleretinal imaging 
program is currently growing by more than five percent each year, we do 
not want this requirement enacted into law because it is overly 
prescriptive. Advances in technology or clinical care within the next 
five years could produce a more effective approach to treatment, so a 
requirement to expand enrollment in one program that has been 
superseded by another would run contrary to the best interests of our 
Veterans. VA estimates this proposal would cost $455,000 in FY 2010 and 
would have a five-year cost of $2.5 million.
    While VA supports the concept of expanding opportunities for 
medical residents to participate in telemedicine programs and to gain 
experience in these technologies, we oppose the provision in this bill 
that would require each facility involved in resident training to 
develop an elective rotation in telemedicine as it cannot be 
implemented. The curriculum in medical residency training programs is 
tightly regulated by the Accreditation Council for Graduate Medical 
Education, which does not approach specific delivery methods as 
separate from the scientific curriculum. However, VA does provide 
opportunities for many residents to participate in telemedicine health 
care delivery and will continue to do so. There are no significant 
costs associated with this provision.
    VA supports subsection 6(c) concerning enhancements of VERA. In the 
absence of appropriate VERA incentives to encourage VISNs and 
facilities to adopt telehealth, the expansion of telehealth can be 
delayed and in some cases faces disincentives when compared with other 
means of care delivery. This proposal would expand access to care in 
areas where telehealth can address unmet patient needs while reducing 
costs through home telehealth and telemental health. VA estimates no 
costs associated with this provision.
    Section 7 addresses oversight of contracts and fee basis care. From 
a legal perspective, the provision 7(a) raises issues with regard to 
prohibited `bundling' of contracts. `Bundling' is combining two or more 
requirements previously performed under separate contracts and thus 
making it unlikely to be suitable for award to small businesses. Many 
VA Community-Based Outpatient Clinic acquisitions are set aside for 
small business. Our interpretation of ``consolidate such contracts'' 
would be to make a single contract whenever multiple contracts awarded 
to the same provider. Upon re-competition, VA would then necessarily 
advertise that combined requirement and that may make the requirement 
too large for a small business set-aside. Federal Acquisition 
Regulation 7.107 includes specific determinations that have to be made, 
including anticipated cost savings, for bundling that must be made and 
approved prior to `bundling' contracts. While this section includes a 
qualifier, that each VISN ``to the maximum extent practicable'' shall 
consolidate such CBOC contracts, if enacted, this section would create 
a conflict with the bundling rules. Further, we do not believe this 
provision would result in any significant administration or oversight 
savings or relief.
    Subsections (c), (d), and (e) appear to treat peer review and 
accreditation as worthy of additional compensation. VA does not support 
these provisions as we believe our obligation is to ensure Veterans 
receive the highest possible standard of care, regardless of where that 
care is provided. Accreditation and participation in peer-review 
programs are ``floor requirements'' that every provider should already 
meet. Moreover, we interpret these provisions as providing the same 
level of compensation for participation in a peer review program as for 
obtaining accreditation. This would create a greater incentive to 
participate in peer review as there are additional costs for the 
medical practice associated with accreditation that are not present for 
peer review. VA estimates this section would cost $385,000 in FY 2010, 
with five-year costs of $2 million, and ten-year costs of $4.6 million.
    Section 8 would authorize the use of air transportation when travel 
by air is the only practical way to reach a Department facility. We 
believe this criterion is vague and subject to broad interpretation. 
Even with carefully crafted regulatory implementing language, this 
criterion could result in substantial confusion for Veterans and VA 
staff and wide variations in actual benefit implementation and 
administration. Moreover, the benefit outlined in Section 8 would not 
be limited to veterans living in rural areas. The cost of implementing 
Section 8 is also very difficult to calculate since VA does not know 
how many Veterans, either currently eligible or eligible under the new 
legislation, might be considered to require air transport. We cannot 
precisely predict the distances that will be traveled, how often air 
travel will be required, and any special requirements such as oxygen, 
gurney, or other special needs that may be necessary during flights. 
Based on available data and assumptions of usage, we estimate the cost 
of this provision to be $400 million for the first year, approximately 
$2.3 billion over five years and approximately $5.4 billion over ten 
years.
    Finally, VA opposes Section 9, which would create a three-year 
pilot program offering incentives for physicians who assume inpatient 
responsibilities at community hospitals in health professional shortage 
areas. VA has no statutory authority to bill third-party payers for 
services provided to non-Veterans in non-VA facilities. A more 
practical approach would be to develop agreements with the community 
hospital to reimburse VA for the care provided by VA physicians to non-
Veterans. This would remove the logistical challenges of billing for 
care not provided in a VA facility, not documented in VA records, and 
for which no authority or rate exists. However, VA must strongly 
emphasize that assigning VA doctors to non-VA facilities to provide 
care to non-Veterans is outside of the scope of our mission to care for 
Veterans and other eligible beneficiaries. VA is unable to estimate the 
cost of this section because VA does not currently have authority to 
treat, bill or collect for care provided to non-Veterans.
            s. 801 ``family caregiver program act of 2009''
    S. 801 is divided into four separate sections. I will address each 
section separately; however, VA has not yet evaluated the costs of 
implementing the provisions of S. 801. We will provide an estimate to 
the Committee as soon as it is completed.
    Section 2 would authorize VA to waive charges for humanitarian care 
provided to caregivers accompanying certain severely injured veterans 
as they receive medical care. VA does not object to the concept of 
providing humanitarian medical benefits to caregivers but we must 
oppose this section. As currently written, Section 2 identifies an 
extensive list of family members as potential caregivers and provides 
no criteria regarding the extent or duration of their service to the 
Veteran. Family caregivers could change frequently and we are concerned 
that the provision of humanitarian care could become a primary factor 
in designating a caregiver rather than that person's ability to assist 
the veteran. Further, language that has historically appeared in VA 
appropriation statutes (requiring reimbursement for hospital care and 
medical services provided to individuals who are not otherwise eligible 
for these benefits) may restrict VA's ability to waive charges as 
outlined in this provision of the bill. We are also considering the 
impact of Section 2 on the implementation of the family medical care 
provisions of the National Defense Authorization Act of 2008 
(Sec. 1672(b) of Public Law 110-181).
    Section 3 of S. 801 addresses family caregiver assistance. I have 
previously discussed the family caregiver provisions of S. 252 and S. 
543, which would require the Secretary to conduct pilot programs to 
assess the feasibility of training family caregivers as personal care 
attendants. While the eligibility criteria for this section are very 
similar to those in S. 543, S. 801 differs dramatically from S. 252 and 
S. 543 because it would establish a program of instruction, 
preparation, training, certification and ongoing support for designated 
family caregivers across VA. The mechanics of the program under S. 801 
are also different as eligible veterans and their family member (or 
other designated individual) would make a joint application to VA which 
would then evaluate the veteran to identify the personal care services 
needed by that individual and determine if they could be provided by a 
family member. The applicant family member is also evaluated to 
determine the training they would need to provide those services. 
Unlike S. 252 and S. 253, S. 801 does not address the development of 
the training curriculum. However, it does distinguish between a family 
member who provides personal care services and a family member who is 
designated as the veteran's primary personal care attendant. The agency 
would be required to provide training, certification, technical 
support, and counseling to both; however, a primary personal care 
attendant would also be furnished mental health services, medical care 
under 38 U.S.C. 1781, respite care and a stipend.
    VA strongly opposes Section 3. The same concerns identified in 
conjunction with caregiver provisions of S. 252 and S. 543 apply here 
as well. VA currently contracts for caregiver services with various 
providers and this arrangement is preferable because it does not divert 
VA from its primary mission of treating veterans and training 
clinicians. We also would like to reiterate that S. 801 would establish 
the caregiver program across the agency and we caution against 
implementing a program of this magnitude without first exploring its 
feasibility and effectiveness. Should the Committee decide to proceed 
with a caregiver assistance proposal, we urge you to opt for the 
program defined in section 209 of S. 252 which would allow VA to 
conduct a three-year pilot providing assistance to caregivers of TBI 
patients. Moreover, the concerns that I addressed in discussing Section 
2 relative to the large cadre of eligible caregivers would make this 
proposal challenging to administer and monitor for quality and 
effectiveness. The administrative burden on VA to re-identify and track 
caregivers could be considerable.
    Finally, S. 801 in general, and Section 3 in particular, would 
create preferential benefits for one generation of Veterans that are 
not available to others. VA believes that caregiver assistance would 
benefit veterans of all ages and periods of service and any initiative 
to support caregivers should not be limited to post-September 11 
veterans.
    Section 4 would amend VA's beneficiary travel statute (38 U.S.C. 
111) to include lodging and subsistence as travel expenses for 
attendants of certain veterans receiving VA health care. This provision 
would also define the travel period to include travel to and from the 
facility and the duration of the treatment episode. We believe that the 
proposed amendments would apply to all attendants eligible for 
beneficiary travel under 38 U.S.C. 111, not just those attendants 
defined by S. 801. VA opposes Section 4 as this benefit expansion would 
divert resources from medical care. In addition, 38 U.S.C. 111 already 
provides travel benefit attendants for severely injured veterans.

    Mr. Chairman, this concludes my prepared statement. I would be 
pleased to answer any questions you or any of the Members of the 
Committee may have.
                                 ______
                                 
           Additional Written Views Submitted for the Record
                         The Secretary of Veterans Affairs,
                                      Washington, DC, May 14, 2009.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: This letter is in response to your invitation to 
submit for the record the Department's views on six bills, S.239, 
S.498, S.699, S.772, S.793, and S.821. As you know, we received some of 
these legislative items too late to address in testimony before the 
Committee on April 22, 2009. In addition, while our views remain the 
same, we are submitting additional information and costs on four bills 
that were addressed in the April 22 testimony, S.252, S.404, S.423, and 
S.801. Thank you for giving us this valuable opportunity to submit our 
views before the hearing record closes.
              s.239 ``veterans health equity act of 2009''
    Section 2 of the Veterans Health Equity Act of 2009 would amend 38 
U.S.C. 1716 to require the Department to ensure Veterans in each of the 
48 contiguous states have access to at least one full-service VA 
hospital or to comparable hospital care and medical services through 
contract with other providers in the State. It also requires VA submit 
a report to Congress describing the extent to which the Department has 
complied with this provision and the effect this requirement has on 
improving the quality and standards of care provided to Veterans.
    While VA supports the intent of S.239, which we believe is to 
ensure Veterans access to medical treatment and hospital care in the 
State of New Hampshire, we are opposed to the bill as drafted because 
it is vague and confusing. Subsection (b), Rules of Construction, 
discusses ``enhanced care'' but does not define this term. Moreover, 
this provision indicates that subsection (a) should not be construed to 
prevent a Veteran from receiving care at a VA hospital in another State 
but subsection (a) addresses only access to care, not the provision of 
care. Further, subsection (b) is silent about providing out-of-state 
contract care. This is concerning as many Veterans now obtain nearby 
services from both VA hospitals and contract facilities across state 
lines, but would have to travel considerable distances to receive 
comparable services within their state of residence.
    We understand that there is considerable interest in establishing a 
full-service VA hospital in Manchester, New Hampshire. VA engages in 
extensive analysis of factors in order to identify appropriate sites 
for VA health care facilities. These factors include, but are not 
limited to, projected total Veteran population, Veteran enrollee 
population, and utilization trends.
    To address the needs and concerns of the New Hampshire 
constituency, VA is providing expanded acute care services to New 
Hampshire Veterans by means of a contract with a local acute-care 
facility. This model has been used for nine years to provide VA 
coordinated care in a safe and cost-effective manner. An expanded 
contract is now being negotiated that will service additional Veterans 
who are currently being transferred to other VA facilities.
    In evaluating the impact and estimating the cost of S.239, VA 
focused attention specifically on the State of New Hampshire. We have 
assumed that contractor services would be provided in-state. With these 
parameters in mind, we estimate that the proposal would cost $3.4 
million in 2010, approximately $20 million over five years, and nearly 
$48 million over ten years.
        s.252 ``veterans health care authorization act of 2009''
    VA provided testimony on many provisions of S.252 for the April 22, 
2009, hearing. Below are the views and costs on provisions of S.252 
that were not provided in that testimony.
    Subsection 101(f) would amend 38 U.S.C. 7410 to add a new 
subsection to establish ``comparability pay'' for VHA non-physician/
dentist section 7306 employees and SES employees of not more than 
$100,000 per employee in order to achieve annual pay levels comparable 
to the private sector. VA requests that the new administration be given 
an opportunity to review this matter. The estimated cost would be 
$10.35 million in the first year, approximately $54 million over five 
years and $113.3 million over ten years.
    Section 101(g) would provide special incentive pay for Department 
Pharmacist Executives. We expressed support for this provision in VA's 
April 22 testimony; however, our support is contingent upon finding 
offsets within the 2010 funding level requested by the President. VA 
estimates the cost to be $1.44 million in 2010, $7.72 million over five 
years and $16.85 million over ten years.
    Section 103(a) would reinstate the Health Professionals Educational 
Assistance Scholarship Program and extend it through 2014. VA supports 
the proposal, contingent upon finding offsets within the 2010 funding 
level requested by the President. We estimate the cost to be $725,000 
in 2010 and $21,380,000 over the five year period.
    Section 103(b) would make amendments to VA's Education Debt 
Reduction Program (EDRP). As the Committee had several questions 
related to VA's April 22 testimony on EDRP, we would like to elaborate 
on our assertion in that testimony that section 103(b) can be 
implemented in a cost-neutral fashion. Specifically, this provision 
would amend 38 U.S.C. 7683 to increase the authorized EDRP statutory 
amounts to $60,000 and $12,000, respectively. VA generally awards 
amounts below the statutory maximum to ensure a greater number of 
applicants will receive awards. If the award amounts are not limited, 
fewer applicants will receive them, thus limiting the recruitment 
benefits of the program. Though section 103(b) raises the maximum award 
payable under EDRP, VA would continue to implement the program within 
the existing budget allocation. Currently, $20 million annually is 
allocated for the program.
    Section 206 would authorize VA to require that applicants for, and 
recipients of, VA medical care and services provide their health-plan 
contract information and social security numbers to the Secretary upon 
request. It would also authorize VA to require applicant's for, or 
recipients of, VA medical care or services to provide their social 
security numbers and those of dependents or VA beneficiaries upon whom 
the applicant's or recipient's eligibility is based. Recognizing that 
some individuals do not have social security numbers, the provision 
would not require an applicant or recipient to furnish the social 
security number of an individual for whom a social security number has 
not been issued. Moreover, VA will assist veterans who are unable to 
provide a social security number due to homelessness, mental illness, 
or other infirmity to gain access to this information. Under this 
provision, VA would deny the application for medical care or services, 
or terminate the provision of medical care or services, to individuals 
who fail to provide the information requested under this section. 
However, the legislation authorizes the Secretary to reconsider the 
application for, or reinstate the provision of, care or services once 
the information requested under this section has been provided. Of 
note, this provision makes clear that its terms may not be construed to 
deny medical care and treatment to an individual in a medical 
emergency.
    There is no permanent provision in title 38 to require the 
provision of information concerning health insurance coverage. This 
section would ensure that VA obtains the health-plan contract 
information.
    This legislation would enable VHA to use social security numbers to 
accurately match an individual's information with both internal and 
external sources. Consistent with Executive Order 9397, collection of 
this information is necessary to meet the compelling business needs of 
the agency. Specifically, social security numbers for veterans, 
beneficiaries and dependents could be used to match veteran income data 
with the Internal Revenue Service and the Social Security 
Administration, allowing VA to carry out its income verification 
responsibility under 38 U.S.C. 5317 and 5317A. While VHA has obtained 
verified social security numbers from the vast majority of veterans and 
spouses through voluntary reporting, there were over 1 million 
beneficiaries' household incomes in 2008 that VHA was unable to match 
because the social security numbers had not been provided. Social 
security numbers are also necessary for data matching with the 
Department of Defense. Military service data is essential for VHA as 
medical care eligibility determinations may be based on such factors as 
qualifying military service and service-connected disabilities. In 
addition, VHA uses social security numbers to collect health care 
expenses from insurance companies as most insurance companies use 
social security numbers to ensure a match. VHA may also obtain or 
verify individual information from internal VA components, such as the 
Veterans Benefits Administration (VBA), which currently has authority 
to require social security numbers for compensation and pension 
benefits purposes.
    Be assured that VA would provide the same high degree of 
confidentiality for the beneficiaries' health plan information and 
social security numbers as it provides to patients' medical information 
in its records and information systems. There are no direct costs 
associated with this provision other than administrative costs 
associated with collecting revenue. Those costs will be paid from 
future discretionary appropriations. Enactment of section 206 would 
require VA to issue an updated notice of privacy practice and review 
and update all associated information collection forms.
    Section 213 would amend sections 5701 and 7332 of title 38, United 
States Code. The amendments would authorize VA to disclose 
individually-identifiable patient medical information, without the 
prior written consent of a patient, to a third-party health plan to 
collect reasonable charges under VA collections authority for care or 
services provided for a non-service-connected disability. The section 
5701 amendment would specifically authorize disclosure of a patient's 
name and address information for this purpose. The section 7332 
amendment would authorize disclosure of both individual identifier 
information and medical information for purposes of carrying out the 
Department's collection responsibilities. Given the significant privacy 
concerns related to this provision, we defer views on this section 
until further analysis can be made. VA projects revenue from this 
proposal to be close to $10 million in the first year, $51.4 million 
over five years, and $113.3 million over ten years.
    Section 217 would establish a pilot program on providing dental 
insurance plans to Veterans and survivors and dependents of Veterans. 
As indicated in our April 22 testimony, VA opposes this provision. The 
estimated cost of this pilot is $8 million over three years.
     s.404 ``veterans emergency health care fairness act of 2009''
    This bill would expand Veteran eligibility for reimbursement by VA 
for emergency treatment furnished in a non-VA facility. As discussed in 
our April 22, 2009, testimony, VA supports this legislation as it would 
establish VA as a secondary payer thereby fully extinguishing a 
Veteran's liability to the private provider who furnished the emergency 
treatment. However, we inadvertently overlooked the absence of a 
specific amendment to 38 U.S.C. 1725 necessary to fully achieve the 
purpose of this legislation. Specifically, S.404 should further amend 
38 U.S.C. 1725 by striking subsection (f)(2)(E).
    Currently, section 1725 grants the authority to reimburse certain 
Veterans the reasonable value of emergency treatment furnished in a 
non-Department facility. To be eligible for reimbursement, among other 
requirements, a Veteran must be personally liable for the treatment. 
``A Veteran is personally liable * * * if the Veteran * * * has no 
entitlement to care or service under a health-plan contract.'' 38 
U.S.C. 1725(b)(3)(B). A health-plan contract includes a State law `` * 
* * that requires owners or operators of motor vehicles registered in 
that State to have in force automobile accident reparations 
insurance.'' 38 U.S.C. 1729(a)(2)(B); 38 U.S.C. 1725(f)(2)(E). In other 
words, a Veteran who is emergently treated in a non-VA facility for 
injuries sustained in a motor vehicle accident is not, pursuant to 38 
U.S.C. 1725, personally liable for the cost of his treatment if he is 
required by State law to maintain motor vehicle reparations insurance. 
Consequently, this Veteran would not be eligible for reimbursement from 
VA. To fully achieve the intent of S.404, language should be added to 
strike subsection (f)(2)(E) from 38 U.S.C. 1725. This technical 
amendment would ensure that Veterans required by State law to maintain 
certain automobile insurance remain eligible for reimbursement for 
emergency treatment. We estimate the cost of implementing S.404 to be 
$500,000 for FY 2010, $3 million over a 5-year period, and $7.8 million 
over a 10-year period. Note that our support for this provision is 
contingent upon finding offsets within the 2010 funding level requested 
by the President.
           s.423 ``veterans health care budget reform act ''
    S.423 would authorize advance appropriations for three critical 
medical care accounts of the Veterans Health Administration: Medical 
Services, Medical Support and Compliance, and Medical Facilities. These 
are vital accounts that should never fall prey to interruptions of 
funding. VA shares the President's support for advance appropriations 
as a way to provide uninterrupted care to our Nation's Veterans.
    Implementing an advance funding mechanism is not without 
challenges, and careful planning is needed to ensure timely funding 
without unintended consequences. Budget projections are rarely right on 
the mark, and the further out they are made, the farther off the mark 
they are likely to be. For an advance appropriations mechanism to 
function effectively, it must be linked to a forecasting model that is 
both reliable and accurate, to the extent possible. VA's principal 
forecasting model is the Enrollee Health-Care Projection Model.
    The Enrollee Health-Care Projection Model, or VA Model, is a 
comprehensive enrollment, utilization, and expenditure-projection 
model. It was originally developed in 1998 in partnership with 
Milliman, Inc. Through the past 11 years of periodic updates and 
continuous refinement, VA and Milliman have developed a strong 
partnership that has resulted in a powerful modeling tool. VA guides 
the overall development of the VA Model and ensures that it meets the 
needs of stakeholders. VA program staff provide expertise on the unique 
needs of Veterans, patterns of practice in the VA health-care system, 
and how the system is expected to evolve over the next 20 years. 
Milliman brings specialized expertise, access to extensive amounts of 
health-care utilization data, and excellent research to the overall 
modeling effort.
    The VA Model produces multi-year projections to inform the VHA 
budget process, estimate the impact of proposed policies, and support 
strategic and capital planning. For each year, the VA Model projects:

     the number of Veterans expected to be enrolled;
     the priority level, age, gender, and geographic location 
of enrolled Veterans;
     the total health-care demand for enrolled Veterans across 
58 health-care services;
     the portion of that care enrollees are likely to receive 
from VA versus other health-care providers; and
     the expenditures associated with the projected 
utilization.

    The enrollment modeling process begins with comprehensive and 
accurate Veteran population data developed by VA's Office of the 
Actuary using a ``VetPop'' model. The Office of the Actuary projects 
Veteran populations over 30 out-years using data from the Census Bureau 
and the Department of Defense, and mortality and supplemental data to 
develop refined estimates of the current Veteran population and 
projected future levels. In 2005, independent verification and 
validation of the VetPop model by the Institute for Defense Analysis 
found the baseline Veteran population estimate to be accurate in 
providing baseline estimates broken out by demographic characteristics 
such as age and gender. Additionally, VA completes a detailed 
validation annually to assure confidence in the VetPop output. This 
includes extensive peer review of our methodology and assumptions for 
parameters as well as of our programs, logs and output lists. All 
results are examined for consistency and compared with previous data 
and Census estimates. It should be noted the accuracy of the total 
Veteran population is unlikely to change significantly over the short 
term because the Veteran population changes little over the short term. 
The accuracy of the long-term forecast is largely dependent on the 
accuracy of the projections of deaths and military separations.
    Projections for health-care services VA offers that are comparable 
to the private sector, including inpatient, surgical, and ambulatory 
care, are based on private-sector benchmarks, which are adjusted for 
the demographics of the Veteran enrollee population and the VA health-
care delivery system. Private-sector benchmarks used in the VA Model 
come from the Milliman Health Cost Guidelines, which are updated and 
expanded annually. These guidelines are a combination of consultants' 
expertise, research, and actuarial judgment; they also represent the 
health-care utilization of over 60 million Americans. The guidelines 
have been validated and used extensively by private-sector health 
plans. The guidelines also provide extensive information on the impact 
of age and gender, changes in health-care benefits, and changes in 
copayments on health-care utilization. The enormous volume of data 
allows VA to develop projections at a very detailed level. Projections 
for services that are unique to VA, such as blind rehabilitation, and 
services where VA has a unique practice pattern, such as prosthetics, 
are developed based on analyses of historical VA data.
    The VA Model is supported by in-depth analyses of VA data, 
including enrollment rates, enrollee mortality, morbidity, and reliance 
on VA versus other health-care providers, and VA's level of health-care 
management. An annual VHA Survey of Enrollees provides data on enrollee 
insurance coverage, income, period of service, and self-reported health 
status. The 2008 Survey included new questions developed to identify 
the key drivers of Veterans' decisions to enroll and use VA health 
care.
    The VA Model uses utilization and cost trends to project modeled 
services forward 20 years into the future from the most recently 
completed fiscal year, or base year. Assumptions about future trends 
are developed by a workgroup of VA staff and Milliman experts on 
health-care trends. The workgroup reviews VA historical trends and 
historical and estimated future trends in the broader health-care 
industry in developing the assumptions. While there are differences 
between VA's closed-panel, integrated system and the fee-for-service 
environment in Medicare and the private sector, the broader health-care 
industry trends serve as a frame of reference for how future changes in 
the provision of health care will impact VA. These trends include 
expected changes in medical-care practice and custom. For example, gall 
bladder surgery is now routinely performed on an outpatient basis, so 
trends and projections now include a reduction in inpatient surgery 
utilization rates based on this shift.
    The projections are developed at a very detailed level and then 
aggregated to provide national projections. Projections are developed 
by 13 priority levels and by five-year age bands. Projections are also 
developed separately for enrollees who used VA health care before 
eligibility reform since they have unique demographic and utilization 
patterns. Geographically, the projections are developed at the sector 
level, which is the lowest geographic area for which credible 
projections can be developed at the level of detail used in the model. 
A sector consists of one or more complete counties and is fully 
contained within a single submarket. Over 3,100 counties are mapped 
into 506 sectors. Sector-level projections are then aggregated into 103 
submarkets, 80 markets, 21 Veterans Integrated Service Networks 
(VISNs), and the national level.
    The VA Model has evolved significantly since 1998 and continues to 
evolve. Plans for future model enhancements are developed through an 
assessment of the predictive capability of various model components or 
the identification of new data sources. For example, we recently 
assessed the accuracy of the 2008 enrollment and patient projections 
from the 2006 Model, which supported the 2008 Budget. The 2006 Model 
projected Veteran enrollment to within 0.3 percent, or 26,607, of 
actual 2008 enrollment, while it over-projected patients by 161,166, or 
3.3 percent. In the last five fiscal years, the average variance 
between the VA Model's projection of enrollees and the actual enrollee 
population was 0.54% under-forecast. In other words, slightly more 
Veterans enrolled than were projected. In the same five years, the 
average variance between the VA Model's projection of Veteran patients 
and actual patients was 1.7% over-forecast. In other words, slightly 
fewer patients were actually seen in Veterans Health Administration 
than projected.
    Regarding the latest generation of Veterans with service in 
Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), or 
other theaters, VA initially had difficulty modeling this population 
because we did not have estimates of the total force expected to be 
deployed in these conflicts. However, since 2007, VA has used a future 
force deployment scenario developed by the Congressional Budget Office 
to estimate the number of future OEF/OIF Veterans. We have conducted 
extensive analyses of the enrollment and health care utilization of 
this population, and with each additional year of data, we gain more 
insight into their unique characteristics. The VA Model reflects the 
fact that OEF/OIF enrollees have exhibited significantly different VA 
health-care utilization patterns than non-OEF/OIF enrollees. For 
example, OEF/OIF enrollees have an increased need for dental services, 
physical medicine, prosthetics, and outpatient psychiatric and 
substance use disorder treatment. Alternatively, OEF/OIF enrollees seek 
about half as much inpatient acute surgery care from VA as non-OEF/OIF 
enrollees.
    The VA Model addresses many but not all areas of the health care 
budget. Approximately 16 percent of VA's health care budget is 
developed through alternative models and estimates, and each present 
challenges in projecting future costs.
    Long-Term Care (both institutional and non-institutional) estimates 
are developed in accordance with the VA's Long-Term Care Strategic Plan 
and historical cost and workload trends. VA will continue to focus its 
long-term care treatment in the most clinically appropriate and least 
restrictive setting by providing more non-institutional care than ever 
before and making more care available to Veterans closer to their 
homes.
    The Civilian Health and Medical Program of the Department of 
Veterans Affairs (CHAMPVA), the Foreign Medical Program, the Spina 
Bifida Program, and Children of Women Vietnam Veterans estimates are 
based on the current benefit structure, the mix of users, and workload 
estimates that reflect historical trends.
    Readjustment Counseling estimates reflect historical trends and the 
establishment of new Vet Centers and provide for the three major 
functions of direct counseling for issues related to combat service, 
outreach, and referral.
    Non-Veteran health-care cost estimates reflect collateral care, 
consultations and instruction for spouses, reimbursable workload from 
affiliates (such as sharing agreements with the Department of Defense), 
humanitarian care, and preventive health occupational immunizations for 
VA employees. They are based on historical workload and cost trends 
adjusted to reflect the current benefit structure.
    As noted earlier, while VA's methodology for health-care budget 
development is sound, we recognize the realities of economic, policy 
and other uncontrollable factors which alter the requirements for care 
and the ultimate costs of it. This limitation should be recognized in 
any proposal to implement an advance appropriations process. Any such 
proposal should provide flexibility for near-term changes in workload 
or performance needs.
    VA supports the intent of S.423 and is committed to working with 
Congress to provide our Veterans with the timely, accessible, and high-
quality care that they expect and deserve. We also believe that close 
consultation between Congress, the Administration, and other 
stakeholders is necessary to develop the details in overcoming the 
challenges for the implementation of an advance appropriations 
proposal.
         s.498 ``dental insurance for veterans and survivors''
    Similar to the pilot program proposed in section 217 of S.252, 
S.498 would require the Department to provide a dental insurance plan 
for Veterans enrolled under section 1705 of title 38 and the dependents 
of Veterans eligible for medical care under section 1781. The bill 
provides the Secretary the discretion to define the benefits 
appropriate for such a dental insurance plan and makes enrollment in 
the insurance plan voluntary. Enrollment would be for a period of time 
as established by the Secretary, who would also establish premiums 
adjustable on an annual basis. The legislation would not impact the 
Department's obligations to provide dental care to Veterans under 
section 1712. VA opposes this bill as it would establish an entirely 
new and dramatically different role for VA. The cost estimate for this 
proposal would be $10 million in the first year, $18 million over five 
years, and $29 million over ten years. All costs for premiums and 
deductibles would be borne by Veterans or dependents.
     s.699 ``far south texas veterans medical center act of 2009''
    The proposed bill would allow the Secretary to carry out the 
construction of a major medical facility project in Far South Texas 
consisting of a full service Department of Veterans Affairs hospital. 
The bill authorizes appropriation for fiscal year 2009 such sums as 
such may be necessary for the project.
    VA does not believe that a full-service hospital is the best 
approach to providing medical care and treatment to Veterans in Far 
South Texas. VA projections illustrate that this region will see a 
continued increase in the outpatient workload but low levels of 
inpatient care. VA's Fiscal Year 2008 Appropriation (Public Law 110-
161), included authorization for a Major Lease to construct a build-to-
suit Health Care Center (HCC) in Harlingen, Texas, in collaboration 
with the University of Texas (UT), Harlingen. The HCC will provide 
primary care, specialty care, mental health services, ambulatory 
surgery and expanded diagnostics and imaging in approximately a 120,000 
square foot facility. Agreements will be made with the local hospital 
and UT to provide the required inpatient services. VA has entered into 
a 20-year lease for the HCC pursuant to the authorization provided by 
Congress.
                          s.772 ``honor act''
    Section 2 of the Honor Act of 2009 would require the Secretary to 
establish a scholarship program for qualifying Veterans pursuing a 
graduate or post-graduate degree in behavioral health sciences. 
Veterans would qualify for this scholarship if: (1) during service on 
active duty in the Armed Forces, they served in a theater of combat or 
during a contingency overseas operation; (2) they were retired, 
discharged, separated or released from service on or after a date not 
earlier than August 2, 1990, as specified by the Secretary; (3) at the 
time of application to the program, they hold an undergraduate or 
graduate degree that qualifies them for pursuit of a graduate or post-
graduate degree in behavioral sciences; and (4) they meet other 
qualifications as established by the Secretary. The scholarship is to 
include tuition, reasonable educational expenses, a stipend and an 
obligation of service to the Department of Veterans Affairs, the 
Department of Defense, or some combination of both agencies.
    This provision links two important but independent concepts: 
enhancing educational opportunity for returning soldiers and providing 
mental health care to Veterans. However, it is not clear that linking 
these two distinct ideas has merit, as the proposed program would 
entail substantial costs over a long time period while producing few 
tangible benefits.
    It takes an average of two to seven years to become a behavioral 
specialist suitable for employment in VA. This is a long lead time to 
wait for behavioral specialists and we have no way of knowing that 
there will be a need for these behavioral health graduates by the time 
they complete their degrees. Assuming that each Veteran student already 
has an undergraduate degree, the time estimates for each discipline are 
summarized below.

     VA facilities, under the guidance of VHA's Office of 
Mental Health Services, only hire behavioral health specialists with 
advanced degrees. In particular, VA relies on doctoral level 
psychologists, masters level social workers, psychiatric nurses, and 
nurse practitioners to provide the high quality care Veterans deserve.
     Clinical practice in VA in psychology requires admission 
into an accredited graduate program, four to six years of graduate 
education, one year of full time supervised internship before receipt 
of the doctoral degree, and another year of supervised clinical 
practice before becoming license eligible in most states. VA estimates 
the duration of a scholarship is between six and eight years.
     Clinical practice as a masters-prepared social worker 
would require a two year masters program, followed by clinical 
experience. VA estimates the duration of a scholarship between two and 
three years.
     Clinical practice as a master's prepared behavioral health 
nurse or nurse practitioner requires a one to two year master's 
program, followed by certification. VA estimates the duration of a 
scholarship between two and four years.

    VA has had success recruiting internally from VA training programs 
and externally from the private sector for its mental health staffing 
needs. Over 3,800 additional mental health workers have been hired in 
the past three years. VA has also developed several successful 
recruitment resources including expanded funding for mental health 
training. Seventy-three percent of current VA psychologists 
participated in VA training programs.
    Costs for this proposed program, both direct and indirect, would 
also be substantial and it is not clear that VA would receive a return 
on investment from this proposal. Specifically, VA estimates section 2 
would cost $5.9 million in fiscal year 2010, with a five-year total of 
$32.6 million and ten-year total of $65.2 million.
    Section 3 of the Honor Act of 2009 would require the Department of 
Defense to carry out a program to employ and train qualifying former 
members of the Armed Forces as psychiatric technicians and nurses. VA 
defers to the Department of Defense for views on this section.
    Section 4 would reinstate provisions originally contained in the 
initial Vet Center legislation (Public Law 96-22, June 13, 1979) that 
were repealed in October 1996 (Public Law 104-262). This section is 
similar to section 402 of S.252. Reinstatement of these provisions 
would give Vet Centers the latitude to help Veterans with problematic 
discharges, deemed by Vet Center staff to be related to war trauma, 
through referral to services outside VA and referral for assistance 
with discharge upgrades when appropriate. This provision would give Vet 
Centers the authority to assist a new generation of combat Veterans in 
resolving problems with the character of their discharge. VA estimates 
that the total number of Veterans this section would affect is small, 
so the costs of the provision would be negligible.
    Section 5 would authorize the Secretary to provide mental health 
services through Vet Centers to members of the regular component of the 
Armed Forces and readjustment counseling and mental health services to 
members of the reserve component. It would require any provider who 
determines the servicemember is a threat to himself or herself or 
others to notify an appropriate official of a military medical 
treatment facility, and would require that official to inform the 
servicemember's chain of command.
    VA generally supports this provision as it would augment the 
existing eligibility for Vet Centers to include active duty and reserve 
component servicemembers who served in a combat theater of any era. 
However, we are very concerned by the use of the term ``mental health 
services'' in proposed sections (f)(1)(A) and (B) as Vet Centers 
provide readjustment counseling but do not provide medical services, to 
include mental health services. Veterans in need of these services are 
referred to other facilities. We recommend that the proposed subsection 
(f)(1) be amended to read:

        The Secretary shall, upon the request of a member of the Armed 
        Forces, furnish the member through a center the following:
          (A) In the case of a member of a regular component of the 
        Armed Forces, readjustment counseling authorized to be provided 
        under this section.
          (B) In the case of a member of a reserve component of the 
        Armed Forces, readjustment counseling authorized to be provided 
        under this section.

    By implication the primary target population for Section 5 is OEF/
OIF combat Veterans; however, combat Veterans of all eras would be 
eligible. This provision would promote early access, education, 
prevention, and services to combat Veterans in a confidential setting 
that would greatly assist in overcoming the effects of stigma and 
promote access to care. Vet Centers provide services in a community-
based environment that does not carry the stigma sometimes associated 
with some other mental health or readjustment care. Many servicemembers 
want to avoid the perception of having a mental illness that could 
affect readiness and their careers. The Vet Center program promotes 
early intervention and makes every effort to reduce the stigma of 
seeking assistance.
    This provision would also make confidential Vet Center services 
available to active duty and reserve component servicemembers through 
the Vet Center Combat Veteran Call Center being implemented in FY 2009. 
The Call Center will be staffed 24/7 by combat Veteran peers to provide 
confidential support and referral information for Veterans and family 
members regarding the full range of readjustment issues following 
service in a combat zone.
    VA estimates section 5 would cost $3.7 million in FY 2010, with a 
five-year total of $20.2 million and ten-year total of $44.9 million. 
Our support of this provision is contingent upon finding offsets within 
the 2010 funding level requested by the President.
    Section 6 would require that the suicide of certain former members 
of the Armed Forces that occurs during the two-year period beginning on 
the date of separation or retirement from the Armed Forces be treated 
as a death in line of duty of a servicemember on active duty in the 
Armed Forces for purposes of survivors' eligibility for certain 
benefits. The former Armed Forces members who would be covered are 
those ``with a medical history of a combat-related mental health 
condition or Post Traumatic Stress Disorder (PTSD) or Traumatic Brain 
Injury (TBI).'' The benefits that would be covered are ``[b]urial 
benefits,'' Survivor Benefit Plan benefits under subchapter II of 
chapter 73, title 10, United States Code, ``[b]enefits under the laws 
administered by the Secretary of Veterans Affairs,'' and Social 
Security Act benefits. Furthermore, for purposes of benefits under 
section 6, the date of death would be considered to be the date of 
separation or retirement from the Armed Forces, except that, for 
purposes of determining ``the scope and nature of the entitlement,'' 
the date of death would be considered to be the date of the suicide. It 
appears that this last provision (subsection (d)(2)) is intended to 
provide the date of death for determining the effective date of an 
award or amount of benefits, although this is not clear from the bill's 
language. Essentially, under section 6 the suicide of a covered 
individual would be treated as a service-connected death for VA benefit 
purposes.
    VA does not object to section 6. Because it would essentially deem 
a suicide under the specified circumstances a service-connected death, 
it would, for cases falling within its ambit, relieve VA of the 
administrative burden of having to obtain a medical opinion to 
determine whether a suicide is due to a service-connected mental 
disorder. Survivor benefits would be payable based on these suicides 
the same as they would based on any other suicide that DOD determines 
was in line of duty. This amendment would facilitate the expeditious 
provision of needed benefits to Veterans' survivors at a very difficult 
time in their lives.
    However, we would like to note that this provision may have an 
unintended implication for veterans suffering from depression, PTSD, or 
other mental disorders. It is conceivable that a Veteran whose judgment 
is clouded by severe depression could conjecture that more Federal 
financial assistance would be provided under this provision than he or 
she could provide alive, and thus might perceive that the Government 
was offering a perverse incentive to suicide. We ask that the Committee 
consider the potential risk of this misperception along with the 
potential benefits of the provision.
    We have several technical concerns with section 6. Subsection (b) 
identifies the covered former Armed Forces members as those ``with a 
medical history of a combat-related mental health condition or [PTSD] 
or [TBI].'' It is unclear from the provision's language whether the 
adjective ``combat-related'' is meant to modify PTSD and TBI as well as 
mental health condition. In addition, subsection (c)(1) identifies 
``[b]urial benefits'' as one of the covered benefits, but fails to 
specify from which Federal department or agency. Subsection (c)(3) 
identifies as covered benefits ``[b]enefits under the laws administered 
by [VA],'' which would cover VA burial benefits and therefore, implies 
that subsection (c)(1) refers to another agency. Furthermore, an 
ambiguity would remain even if subsection (c)(1) is intended to refer 
to VA burial benefits. It is unclear whether that term refers only to 
burial benefits under chapter 23, title 38, United States Code, or 
includes benefits such as burial in a national cemetery, provided by 
chapter 24, title 38, United States Code. The bill language could be 
clarified to address these ambiguities.
    Because under current law VA is likely to determine that a suicide 
under the circumstances described in section 6 is a service-connected 
death, albeit after more development of the claim, requiring the 
provision of service-connected benefits, VA estimates no benefit cost 
associated with this provision if enacted. There also would be no 
additional administrative costs.
  s.793 ``department of veterans affairs vision scholars act of 2009''
    S.793 would establish a new scholarship program for individuals who 
are accepted for enrollment, or currently enrolled, in a program of 
study leading to a degree or certificate in visual impairment or 
orientation and mobility. In exchange for the scholarship assistance, 
participants would incur a three year service obligation to the 
Department to be fulfilled within the first six years after their 
graduation. The bill would limit to $15,000 the total amount of 
assistance that a participant who is a full-time student could receive 
during an academic year. It would establish a maximum cap of $45,000 on 
the total assistance that VA could provided to any participant. S.793 
would also require the Secretary to establish terms of participation 
for the program. Participants who fail to meet their service 
obligations would be subject to repayment terms, as established by the 
Secretary.
    VA appreciates the importance of Blind Rehabilitation Services, as 
is evident by its investment of $50 million to enhance its nationwide 
continuum of rehabilitative care for Veterans and active duty military 
personnel with visual impairments. VHA is the first health care system 
to completely integrate such services for patients with visual 
impairments into comprehensive health care benefits. This continuum of 
care will establish 55 new outpatient clinics targeting those who are 
beginning to experience functional loss from visual impairment. New 
programs also include: 22 new Intermediate Low Vision Clinics; 22 new 
Advanced Ambulatory Low Vision Clinics; and 11 new Outpatient Hoptel 
Blind Rehabilitation Clinics. The goal of this initiative is to provide 
rehabilitation services that keep visually impaired Veterans and active 
duty personnel functioning as independently as possible, and integrated 
with their families and communities.
    The Department is committed to ensuring that appropriate staffing 
of blind rehabilitation outpatient specialists and visual impairment 
professionals is maintained to support this important continuum of 
care; however, VA must oppose S.793 because it is unnecessary. The 
Veterans Health Administration (VHA) analyzes data concerning 
recruitment and retention of health care disciplines annually. The 
results of this analysis are published each year in the Succession and 
Workforce Development Plan. This plan provides a detailed, evidence-
based analysis that identifies the categories of health professions 
that could, or should, be targeted with recruitment or retention 
incentives, including scholarship programs. As part of the succession 
planning efforts, VHA has funded technical career field interns in the 
blind rehabilitation occupation. In 2007, nine interns were funded, in 
2008, 20 interns and again in 2009, 20 interns will be funded. We feel 
continued support in the technical career field program will meet the 
needs of the Department and the objectives of the legislation. We do 
not believe creation of an entirely separate scholarship program would 
be cost effective.
    It is also important to note that under the bill participants would 
be treated far more leniently than participant's in VA's existing 
scholarship program in the event they breach their service obligations. 
Participants in VA's Education Incentive Scholarship Program (EISP) 
risk other forms of liability depending on the type of breach committed 
by the participant, including failure to accept the scholarship money, 
failure to complete the program, or failure to obtain licensure. This 
bill does not address the other scenarios covered under the EISP.
    VA estimates the total cost of implementing S.793 to be $521,000 in 
fiscal year 2010, $2.72 million over five years, and $5.7 million over 
a 10-year period.
             s.801 ``family caregiver program act of 2009''
    VA's opposition to S.801 was detailed in the April 22, 2009, 
testimony. The costs for each section of the bill are outlined below.
    Section 2 would amend 38 U.S.C. Sec. 1784 to allow for waiver of 
charges for hospital care or medical services provided to certain 
family members of Veterans receiving VA health care. We project that 
this provision would cost approximately $330,000 in 2010, $2 million 
over five years, and $5.3 million over ten years.
    Section 3 addresses family caregiver assistance. VA has identified 
65,798 Veterans with a serious injury incurred on or after September 
11, 2001, that would be eligible for this program during its first two 
years. It is expected that an additional 1,440 Veterans would become 
eligible each subsequent year. VA estimates that this provision would 
cost $5.056 billion in fiscal year 2010, $26.859 billion over five 
years, and $62.8 billion over 10 years. Note that these costs do not 
include Veterans severely injured prior to September 11, 2001, that may 
become eligible for this program after the first two years.
    Section 4, Lodging and Subsistence for Attendants, would amend 38 
U.S.C. Sec. 111 to allow for travel, including lodging and subsistence, 
for the period consisting of travel to and from a treatment facility 
and the duration of the treatment episode for certain family members of 
certain Veterans receiving VA health care. We estimate the cost of this 
provision to be $8.6 million in 2010, $57.7 million over five years, 
and $163 million over ten years.
 s.821 ``prohibition on collection of certain copayments from veterans 
                      catastrophically disabled''
    This bill would amend 38 U.S.C. 1710 to prohibit a Veteran who is 
catastrophically disabled from making any payment for the receipt of 
hospital care or nursing home care provided pursuant to section 1710.
    VA has no objection to this proposal. However, we note it is 
unclear if this proposal is intended to eliminate nursing home co-
payments since the legislation refers to only section 1710 of title 38, 
while authority for VA nursing home care falls under section 1710A of 
title 38. We believe any co-payment requirements under this provision 
would remain in place. We further note the bill does not address 
pharmacy copayments.
    The Office of Management and Budget advises that there is no 
objection to the submission of this letter from the standpoint of the 
Administration.
    Thank you again Mr. Chairman, for the opportunity to provide VA's 
views on these bills.
            Sincerely,
                                          Eric K. Shinseki.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
                  U.S. Department of Veterans Affairs
                                 s.801
    Question 1. In written testimony, the Department expressed concern 
``that the provision of humanitarian care could become a primary factor 
in designating a caregiver rather than the person's ability to assist 
the Veteran.'' Since the legislation states that the designated 
caregiver receives waived charges for emergency medical care in the 
sole instance he or she is accompanying the Veteran, the likelihood of 
the caregiver receiving health care benefits is very small. Please 
elaborate as to why VA has a reservation with this provision?
    Response. Given the extensive list of persons eligible to be the 
Veteran's caregiver, the Veteran may elect to designate, or be under 
pressure to designate, as their caregiver someone who has need for 
medical care and would benefit greatly from the Department of Veterans 
Affairs' (VA) providing that care. This person may not be the best 
choice to assist the Veteran with their daily needs. Moreover, the 
legislation does not provide for limits on the number of times or how 
frequently the Veteran may change caregivers. Potentially, a number of 
persons could receive needed medical care by being designated as 
caregiver.
    Question 2. The Department objects to section 3 of S.801 because of 
a concern that it will force VA to create preferential benefits for one 
group of Veterans. Yet, the legislation allows VA to extend this 
benefit to ``include the largest number of Veterans possible.'' Please 
explain, in detail, why the Department raises an objection to this 
provision?
    Response. The number of Veterans meeting the eligibility of section 
3 for the first 2 years of enactment is small compared to eligible 
Veterans from previous generations. VA believes that any program that 
would benefit one cadre of combat Veterans over another is inequitable, 
whether for a 2-year period or permanently.
    VA has been working on the family caregiver issue for some time and 
believes that the newly developed Veteran directed-home and community-
based service (VD-HCBS) creates a workable infrastructure for family 
caregivers to be paid for the relevant service they provide. The VD-
HCBS program provides Veterans of all ages the opportunity to receive 
home and community based services in a consumer-directed fashion that 
enables them to avoid nursing home placement and continue to live in 
their homes. The VD-HCBS program addresses the home care needs for 
Veterans of all ages, allowing services to be provided to younger, 
seriously-injured and Traumatic Brain Injury (TBI) Veterans. This 
program will also help address the demand for paid family caregivers in 
a comprehensive and structured manner.
    We would be pleased to discuss this program and other alternatives 
to section 3 of S.801 with Members of the Committee staff. VA is 
committed to working with the Congress to create a viable family 
caregiver program.
                                 s.734
    Question 3. VA's testimony states that section 2 ``could result in 
significantly higher educational awards, but would mean significantly 
fewer people could participate.'' According to a March 2009 CRS report, 
VA currently provides an average of $38,000 per award, which is less 
than the statutory maximum. Is there a problem with funding the 
Educational Debt Reduction Program?
    Response. Funding for the educational debt reduction program (EDRP) 
is budget driven. There is always a greater demand for EDRP funding 
than the amount available through centralized funds. Local leadership 
has the option to further fund EDRP awards from its own budget, but 
that allocation is budget driven as well at the local level. EDRP is a 
reimbursement program, meaning that VA provides awards to employees at 
the end of the year covering their out-of-pocket payments on their 
loans. As a result, the amount that is reimbursed to employees each 
year is limited not only by the amount awarded but also by the amount 
of loan repayment the employees can reasonably pay themselves. VA 
generally awards amounts below the statutory maximum to ensure a 
greater number of applicants will receive awards. If the award amounts 
are not limited, fewer applicants will receive them, thus limiting the 
recruitment benefits of the program.
    Centrally, $20 million annually is allocated for EDRP. Because the 
pay-out is over a 5-year period, the amount of funding for new awards 
authorized each year is approximately $3,000,000 to $3,500,000. This 
amount is divided among the 21 networks. In addition to these 
centralized funds, all Veterans Integrated Service Networks (VISN) and 
medical centers are also able use local funds for EDRP. VISNs and 
medical centers have already committed $883,918 for fiscal year (FY) 
2010 out of their local budgets to support EDRP awards.
    In addition, Veterans Health Administration (VHA) is not solely 
reliant on EDRP and also uses other recruitment and retention 
incentives as appropriate. For example, in FY 2007, VHA invested over 
$66 million in recruitment incentives outside of EDRP including over 
$44 million in retention Incentives and $3.3 million in relocation 
Incentives.
    Question 4. VA's testimony states the following: ``EDRP is a 
reimbursement program, meaning that VA provides awards to employees at 
the end of the year covering their out-of-pocket payments on their 
loans. In many situations, employees would be unable to bear the cost 
of higher per year awards.'' Section 7683(b)(1) of title 38 provides 
that ``The Secretary may make education debt reduction payments to any 
given participant in the Education Debt Reduction Program on a monthly 
and annual basis, as determined by the Secretary.'' Does this not 
accord the Department the discretion to determine when such payments 
are made?
    Response. Reimbursements for EDRP are required to be paid after the 
loan payment is made by the employee, whether reimbursed monthly or 
annually. With the number of participants and payments being made, 
monthly reimbursement would be onerous on both the employee (having to 
provide monthly evidence of loan payment prior to reimbursement) and VA 
in certifying monthly payments and processing reimbursements. 
Additionally, as there is no statutory minimum service period for EDRP 
awards, providing reimbursement at the conclusion of each annual 
service period improves retention and is a benefit to VA and Veterans 
served as it encourages employees to remain in service.
    Question 5. VA testimony states that funds proposed to be 
transferred to the Department of Health and Human Services Corps 
utilization could be better used to support VA's recruitment and 
retention programs. Please describe in detail the ways in which VA's 
current programs provide superior financial recruitment and retention 
incentives to those found in the National Health Service Corps.
    Response. It is our understanding that simply providing $20 million 
in funding to the Department of Health and Human Services (HSS) for use 
in the National Health Service Corps (NHSC) program will offer no 
direct benefit or return on investment for VA. VHA health care 
facilities do not meet the criteria for participation in NHSC as the 
criteria include accepting Medicare, Medicaid, and indigent patients 
(not just Veterans as indigent patients). Federal correctional 
institutions and Indian health care systems are specifically included 
as eligible in the HSS program language while VHA facilities are not.
    The employee incentive scholarship program for current VA employees 
was designed following the model provided by HHS as was the now 
inactive scholarship program under title 38 health professionals 
educational assistance program.
    S.252 includes language that will re-authorize this scholarship 
provision giving VHA the ability to operate a program similar to the 
NHSC with a direct service obligation to VA. VA fully supports this 
provision of the bill.
    Question 6. VA's testimony states that section 6(a) is not required 
because VA is already carrying out a program of teleconsultation for 
remote mental health assessments. Please provide information that 
demonstrates that this process is in place at all VA facilities ``that 
are not otherwise able to provide such assessments without contracting 
with third-party providers or reimbursing providers through a fee basis 
system.''
    Response. The provision of mental health services using 
teleconsultation fits into the uniform mental health services package 
(UMHSP). The UMHSP ensures that the balance between VA-provided in-
person care, telemental health and contracted care is appropriate to 
ensure the mental health care needs of patients are equitably met. VHA 
has a nationwide framework whereby telemental health care is provided 
and VA facilities can adopt this to comply with the UMHSP. In FY 2008, 
149 VA medical centers (VAMC) and 353 community-based outpatient 
clinics (CBOC) were actively using teleconsultation capabilities, with 
108 VAMCs and 307 CBOCs specifically providing mental health services. 
This use resulted in a total of 63,598 telemental health consultations 
nationally. Additionally, VA has readily available capability to 
provide this care directly to Veterans in their homes with 781 home 
mental health teleconsultation visits occurring in FY 2008.
    Thus, VA is currently able to substantially meet its telemental 
health requirements. A current limitation relates to inadequate 
telecommunications bandwidth and ensuring suitable space for 
teleconsultation in clinics. These limitations relate equally to any 
approaches that would seek to contract out telemental health 
services.
    Question 7. VA's testimony states that ``VA does not support these 
provisions as we believe our obligation is to ensure Veterans receive 
the highest possible standard of care, regardless of where that care is 
provided.'' Please explain how fee basis providers are presently 
evaluated and how VA ensures that such care is of the highest quality.
    Response. VA is committed to assuring the highest possible quality 
of care for Veterans, regardless of how and where their care is 
delivered. This means care consistent with evidence-based practices and 
proper coordination to assure continuity.
    VA would like to point out that such challenges are not easily met, 
in part because of well-recognized barriers to coordination in 
community practices. Additionally, few community physicians have the 
infrastructure to electronically capture and report the clinical 
variables that VA relies on to ensure quality care. Finally, unless a 
community site meets certain minimal volume thresholds (the statistical 
rule of thumb is approximately 30 unique cases per reporting period), 
performance metrics will have too great an error margin to be usable.
    Recognizing these challenges, a standard set of quality measurement 
tools for both fee basis and contracted care is under development. At 
present, however, because of the wide range of community capabilities, 
VHA's approach to evaluation is based on contractually mandated 
performance elements that are tailored to meet specific local 
requirements. Project HERO, which represents one of VA's first efforts 
at managing and consolidating contracted care, has allowed us to 
develop and test combinations of metrics, such as facility 
accreditation, provider credentialing, access measures, timeliness, 
patient safety incident evaluation, clinical documentation submission, 
patient satisfaction, and others. In addition, the parent VAMC 
currently provides local quality oversight which includes review of 
selected clinical records, to ensure outside care meets our own 
standards.
                                 s.252
    Question 8. I appreciate VA's technical comments on expanding 
authority for the Secretary to move more positions into hybrid status. 
What is meant by occupations which ``would not otherwise be available 
to provide medical care and treatment for Veterans?''
    Response. The statement is related to the availability or ease to 
hire those who provide medical care to Veterans. Currently, if title 5 
occupations are vacant, the facility must go through the process of 
requesting and waiting for a certificate of eligible candidates from a 
delegated examining unit, versus immediate recruitment locally. 
Additionally, pay flexibilities associated with hybrid title 38 makes 
it easier to pay wages set to be reflective of and competitive with the 
health care market.
    Question 9. In VA's testimony regarding EDRP program, it is noted 
that ``it takes more than six months for employees to become aware of 
this very helpful recruitment and retention program.'' How is this 
program a recruitment tool if your employees are unaware of its 
existence until more than six months after the beginning of their 
employment?
    Response. The offer of EDRP is explained in the announcement or 
advertisement posted for eligible positions. Many times new employees, 
coming on board, may have overlooked the information or not fully 
understood requirements to immediately apply and fill out the 
paperwork. The way the program is structured now, if the application 
for EDRP is not submitted within the first 6-months of employment, they 
lose their eligibility. This rule also does not allow for flexibility 
in using the EDRP as a retention tool. If a practitioner, who may have 
a student loan, is planning on leaving employment and was not offered 
EDRP when hired, it can be offered to retain the employee. As the 
statute is written now, it does not allow for use for retention of 
employees.
    Question 10. According to VA's testimony, section 302 is 
``unnecessary'' because VA initiated a planning and implementation 
program in September 2008 to evaluate and enhance the care of women 
Veterans. Please provide the Committee with a copy of this plan.
    Response. The Women Veterans Health Strategic Health Care Group 
(WVHSHG) developed a women's comprehensive health implementation 
planning (WCHIP) tool to assist facilities in analyzing their own 
current health care delivery for women Veterans and plan for care 
delivery enhancement. Every facility was requested to put together a 
multidisciplinary planning and implementation team to address 
comprehensive primary care for women Veterans.
    The WCHIP tool outlines a ``care gap'' analysis, a market analysis, 
and a needs assessment, which facilitate the development of a business 
plan. This plan includes resource needs, goals, timelines, budgets, 
training needs and program evaluation metrics to deliver comprehensive 
health care to women Veterans.
    A final facility-based implementation plan based on a completed 
WCHIP tool is due to the Deputy Under Secretary for Health for 
Operations and Management by August 1, 2009. VA will provide the 
Committee with a copy of that plan when it is available for release.
    Question 11. VA's testimony argues against section 304's 
requirement for staffing standards, noting that retaining the 
flexibility for staffing related determinations ``is essential to 
permit VA and individual facilities to respond to changing needs and 
available resources.'' How often do individual VAMCs conduct 
evaluations of staffing needs regarding mental health professionals 
working with Veterans who experienced MST?
    Response. In response to the issuance of the Uniform Mental Health 
Services Handbook last year, VAMCs are currently evaluating their 
staffing needs and programming related to a wide variety of mental 
health services, including care for conditions related to military 
sexual trauma (MST). More broadly, assessment of staffing needs occurs 
on an ongoing and as needed basis, depending on local needs and 
resources.
    The Office of Mental Health Services' MST support team also issues 
an annual report summarizing the number of Veterans screening positive 
for MST at each VA facility and the amount of care they subsequently 
receive for conditions related to MST. Facilities are instructed to use 
these data to assess the adequacy of their current staffing and 
services.
    Question 12. What specialized training do mental health care 
professionals receive regarding MST? The testimony refers to annual 
four-day training provided to 30 clinicians. Who are the 30 clinicians, 
and how are they selected to receive this training?
    Response. On a monthly basis, the MST support team hosts the MST 
teleconference training series, which cover a variety of topics related 
to MST. Typically, around 120 telephone lines are used, often with more 
than one listener on each line. Recent topics have included overviews 
of several commonly used evidence-based treatment protocols.
    The MST resource homepage is a Web site that serves as a 
clearinghouse for a variety of MST-related resources such as: patient 
education material; sample training presentations, provides educational 
opportunities, reports of MST screening rates by facility, and 
descriptions of VA policies and benefits related to MST. The Web site 
hosts discussion forums that allow providers to share information and 
engage in conversations related to screening and treatment of MST.
    Another major training resource available to VA staff is an 
independent study training course on MST developed by the Veterans 
health initiative.
    Information on MST has been included in each of the national 
rollouts of evidence-based therapies conducted by the Office of Mental 
Health Services. The MST support team encourages MST coordinators to 
attend this training.
    Finally, the MST support team hosts an annual, multi-day training 
program focused on providing clinical care to MST survivors and MST-
related program development. During the first 2-years of the training, 
attendees were MST coordinators selected by VISN leadership based on 
the training needs of the VISN. Each VISN had at least one attendee. 
This year the number of trainees will be expanded to 50. Each VISN will 
now have two attendees, some of whom may be clinicians only. As in 
previous years, a number of slots will be available for staff from Vet 
Centers.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Patty Murray to 
Dr. Gerald M. Cross, Principal Deputy Under Secretary for Health, U.S. 
                     Department of Veterans Affairs


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                                 ______
                                 
Response to Written Questions Submitted by Hon. Bernard Sanders to Dr. 
  Gerald M. Cross, Principal Deputy Under Secretary for Health, U.S. 
                     Department of Veterans Affairs
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                                 ______
                                 
   Response to Written Questions Submitted by Hon. Jon Tester to Dr. 
  Gerald M. Cross, Principal Deputy Under Secretary for Health, U.S. 
                     Department of Veterans Affairs
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    Chairman Akaka. I will now turn to Ranking Member Senator 
Burr for his questions. Senator Burr?
    Senator Burr. Thank you, Mr. Chairman.
    Dr. Cross, I can't let you get by without asking about this 
testimony. I take for granted that the inability to meet the 
deadline was because the Administration didn't return the 
testimony. Is that correct?
    Dr. Cross. Senator, that is not how we want to phrase it. I 
take responsibility and I appreciate the Chairman's comments 
earlier and apologize for the tardiness.
    Senator Burr. Did you or did the VA have it in its 
possession before last night when it was turned in?
    Dr. Cross. Walter, help me--
    Senator Burr. Listen, this is not the first time I have 
been on this cabbage truck, and it has been in Republican 
Administrations and now it happens to be a Democratic 
Administration and the likelihood is your testimony sat at OMB, 
and OMB ignored the rules of the Committee. Let us all concede 
that fact. When you got your testimony back, how different was 
it than what you sent?
    Dr. Cross. Sir, I am not here to point fingers at anyone 
else. I will take responsibility for what I did.
    Senator Burr. Dr. Cross, I appreciate that. I am trying to 
figure out what you wanted to tell the Committee and what the 
Administration instructed you through the changes in your 
testimony you were going to say to the Committee, but we will 
forego that.
    Mr. Hall, as Assistant General Counsel, did you inquire 
with OMB as to whether we would get the testimony so that you 
could meet the rules of the Committee?
    Mr. Hall. Yes, sir. This is, of course, an Administration 
position. We work closely with the Office of Management and 
Budget and other agencies to formulate the Administration's 
views.
    Senator Burr. Did they express any concern that they 
weren't allowing you to meet the rules of the Committee from 
the standpoint of the timeliness of testimony?
    Mr. Hall. Sir, we worked as hard and fast as we could to 
address the many issues that were before us.
    Senator Burr. Let us switch to the Second Amendment issue. 
I am disappointed that the VA has not taken a position on this. 
Let me ask you, do you agree with the Justice Department's 
request of the VA that they continue to submit names? Dr. 
Cross?
    Dr. Cross. Sir, the position that we have coming to you is 
the same as what we put in the written testimony, that we have 
reviewed the proposals and we have deferred officially to the 
Department of Justice.
    Senator Burr. Well, I didn't ask about your comments on my 
legislation. I asked, do you agree with the Justice 
determination that VA should be obligated to provide those 
names, yet other agencies that have people that meet the same 
legitimate threshold do not?
    Dr. Cross. I would like to ask my colleague, the General 
Counsel, to comment on that.
    Senator Burr. Mr. Hall?
    Mr. Hall. Yes, sir. That is the--the Department of Justice 
administers the Brady Bill. It is their responsibility to 
determine who it is that is required to be reported, the names 
that are required to be reported, and we comply with that--with 
those instructions.
    Senator Burr. Mr. Hall, do you believe in your opinion of 
the jurisdiction of the Justice Department. Do they have the 
ability to reverse this decision on their own, or does it 
require legislation?
    Mr. Hall. My understanding of the law is that it says the 
requirement to report is a ``may report.'' They ``may 
determine.''
    Senator Burr. So one would conclude from that that the 
Justice Department today has the ability to say----
    Mr. Hall. Sir, I would defer entirely to the Department of 
Justice as to the interpretation of that law, which they are 
responsible for administering, and they are the----
    Senator Burr. I am not a lawyer, but please tell me this. 
Is there a significant difference between the word ``may'' and 
``shall'' from a legal standpoint? When you see the word 
``may,'' are you compelled?
    Mr. Hall. You may be.
    Senator Burr. You are using ``may'' again. [Laughter.]
    The truth is, the Justice Department could--and this is the 
new Justice Department--they could look at this request that 
they have made of VA and they could say, you know, this has 
been grossly misinterpreted; and they could, on their own, pull 
back the request.
    Mr. Hall. I think that is entirely within the Department of 
Justice to----
    Senator Burr. See, I knew if we worked at this, we were 
going to agree on something.
    Dr. Cross, the Committee has heard from veterans, family 
caregivers, Veterans Service Organizations, that we need to 
provide more support to family caregivers caring for veterans. 
In your testimony, you mentioned that the Department currently 
contracts for caregiver services with home health agencies and 
those agencies, in turn, are employing family members. 
Specifically, how many family members are currently employed by 
home health agencies?
    Dr. Cross. Sir, I don't know that number, but I am 
concerned that the number is quite small. I think that we need 
to address that. I think that is a real issue that we have to 
bring forward. We think the mechanism is sound, to use those 
agencies that are already existing or have expertise in this 
area to help us with this challenge which is so very important. 
But I don't know the number of family members that are 
currently hired, and I am concerned that it is small. I think 
that we need to address that and find some way to increase that 
number.
    Senator Burr. Do you have any idea of the number of family 
members serving as caregivers, whether they are hired or not?
    Dr. Cross. Specifically, no, sir.
    Senator Burr. I hope you understand, these are significant 
things that we need to know the numbers on if, in fact, we 
suggest--and I think your testimony suggests that the way the 
VA currently has it structured is working, and that is that we 
have home health agencies that turn around and hire family 
members to serve as caregivers. And I think what we are going 
to find out is that it rarely happens. Where it does happen, it 
is probably not with the best agreement up front, that the 
majority of caregivers would prefer not to go through a third 
party. As a matter of fact, most of them that supply the 
service today are doing it because of their family member--that 
they believe can only have the level of care if, in fact, they 
commit to do it. Why we would not provide a similar incentive 
for them to do this, versus to work through a third party, is 
somewhat a mystery to me.
    Has the VA done an assessment to make sure that the 
arrangements that are currently out there, meaning home care-
hired family caregivers, work?
    Dr. Cross. The way that it works right now is that the care 
managers interact with the veteran to make sure that they are 
being cared for properly. You have raised a very important 
point, though, in regard to the family members, and actually, 
we have asked the staff to look into the possibility of whether 
or not we can even create a preference when we work with those 
agencies in the community--to have a preference for those 
family members.
    I think, though, that you can understand that there might 
be some challenges for us if we made those family members 
directly employees of the VA, in essence. It would put us, at 
times, in a difficult position between that situation and the 
welfare and care of that veteran--a primary responsibility 
itself. Our primary responsibility is, in fact, the care of the 
veteran. We have to hold people responsible for that. Holding a 
family member responsible for that could be a challenge for us. 
We are much more comfortable at this time having these 
community agencies train and oversee this.
    But I think that you have raised a significant issue as to 
how many family members are actually able to take advantage of 
this.
    Senator Burr. I thank you for your testimony. I have run 
over my time. If I could say to the Chair, I would like my 
colleagues to know that the father, the sister, and the 
brother-in-law of Eric Edmundson are in the audience today. His 
father has cared for him since the day he took him out of a VA 
facility. I think it is--those that have met Eric understand 
the challenges he has gone through. I know without his dad's 
commitment to take care of him as a caregiver, Eric would not 
have made the progress he has today; and we all have great hope 
that he can continue to make progress. That would not have 
happened if it hadn't been for a family that basically dropped 
everything and really made it their life's commitment to serve 
their son as a caregiver. So I want to thank Edgar and Anna and 
Roger for coming up and taking the time to come to Washington 
today.
    Thank you, Madam Chair.
    Senator Murray [presiding]. Thank you very much.
    Dr. Cross, I recently held a press conference on women's 
veterans issues, and in attendance were several female veterans 
who were part of a group that is known as Team Lioness. The 
Army has sent these female soldiers to serve in a support role 
for Marine ground combat troops in Iraq. And the members of 
Team Lioness were exposed to some of the bloodiest 
counterinsurgency battles during their service. All of this was 
done, of course, despite the current prohibition on women 
serving in combat.
    Now, I am told that many members of Team Lioness have not 
had their combat service recorded in their DD-214, which, of 
course, impacts their ability to get compensation or any other 
ancillary benefits that they earned. In fact, a female veteran 
who served as the mechanic in Team Lioness told me that the VA 
claims adjudicator she went to see about her PTSD claim didn't 
believe that she could have any psychological health issues 
because her military records didn't show any record of combat 
service. So this is a real issue for these women.
    Now, I recognize that this is a DOD problem. But I was 
hoping you could tell me if the VA itself is exploring any 
options to ensure that its compensation and pension staff and 
its medical staff are aware of the combat roles that many women 
veterans have played in Iraq.
    Dr. Cross. Thank you, Senator. I believe the group that you 
are referring to actually came over and made a presentation at 
VACO headquarters.
    Senator Murray. Oh, great. I am glad they did.
    Dr. Cross. I am looking forward to learning more about 
them. One organization where we do have some options to support 
them, even in that process, is our Vet Centers--for any combat 
veteran returning--to also help them work with DOD or help them 
work with VBA to resolve issues regarding their DD-214. I think 
that would be a very appropriate place for them in our Vet 
Centers. But we can address that systematically with DOD and 
VBA, as well. We are quite willing to do that.
    Senator Murray. OK. I think it is important to address that 
with DOD and I appreciate that. But I also think, meanwhile, it 
is important to let VA personnel know that there are women out 
there that did serve in combat so that they don't hear, well, 
you can't, it is not on your form, because they did.
    Dr. Cross. Agreed.
    Senator Murray. OK. I have a number of questions I want to 
submit for the record. As you know, Senator Akaka, our 
Chairman, had to leave for a short while. We are going to pass 
the gavel up here among members and I appreciate everybody's 
patience as we do that, and I am going to turn the gavel over 
to Senator Sanders.
    Senator Sanders [presiding]. Thank you. We should put the 
clock on, if we could.
    I want to get to the issue of outreach. My understanding is 
that the VA has opposed legislation that Senator Feingold and I 
introduced--Section 211 of the broader bill. What we believe 
very strongly is that it is terribly important to have 
aggressive outreach; that there are many veterans who do not 
know what they are entitled to. As I said earlier, it doesn't 
matter what you have if people don't know about it.
    And so what we have proposed is that community, local, 
State, and Federal providers of health care be enlisted in an 
outreach effort in the form of a pilot program. I say this 
because my recollection--and somebody can correct me if I am 
wrong--but I think in the early 2000s, maybe 2003 or so, an 
actual memo went out from the VA to halt outreach efforts. I 
think the VA has never been particularly aggressive, in 
general, in outreach efforts. They actually stopped it. I 
brought forth an amendment when I was in the House to undo 
that.
    So I think that, especially in rural areas, it is very 
important that every veteran know the benefits they are 
entitled to. I think the VA, in general, is doing better now 
than they used to. But it is no great secret nor will it shock 
anybody in this room when I say that for many years the VA 
basically did not want veterans to know what they were entitled 
to. Am I right? Because if they don't know what they are 
entitled to, they can't take advantage of it and we save money. 
It is a great way to do business. That is no secret. Everybody 
knows that.
    But, I happen to believe that if we pass legislation and 
veterans are entitled to certain benefits, they should know 
about it, period. That is what it is about. That has not always 
been the case. So we want to expand upon what the VA is doing, 
getting other groups involved in it. Dr. Cross, why is that a 
bad idea? Why aren't you supporting it?
    Dr. Cross. Senator, let me be very clear. We strongly 
support outreach, and I will list a couple of things that we 
are doing that I think are very consistent with what you are 
proposing. The bill itself and Section 211 itself was opposed 
because it appeared to be duplicative of what the Vet Centers, 
case managers, and other outreach we are currently doing, which 
I will elaborate on in just a moment.
    We are doing so many other things right now that I want to 
make sure that you are aware of and that you are proud of. We 
were concerned that coming back from OEF and OIF, a number of 
veterans had not contacted us, had not come to a VA medical 
center. We put in place a contract to call every single one of 
them, and we are doing that by the hundreds of thousands and 
saying, hey, how are you doing? Is there something we can do 
for you--
    Senator Sanders. I am aware of that. We spoke to Dr. Peake 
about that. I think that is an excellent step forward. And I 
do--I am aware, as I said a moment ago, that we are doing 
better.
    Let me just suggest to you, and you tell me this, that you 
have somebody coming back from Iraq with PTSD in rural Vermont. 
What we are doing now in our State is we have people actually 
going out and knocking on his or her door. I think we have got 
to be a lot more aggressive. As I said, I think you are making 
progress, but tell me the problem about why we would not want 
to be even more aggressive, bringing different groups in?
    Dr. Cross. I don't think necessarily there is any problem 
with being more aggressive, and I think we all support that. 
There were technical problems, I think, with the language in 
the bill and how it relates to the Vet Centers that we have. 
The Vet Centers have been tremendously successful.
    Senator Sanders. Vet Centers help. Why don't we do this? I 
am the first to happily concede that we have been making some 
progress. But you will recall, literally, not so many years ago 
where the VA--am I right on that, Dr. Cross?
    Dr. Cross. Senator, I think we----
    Senator Sanders [continuing]. Didn't VA actually send out a 
memo telling VAs all over the country to stop doing outreach?
    Dr. Cross. That may have been before my time, but we agree 
that we made progress.
    Senator Sanders. My recollection is that is exactly----
    Dr. Cross. And the progress was needed.
    Senator Sanders. OK. So we are making some progress. I want 
to make more progress and I look forward to working with you if 
there are any technical problems in the bill, to see how we can 
work that out.
    Dr. Cross. And sir, we will make our staff available to 
meet with your staff, to work through any of those issues at 
any time you would like.
    Senator Sanders. We look forward to working with you.
    Senator Begich?
    Senator Begich. Thank you very much. I will have a few 
questions, but I am busily trying to read your testimony. I am 
not going to try to get into why or whatever. I was a mayor 
once and I understand how the process goes with OMB. Sometimes 
it is painful for an agency, but I will leave it at that. Yet 
it is frustrating, because I am trying to figure out very 
quickly where you are on certain pieces of legislation, where 
you are not on certain pieces of legislation. So I have a 
couple questions and then I will probably go to some early 
parts of the testimony, because that is all I have gotten 
through so far.
    And I may be wrong on this, but I am just trying to 
remember my visit to Alaska. I just came back Monday, but I was 
there for a couple of weeks. If you are a doctor--and I will 
use Alaska--and you are a certified physician and you are going 
to do contract work for the VA, does the VA put you through 
another certification process? I guess the question is, why; 
because if the medical care I am getting--I am not a veteran--
from that same doctor, I think I am getting pretty good 
quality. Why duplicate that? Why not just get them into the 
process? Why do we waste the time? I mean, you have gotten my 
answer to the question from my perspective by my statement, 
so----
    Dr. Cross. I appreciate that, and quite frankly, the 
process they have to go through and that I had to go through 
when I came in is a bit cumbersome.
    Senator Begich. Why do we do it?
    Dr. Cross. Think back to Marion--Marion, Illinois--and what 
happened there a couple of years ago. We believe very strongly 
that the additional safeguards that we have to put in place are 
very important for the safety and welfare of our veterans. Not 
everyone in the community who is practicing and working in the 
community is someone that we would want working in the VA.
    Senator Begich. Is there a way to figure out how to 
streamline it by working with the local agencies that do the 
board certification already, rather than create a whole new 
system?
    Dr. Cross. One thing that we have done is contract with an 
organization to do reports about individual physicians 
automatically for us. We started that in November 2008, to 
identify any problem cases. But quite frankly, that is only for 
those who are already employed by us.
    Senator Begich. So it is not the recruitment of new 
contract doctors or doctors.
    Dr. Cross. I think there is more that we could do to 
streamline that process.
    I was thinking about your situation in Alaska and the 
individuals who fly often to the very rural areas that you 
mentioned----
    Senator Begich. Right.
    Dr. Cross [continuing]. And I have asked my counsel sitting 
next to me if there was a technique that we might be able to 
use to address those, by making them something called WOCs. We 
will look into that. I don't know the answer at this point.
    Senator Begich. That would be great. I would be very 
interested in that.
    The second thing is--again, if my information is wrong, 
just correct me--but the contract periods that you can do for 
contract services for doctors or other professionals is 1-year 
increments with renewals, basically. Am I close on that? [Dr. 
Cross nods affirmatively.]
    OK. Here is the complaint I hear, It is too short. What do 
we need to do to extend that, yet still give you the 
flexibility if the contractor is not performing to the levels 
that you prefer or need? I mean, the reality is in 1 year you 
are not even getting into the depths of what potentially is 
available out there because people just don't want to do it for 
1 year. They want more security, up to 3 years. Besides the 
appropriation issue, what can we do here to fix this problem?
    Dr. Cross. Now, I am not briefed on that, but I agree with 
you on what you are telling me, that the 1 year is too short. I 
just got my privileges renewed at the Washington VA Medical 
Center where I keep mine. It is for 2 years.
    Senator Begich. Well, that is a change. That is good. So 
could you get me some information on that?
    Dr. Cross. Yes, sir.
    Senator Begich. I mean, that is a complaint I have heard. 
There are professionals that want to do it but they think of 
this 1-year increment and decide it is not worth it for what 
they have to go through to get there, and then they are not 
sure if it extends beyond. We all recognize part of it is 
budgetary and so forth, but more security in that arena, I 
think, would help ensure a more stable workforce. That is just 
a thought.
    Dr. Cross. I agree, sir. Thank you. We will look into it.
    Senator Begich. Thank you. I have just a few more seconds 
left and I would just ask this general question. I think it was 
in your earlier--in the very front pages of the testimony. I 
know the issue is about reimbursement. How do you deal with 
folks who you want to get into the system, recognizing it could 
be 6 or 7 years before they are actually finally into it? The 
specialty they are going for may not be worthwhile at that 
time. But isn't it true you could go back 10 years and you 
could probably pick the half-a-dozen certain types of 
professional classifications that you always have shortages?
    You can say, OK, this is a group we are going to focus on, 
knowing there is--like there is right now--a high demand for 
mental health professionals. Five years ago, it was different. 
But we know there is at least a half-a-dozen or more 
classifications that we want to dive into to figure out how to 
recruit, knowing that it may take 7 years, but we are going to 
need them anyway, because there has been no time you have had a 
surplus of physicians. I mean, that is a rare occasion----
    Dr. Cross. Yes.
    Senator Begich [continuing]. You have a surplus of 
physicians or nurse practitioners in the business of health 
care.
    Dr. Cross. I am going to ask my colleague, Joleen, to 
comment on that. But first, let me say, becoming a physician is 
about a 14-year process--pre-medicine, medicine, residency, 
fellowship, all of those kinds of things. When I was going 
through that process, I changed my mind about three or four 
times as to what specialty I wanted to go in. So if we targeted 
one of those specific specialties, it may not be what comes out 
at the other end of the pipe, so to speak.
    Joleen?
    Senator Begich. Can I add, and no disrespect to the Doctor, 
but 67 percent of the care is nurses, physician assistants, 
which are shorter periods of time, 18 months to 36. I know this 
because we have one of the top nursing schools in the country 
in Alaska, in Anchorage. So, no disrespect to physicians, but 
there is also a huge gap in this other area. So that is----
    Dr. Cross. Right.
    Senator Begich [continuing]. So there is a shortage that 
you can supply quickly.
    Ms. Clark. We have a couple of things that we are doing, 
but S. 252 does reinstate that scholarship program and we are 
hoping that that will help us to be able to expand past just 
physicians and help us with nurses and physicians. Also, the VA 
Nursing Academy has just expanded to five additional 
universities this year and we are hoping that that helps us to 
educate more nurses so that we can hire additional nurses. In 
the last 5 years, we have been able to hire--because of the 
flexibilities that the legislation that has been approved by 
these committees has allowed us--we have been able to hire 
10,000 additional nurses in the last 5 years, 4,000 additional 
physicians. The physician pay bill helped us tremendously with 
that. And the legislation in----
    Senator Sanders. Does that mean that we have 10,000 more 
nurses in the VA?
    Ms. Clark. Yes. We had approximately 37,000 5 years ago. 
Right now, actually, we have 49,000. We had 47,000 at the end 
of the year--or, excuse me----
    Senator Sanders. And 4,000----
    Ms. Clark. Yes, 47,000. Yes.
    Senator Sanders. Four-thousand more physicians?
    Ms. Clark. Four-thousand more physicians actually on board, 
yes. So we have been able to do tremendous things. We know 
there are certain areas--especially the rural areas--that we 
have work to do. We have a pilot program going on for 
recruiters, especially in rural areas, to try to target some of 
those positions that are hard to recruit, like the scarce 
specialty in physicians, some of those nurses that are critical 
care positions and nurses. So, we do realize there are going to 
be those areas that are always harder to fill and that we 
really need to target those specifically. We are working on 
trying some pilots out to see how to best do that.
    Senator Begich. Great. Thank you.
    Senator Sanders. Thank you, Mr. Begich. If that is the span 
of your questioning----
    Senator Begich. I will stop now.
    Senator Sanders. All right. Thank you, and let me thank the 
panelists and welcome our second panel.
    OK. I am delighted to welcome our witnesses from Veterans 
Service Organizations and advocacy groups to the second panel. 
I appreciate your being here today and we look forward to your 
testimony.
    First, I want to welcome Adrian Atizado, Assistant National 
Legislative Director for the Disabled American Veterans. Next, 
I welcome Ammie Hilsabeck, R.N., of the Iron Mountain, 
Michigan, VA Medical Center, representing the American 
Federation of Government Employees. Thanks for being here.
    Mr. J. David Cox, R.N., was scheduled to appear today but 
could not because of a death in his family, so please extend 
our deepest condolences to him and his family when you see him.
    We also welcome Hilda Heady, former President for the 
National Rural Health Association. Thank you very much for 
being here.
    We welcome Ralph Ibson, Health Policy Senior Fellow for the 
Wounded Warrior Project. Thank you very much for being here, 
and a familiar face for this Committee.
    Last, we welcome Blake Ortner, Senior Associate Legislative 
Director for Paralyzed Veterans of America.
    We thank all of you for joining us today and your full 
statements will appear in the record of the Committee.
    Let us begin with Mr. Atizado. Again, we thank you very 
much for being here.

  STATEMENT OF ADRIAN ATIZADO, ASSISTANT NATIONAL LEGISLATIVE 
              DIRECTOR, DISABLED AMERICAN VETERANS

    Mr. Atizado. Thank you, Senator. I would like to thank the 
Committee for inviting me to testify at this legislative 
hearing. We appreciate the opportunity to present our views on 
the 19 bills on today's agenda. Of course, at the Committee's 
request, I will limit my oral statements to a select few of 
these important bills.
    Mr. Chairman, the DAV and allies in the partnership for 
veterans' health care budget reform believe that S. 423 
proposes a reasonable alternative to achieve sufficient, 
timely, predictable, and transparent funding for VA medical 
care. The bill would authorize Congress to appropriate funding 
for veterans' health care 1 year in advance and provide greater 
transparency to VA's health care budget formulation process. 
Equally important, after enactment, Congress will retain its 
oversight authority and full discretion to set actual 
appropriated funding levels for each fiscal year.
    We are delighted to know that this important bill is being 
considered by the Committee today and we thank the 35 Senators 
whose cosponsorship made this a bipartisan bill, including the 
ten Members of this Committee. We are encouraged by the Senate 
action on April 3 when it passed a budget resolution that 
allows advance appropriations for VA medical care, and on April 
9, when President Obama and VA Secretary Shinseki publicly 
reaffirmed their support for advance appropriations 
legislation, as well as in VA's testimony today. We urge the 
Committee to approve this bill because its passage in the 111th 
Congress would address DAV's highest priority in VA health 
care.
    Mr. Chairman, the DAV recently had occasion to help 
organize and sponsor a Capitol screening of the independent 
documentary film ``Lioness'' that Senator Murray had mentioned. 
This is to be shown on PBS on June 2. The story is of five Army 
women who served in Marine ground combat teams in Fallujah and 
Ramadi. Their role was to assist in offensive operations by 
providing body weapon searches of Iraqi women and children. 
These women were mechanics and clerks, as the Senator had 
mentioned, who found themselves fighting in some of the most 
violent counterinsurgency combat in this war.
    Now, I mention this because it serves as a reminder that a 
significant new women veteran population is beginning and will 
continue to present certain needs that VA has likely not seen 
before and will now need to address. Women veterans are a 
dramatically growing segment of the veteran population, and as 
mentioned, according to VA, the number of women veterans 
utilizing VA health care will likely double in the next 5 
years.
    We believe the Women's Health Care Improvement Act of 2009 
will allow VA to effectively meet the needs of women veterans. 
This bill is fully consistent with a series of recommendations 
that have been made in recent years by VA researchers, experts 
in women's health, the VA's Advisory Committee on Women 
Veterans, the Independent Budget, and the DAV. Our organization 
was proud to work with Senator Murray and the original 
cosponsors of the bill in crafting the proposal. DAV strongly 
supports this measure and urges its approval.
    We also commend the decision to include an earlier version 
of the bill in S. 252, the Omnibus Health Proposal, and we 
trust that the Committee staff and Senator Murray's staff will 
work out any differences between these excellent bills.
    With regards to the two bills proposing a caregiver support 
program, the DAV would like to thank both Chairman Akaka and 
Senator Durbin on their leadership in this very sensitive 
matter. We are also appreciative of the efforts by 
Congressional staffs who worked with our organization and 
sought our views in crafting both bills. These bills seek to 
address those informal caregivers of severely disabled veterans 
who today remain untrained, unpaid, unrecognized, undercounted, 
and exhausted by their duties. The DAV supports both measures, 
given that our national resolution calls for legislation to 
provide comprehensive support services to caregivers of 
severely injured veterans.
    We believe S. 801, the Family Caregiver Program Act of 
2009, proposes a more comprehensive program and we ask for the 
Committee's approval of that legislation. I would like to note, 
though, that S. 543, as well as the provisions in S. 252, 
contain worthwhile sections and provisions that we hope will be 
considered by this Committee as it finalizes the authorization 
of this new VA caregiver program.
    Mr. Chairman, this concludes my testimony. I would like to 
ask the Committee to refer to my written testimony for the 
DAV's position and comments on the other bills that I did not 
include in my remarks. I would be happy to answer any questions 
you may have.
    [The prepared statement of Mr. Atizado follows:]
 Prepared 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 testify at this important 
hearing of the Committee on Veterans' Affairs. 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 nineteen (19) bills 
before the Committee today.
 s.423--veterans health care budget reform and transparency act of 2009
    Mr. Chairman, while great strides have been made to increase the 
level of VA health care funding during the past several years, there is 
a long history of significant delays in actually receiving those funds. 
Notwithstanding notable improvements over the past two years, including 
passage of a regular appropriation on September 30, 2008, VA has 
received its annual funding for veterans' health care late in 19 of the 
past 22 years. Unlike Medicare's mandatory trust funds, the VA must 
rely on Congress and the President to pass a new discretionary 
appropriations law each year to provide VA hospitals and clinics with 
the funding they need to treat sick and disabled veterans.
    Due to the late and unpredictable budget process, VA is 
increasingly challenged to properly treat the physical and mental scars 
of war for all veterans needing care. Further, not knowing when or at 
what level VA will receive funding from year to year--or whether 
Congress would approve or oppose the Administration's proposals--
hinders the ability of VA officials to efficiently plan and responsibly 
manage VA health care.
    Broken financing causes unnecessary delays and backlogs in the 
system: hiring key staff is put off, or just not done, while injuries 
like PTSD or Traumatic Brain Injury (TBI) are too often not diagnosed 
or treated in a timely manner. Since 2001, the number of VA patients 
has grown by two million--a 50 percent increase--and our newest 
generation of veterans has increasingly complex mental and physical 
health care needs that will require a lifetime of care. Moreover, a 
2007 report by the VA's Office of Inspector General concluded that 27% 
of the injured veterans seeking treatment at VA facilities had to wait 
more than 30 days for their first appointments.
    For the past decade, the DAV and its allies in the Partnership for 
Veterans Health Care Budget Reform--a coalition of nine veterans 
service organizations with a combined membership of eight million 
veterans--have sought to fundamentally change the way veterans health 
care is funded. While mandatory funding has been the focus over the 
past several years, the Partnership helped develop and fully endorsed 
S.3527, the Veterans Health Care Budget Reform Act, introduced in the 
110th Congress. This legislation was endorsed by The Military 
Coalition, comprised of 35 organizations representing more than 5.5 
million members of the uniformed services--active, reserve, retired, 
survivors, veterans--and their families.
    We believe this legislation, the successor to S.3527, proposes a 
reasonable alternative to achieve the same goals as mandatory funding, 
by authorizing Congress to appropriate funding for veterans' health 
care one year in advance, and by adding more transparency to VA's 
health care budget formulation process. With the goal of ensuring 
sufficient, timely, and predictable funding through advance 
appropriations, Congress retains full discretion to set actual 
appropriated funding levels for each fiscal year. The legislation does 
not eliminate, reduce or diminish, but rather enhances, Congress's 
ability to provide strong oversight over VA programs, services and 
policies.
    We at DAV are delighted to know this important VA health care 
funding reform bill is being considered by the Committee today. We 
thank the 32 Senators who have given this bill co-sponsorship on a 
bipartisan basis, including ten of the 15 Members of this Committee. 
Also, only in recent days have we confirmed in a meeting with President 
Obama and Secretary Shinseki that both the President and the VA 
Secretary fully endorse the Senate's decision to make provision for 
advance appropriations for VA health care funding for Fiscal Year 2011 
in the Fiscal Year 2010 Senate budget resolution. We hope the Committee 
would approve, that the Senate and House would pass, and that President 
Obama would sign S.423 into law.
    Passage of the Veterans Health Care Budget Reform and Transparency 
Act in the 111th Congress would address DAV's highest priority in VA 
health care; thus, we urge its enactment.
       s.597--women veterans health care improvement act of 2009
    Title I, Section 101 would require the Secretary to submit a report 
to Congress on existing stigma and other barriers that impede or 
prevent women from accessing health care and other services from VA. 
The bill would require an assessment of its existing health care 
programs for women veterans, and an evaluation of the needs of women 
who are currently serving, and women veterans who have completed 
service, in OIF/OEF.
    Section 102 would require VA to contract with a non-VA entity to 
study the health consequences is women veterans from environmental and 
occupational exposures while serving in OIF/OEF.
    Section 103 would require the VA to report to Congress on whether 
there is at least one established full-time women veterans program 
manager at each VA medical center.
    Title II, section 201 requires the Secretary to identify available 
services, personnel and other resource requirements to develop a plan 
and make recommendations to appropriately meet the future health care 
needs, including mental health care needs, of women who served in OIF/
OEF.
    Section 202 would make improvements in VA's ability to assess and 
treat veterans who have experienced military sexual trauma (MST) by 
requiring a new training and certification program to ensure VA health 
care providers develop competencies and the use of evidence-based 
treatment practices and methods in caring for these conditions 
consequent to MST. The Secretary would be required to establish 
staffing standards to ensure adequacy of supply of trained and 
certified providers to effectively meet VA's demands for care of MST. 
Section 202 would also require VA to ensure appropriate training of 
primary care providers in screening and recognizing symptoms of sexual 
trauma and procedures for prompt referral and would require qualified 
MST therapists for counseling. Under this authority the Secretary would 
also be required to provide Congress an annual report on the number of 
primary care and mental health professionals who received the required 
training, the number of full-time employees providing treatment for MST 
and PTSD in each VA facility, and the number of women veterans who had 
received counseling, care and services associated with MST and PTSD.
    Section 203 would establish a non-medical model pilot program of 
counseling in retreat settings for recently discharged women veterans 
who could benefit from VA establishing off-site counseling to aid them 
in their repatriation with family and community after serving in war 
zones and other hazardous military duty deployments.
    Section 204 would require recently separated women veterans to be 
appointed to certain VA advisory committees.
    Section 205 would authorize a two-year pilot program in at least 
three VISNs of providing subsidies for child care services expenses for 
qualified veterans receiving mental health, intensive mental health or 
other intensive health care services, whose absence of child care might 
prevent veterans from obtaining these services. ``Qualified veteran'' 
would be defined as a veteran with the primary caretaker responsibility 
of a child or children. The authority would be limited to subsidizing 
expenses.
    Section 206 would amend title 38, United States Code to authorize a 
period of not more than seven days of VA-provided or authorized 
contract care for the newborn infant child of a woman veteran.
    Mr. Chairman, women veterans are a dramatically growing segment of 
the veteran population. The current number of women serving in active 
military service and its Guard and Reserve components has never been 
larger. According to VA, the number of women veterans utilizing VA 
health care will likely double in the next 2 to 4 years. We expect they 
will undoubtedly use other VA benefits in addition to health care. 
Also, women are serving today in military occupational specialties that 
take them into combat theaters and expose them to some of the harshest 
environments imaginable, including service in the military police, 
medic and corpsman, truck driver, fixed and rotary wing aircraft pilots 
and crew, and other hazardous duty assignments. VA must prepare to 
receive a significant new population of women veterans in future years, 
who will present needs that VA has likely not seen before in this 
population.
    We recently had occasion to help organize and sponsor a Capitol 
screening of the independent documentary film Lioness, to be shown on 
the Public Broadcasting System on June 2, 2009. It is the story of five 
Army women who served in Iraq, in regular military occupational 
specialties, but who were pressed into service in Marine ground combat 
teams in Fallujah and Ramadi, Iraq, to assist in offensive operations 
providing body weapons searches of Iraqi women and children, to ensure 
the safety of the Marines and other Iraqi civilians. These women, who 
were not trained as infantry combatants, were exposed to some of the 
most violent counterinsurgency combat hazards in this war.
    This comprehensive legislative proposal is fully consistent with a 
series of recommendations that have been made in recent years by VA 
researchers, experts in women's health, VA's Advisory Committee on 
Women Veterans, the Independent Budget, and DAV. DAV was proud to work 
with Senator Murray and the original cosponsors of the bill in crafting 
this proposal. A similar bill was introduced in the House (H.R. 1210) 
on a bipartisan basis by Representatives Herseth Sandlin and 
Representative Moran of Kansas. DAV strongly supports this measure and 
urges the Committee to approve it and move it toward enactment.
                   Family Caregiver Support Services
     s.543--veteran and servicemember caregiver support act of 2009
    This legislation would establish a pilot program at six locations, 
with one required to be conducted at a VA facility in a rural area and 
another at a qualified private rehabilitation facility. The proposed 
pilot program would provide support services and financial assistance 
to family caregivers of veterans or members of the military seriously 
injured in the line of duty since September 11, 2001. VA would provide 
training and certification of family caregivers, and of an alternate 
caregiver to relieve a primary caregiver, if deemed necessary. Once 
trained and certified, family caregivers would receive payments for the 
care they provide.
    In addition, the bill would require VA and DOD to make available to 
caregivers, mental health and support services, on the assumption that 
the need for services would be related to their role as caregivers. VA 
would be required to conduct a survey of family caregivers to better 
understand the value of the services they provide and to assess and 
report to Congress on the effectiveness of these pilot programs. 
Furthermore, if the pilot programs are successful, they could be 
expanded nationwide.
    While we support the spirit of this bill, appreciate Senator 
Durbin's leadership in introducing it, and would not object to its 
passage, we believe a number other provisions are necessary to 
underwrite a more fully developed caregiver support program.
              s.801--family caregiver program act of 2009
    Section 2 of this bill would amend Section 1784, title 38, United 
States Code, to require VA to waive any charges for emergency medical 
care provided on a humanitarian basis to family caregivers while 
accompanying certain severely injured veterans. This provision would 
only apply to family caregivers of those veterans whose injury was 
sustained on or after September 11, 2009, and such injuries meet a 
prescribed level of severity.
    Section 3 of this bill would create a new VA program for family 
caregivers or personal care attendants of severely injured veterans. 
The goal of this program would be to allow eligible veterans to reside 
in their communities and maintain their quality-of-life with caregiver 
assistance. We note that veterans, or servicemembers awaiting discharge 
for their injuries sustained on or after September 11, 2001, and in 
need of personal care services, would be the first categories to be 
eligible for this program. The DAV believes the program proposed in 
this bill would be beneficial to all disabled veterans, and we thank 
the Chairman for including a provision in the bill to address this 
matter. Specifically, for all other veterans, the Secretary would be 
required to make a determination two years following enactment of this 
bill to ``include the largest number of veterans possible'' in this 
program.
    Taking on the role of a family caregiver is a personal choice made 
by the family member and the veteran affected. We believe this bill 
would respect the privacy of this decision, and recognizes the 
contributions caregivers make to the health and well being of severely 
injured veterans. Under this program, more than one caregiver could 
receive basic instructions. In addition, only one caregiver would be 
certified by VA as the primary personal care attendant of a veteran 
after completing basic instructions provided by VA and any additional 
training identified by an evaluation of the veteran's needs. To assist 
in completing the required training and certification, this bill would 
require VA to provide for necessary travel, lodging, and per diem to 
the caregiver, and respite care to the veteran as needed during such 
caregiver training and certification.
    To support and sustain caregivers, the bill would provide ongoing 
assistance such as mental health counseling, eligibility for the 
Civilian Health and Medical Program of Veterans Affairs (CHAMPVA), 
payment of a stipend, and other critical services such as respite care. 
Even though most family caregivers take great pride in providing care 
to their loved ones so that these veterans can remain at home, the 
physical, emotional and financial consequences can be overwhelming for 
them without support, with respite services being a good example 
thereof. Research has shown that providing respite for caregivers can 
have a positive effect on the health of the caregiver as it provides 
the much needed temporary break from the often exhausting challenge 
imposed by constant attendance of a severely disabled person. 
Currently, VA's system for providing respite care is fragmented and 
inflexible, governed by local policies for Community Living Center 
(formerly VA Nursing Homes) and Adult Day Care programs. As part of the 
ongoing assistance this bill proposes, VA would be required to provide 
no less than 30 days annually, including 24-hour respite care. The DAV 
is hopeful this provision will encourage VA to establish clearer 
policies expecting every Community Living Center and Adult Day Care 
Program to provide priority for age-appropriate respite care for 
severely injured veterans.
    The DAV believes that family caregivers are motivated by empathy 
and love, but they are also often dealing with guilt, anger and 
frustration. The very touchstones that have defined their lives--
careers, love relationships, friendships, and their personal goals and 
dreams--have been sacrificed, and they face a daunting lifelong duty as 
caregivers. Put simply, family caregivers of severely disabled 
veterans, who are vital for VA's patient-centric care provided in the 
least restrictive settings, must not remain untrained, unpaid, 
unappreciated, undercounted, and exhausted by their duties.
    DAV Resolution No. 165 was passed by the delegates to our most 
recent national convention. That resolution calls for legislation that 
would provide comprehensive supportive services, including but not 
limited to financial support, health and homemaker services, respite, 
education and training and other necessary relief, to immediate family 
member caregivers of veterans severely injured, wounded or ill from 
military service. Accordingly, the DAV supports this measure. We thank 
Senator Akaka for introducing this bill and congressional staffers for 
working with DAV to address the unmet needs of caregivers of severely 
injured veterans.
    This bill is an important measure and DAV urges the Committee's 
approval. In addition, we believe S.543, as discussed above, contains 
worthwhile provisions that we hope will be considered by this Committee 
as it finalizes the authorization of these new benefits.
       s.658--rural veterans health care improvement act of 2009
    Section 2 of this bill would amend Section 111, title 38, United 
States Code, to insert a fixed rate of 41.5 cents for the purposes of 
VA's travel beneficiary program. Reimbursement at this rate may exceed 
the cost of travel by public transportation regardless of medical 
necessity. We note section 401 of Public Law No. 110-387, enacted 
October 10, 2008, amended the federal veterans' benefits provisions to 
repeal a requirement that the Secretary of Veterans Affairs adjust the 
amounts deducted from payments or allowances made by the VA for 
beneficiary travel expenses in connection with health care whenever the 
payment or allowance is adjusted. It required the Secretary to use the 
same mileage reimbursement rate in beneficiary travel as for government 
employees use of privately own vehicles on official business as 
authorized in title 5, United States Code. A report is required no 
later than 14 months upon enactment of the Act.
    Section 3 of this bill would require VA to establish at least one 
and no more than five Centers of excellence for rural health research, 
education, and clinical activities.
    Section 4 would require the Secretary to establish a transportation 
grant program to veterans service organizations to allow for other 
transportation options to assist veterans residing in highly rural 
areas to travel to VA facilities.
    Section 5 would require the VA's Office of Rural Health to conduct 
demonstration projects with the goal of expanding care in rural areas.
    Section 6 of the bill would require the VA to establish a contract 
care program through community mental health centers and other 
``qualified entities'' for the provision of certain readjustment, 
mental health, peer counseling and similar services to OIF/OEF veterans 
and their dependents in rural and remote regions. The program would be 
restricted to areas determined by the Secretary to be inadequately 
served by direct VA services.
    Section 7 of the bill would establish a Native American health care 
coordination function in the 10 VA medical centers that serve the 
greatest number of Native Americans per capita, with specification of 
the duties associated with the new function. Also, the bill would 
require the Secretary and the Secretary of the Interior to execute a 
memorandum of understanding that would ensure the health records of 
Indian veterans may be transferred electronically between the Indian 
Health Service and the Veterans Health Administration (VHA).
    Section 8 would require an annual report to Congress as a part of 
the President's budget on a variety of matters concerned with rural 
veterans.
    The conference report accompanying the Consolidated Appropriations 
Act of 2008, specified that $125 million of the funds provided for 
Veterans Medical Services should be used to increase the travel 
reimbursement rate. The Consolidated Security, Disaster Assistance, and 
Continuing Appropriations Act of 2009, provided an additional $133 
million to increase the beneficiary travel reimbursement mileage rate 
to 41.5 cents per mile, while freezing the deductible at current 
levels. Subsequently, the Veterans' Mental Health and Other Care 
Improvements Act of 2008 revised VA's beneficiary travel program to 
establish a mileage reimbursement rate equal to that for Federal 
employees when a government vehicle is available, but the individual 
chooses to use their own vehicle. Further, Public Law 110-387 changed 
the mileage deductible to $3 for each one-way trip; $6 per round trip; 
with a calendar month cap of $18 as specified in title 38, United 
States Code, section 111(c)(1) and (2) for travel expenses incurred on 
or after January 9, 2009.
    The DAV appreciates Senator Tester's leadership in improving health 
care for veterans residing in rural areas. We support enactment of this 
bill as consistent with our DAV Resolutions 159 (on beneficiary travel 
policy) and 177 (on access to rural health care), adopted by our 
membership at DAV's 2008 National Convention.
          s.404--veterans' emergency care fairness act of 2009
    This bill would amend subparagraph (b)(3)(C) of section 1725, title 
38, United States Code, by striking the words ``in whole or in part'' 
where they appear in current law. The bill would also add new language 
to clarify Congressional intent that VA would be required to assume 
responsibility as payer of last resort in a case in which an otherwise 
eligible veteran has private insurance coverage that pays a portion or 
part of the cost of an episode of emergency care in a private facility. 
Under the bill, VA would pay the remainder of the veteran's obligation, 
less any required copayments under the associated private insurance 
coverage.
    While the bill also provides the date of the enactment as the 
effective date, many veterans have been adversely affected by the VA's 
non-reimbursement for emergency treatment under the current law. This 
bill provides VA discretionary authority to reimburse veterans for 
emergency treatment provided prior to the date of enactment who have 
been financially harmed under the VA's current non-reimbursement 
policy.
    DAV supports the purposes of this bill and appreciates the 
sensitivity of the Committee leadership in developing an effective 
solution to a nagging problem plaguing both service-connected and 
nonservice-connected veterans who rely on VA to meet their primary 
health care needs, but who find themselves confronted by medical 
emergencies.
         s.252--veterans health care authorization act of 2009
    Sections 101, 102, and 103. These provisions would aid VA in 
retaining health care professionals in the VA system, and clinical 
executives in facilities and in VA Central Office; would limit VA's use 
of overtime, clarify policies on weekend duty and use of alternative 
work schedules for nurses; and, would improve VA's educational 
assistance programs. DAV provided detailed testimony during the 110th 
Congress on these matters in S.2969, from which its sections 2, 3, and 
4 were incorporated as sections 101, 102, and 103 in this bill.
    Mr. Chairman, DAV has no resolution adopted by our membership 
addressing these specific matters, but we are strong supporters of VA 
as a preferred Federal employer. We believe these provisions in general 
would be supportive of that goal; therefore, DAV would not object to 
their enactment. Nevertheless, we note that our colleagues in the VA 
labor community appear to be deeply concerned about ceding additional 
authority to the Secretary to expand the ``hybrid'' title 5--title 38 
appointment authority without further authorization by Congress. Labor 
has made the point strongly that VA should first be held accountable 
for disclosing the manner by which the Department has carried out prior 
authority in dealing with hybrid appointments across more than 20 
career fields. Based on VA's apparent struggle to establish 
qualification and classification standards for some of the occupational 
classes already included in the hybrid appointment authority, we 
believe Federal unions may have a valid basis for those concerns. 
Therefore, we defer to their expertise in this case and ask the 
Committee's further consideration of those matters in sections 101, 102 
and 103 in Title I of the bill in recognition of the concerns of labor.
    Section 104. DAV provided testimony in the past Congress on S.2377, 
Section 2 thereof which has been incorporated as Section 104 of this 
bill.
    DAV has no adopted resolution from our membership on these specific 
issues. Under current policy, VA is required to investigate the 
background of all appointees, including verifying citizenship or 
immigration status, licensure status, and any significant blemishes in 
appointees' backgrounds, including criminality or other malfeasance. 
The facility in question that likely stimulated the sponsor to 
introduce S.2377 was not in compliance with those existing 
requirements, thus raising questions about VA's ability to oversee its 
facilities in the area of physician employment. Corrective action was 
taken by the VA Central Office when some unfortunate incidents related 
to these lapses came to light at that particular facility, and VA has 
advised that it has strengthened its internal policies.
    We appreciate and strongly support the intent of the bill to 
stimulate recruitment and to promote VA physician careers with various 
new incentives, and, while it seems clear that additional oversight is 
necessary, we trust that the new reporting, State licensure and 
certification requirements in the bill would not serve as obstacles to 
physicians in considering VA careers in the future.
    Section 201. At the Chairman's request, DAV provided testimony in 
the 110th Congress on Title III of S.2984, which has in part been 
incorporated as Sections 201 through 206 of this bill. Although DAV has 
no resolutions specific to the matters entertained in S.2984, we were 
generally supportive of the provisions in that bill with the exception 
of those matters in section 304 (now in section 201 of this bill). We 
believe in both instances of its knowledge of, and oversight in, VA 
practices with regard to compensating nursing personnel and in 
conducting long-term strategic planning, that these reporting 
requirements should be retained. We are particularly concerned at the 
prospect of VA's discontinuing its construction-related reporting with 
the Committee relying primarily on VA's annual budget proposal as a 
source for relevant information on construction planning. The current 
reporting requirement in Section 8107 of title 38, United States Code, 
covers extensively more than simply the requested facility construction 
and leasing authorizations contained in the annual budget for a given 
year. We believe both Congress and the community of veterans service 
organizations, in properly representing and protecting veterans' 
interests, need to continue receiving comprehensive reports on VA's 
strategic plans, including its major construction planning.
    Sections 202-206. DAV takes no positions on these matters, but 
offers no objections to their enactment.
    Sections 207-208. These sections would establish health care 
quality management officers and new functions nationally, regionally 
and locally in the VHA, and would require a series of reports to 
document progress in quality management. DAV provided testimony in the 
110th Congress on S.2377, section 3, which has been incorporated as 
Sections 207 and 208 of this bill. DAV has no adopted resolution from 
our membership on these specific issues; however, we expressed our 
appreciation and strong support the intent of S.2377 and do so again 
with respect to these provisions. While it seems clear that additional 
oversight is necessary given the VA Office of Inspector General's 
January 2008 report documenting unacceptable practices at the VA 
Medical Center Marion, Illinois, that served in part as an impetus for 
section 207 in this bill, we trust that the new reporting, State 
licensure and certification requirements in the bill would not serve to 
dampen future physicians' interest in considering VA careers.
    Sections 209 and 210. These provisions would establish training and 
certification pilot programs, an innovative respite program for family 
caregivers, and new health care trainees in caring for severely brain-
injured veterans. DAV provided testimony in the past Congress in 
support of Sections 2 and 3 of S.2921, which have been incorporated as 
Sections 209 and 210 of this bill.
    Section 211. DAV provided previous testimony in the past Congress 
on S.2796, which has been incorporated as Section 211 of this bill. 
This section would establish a five-site pilot program to facilitate 
veterans' use of community-based organizations to ensure they receive 
the care and benefits they deserve in transitioning from military to 
civilian life. The program would be conducted through VA grants to 
community-based organizations with the goal of providing information, 
outreach, mental health counseling, benefits, transition assistance, 
and other relevant services in rural areas and in areas with a high 
proportion of minority veterans.
    While we have no adopted resolution from our membership supporting 
this precise concept, DAV believes this is a well-intentioned proposal. 
We have some concerns about VA becoming a granting agency for such 
broad purposes, but we believe if it is targeted and carefully managed 
by VA, this function could be an important and creative new tool in 
rural and remote areas where establishing a direct VA service presence 
would be impractical. If this section is enacted, we also recommend VA 
carefully craft the services expected from a grantee in the area of 
aiding these veterans with their VA disability benefits claims. These 
are highly technical matters and require the assistance of expert 
service officers from the states, the veterans service organization 
(VSO) community and the Veterans Benefits Administration through its 
veterans benefits counselor function. Finally, for any health care 
involvement associated with these grants, we urge VA to coordinate this 
new grant program through its Office of Rural Health. With these 
caveats, DAV supports the enactment of this section.
    Section 212. DAV provided previous testimony last Congress on 
S.2889, which has been incorporated as section 212 of this bill. 
Section 212 would provide VA a specific contracting authority to obtain 
specialized residential care and rehabilitation services for OIF/OEF 
veterans who are suffering from TBI and who are exhibiting such 
cognitive deficits that they would otherwise require admission to 
nursing home facilities. DAV Resolutions 161 and 164, adopted by our 
members at our 2008 national convention, call for strengthening and 
enhancing VA long-term care programs for service-disabled veterans, and 
for addressing comprehensively the needs of disabled veterans of all 
wars who suffer from TBI. Again, we ask the Committee to consider 
broadening the eligibility for this new contract residential 
rehabilitation care option in Section 212 of the bill to any veteran 
with a service-incurred TBI.
    Section 213. This section was incorporated from Section 6 of S.2889 
from the 110th Congress. This section would authorize VA to disclose 
the name and address of a member of the armed services or of a veteran 
to a third party insurer in order to bill for collections of reasonable 
charges for care or services provided for an individual's nonservice-
connected condition(s). DAV does not have a resolution from our 
membership on this matter; therefore, DAV takes no position on this 
provision.
    Section 214. This section would require VA to contract with the 
Institute of Medicine for an expanded study related to veterans' 
health-related exposures from participating in Project Shipboard Hazard 
and Defense (``Project SHAD''). DAV does not have a resolution from its 
membership on this matter. However, the DAV believes this is a 
worthwhile provision in light of our policy regarding environmental 
exposure of sick and disabled Persian Gulf War Veterans and in 
recognition of DAV Resolution 022, adopted at our 2008 National 
Convention, which opposes any rule or provision that would authorize 
use of servicemembers for human experimentation without their knowledge 
and informed consent.
    Section 215. DAV provided previous testimony during the last 
Congress on Section 4 of S.1233, which has been incorporated in part in 
Section 215 of this bill. We note that in passing Public Law 110-181, 
the National Defense Authorization Act for Fiscal Year 2008, Section 
1703 did not follow the language contained in Section 4 of S.1233 of 
the last Congress. We believe Section 215 of this measure would clarify 
that veterans with Traumatic Brain Injury have a right to access 
community-based rehabilitation, but only when VA cannot provide the 
care and when the non-VA provider is accredited and adheres to 
appropriate VA clinical and rehabilitation standards. We support 
Section 215 of this measure which contains the same two key implied 
presumptions that we supported in Section 4 of S.1233 in the 110th 
Congress: (1) that the VA must have the capacity to be the provider of 
choice, and (2) that proximity to care is a key component to ongoing 
rehabilitation and community reintegration for the traumatically brain-
injured veteran.
    Also, we support the implicit goal of this section to give VA an 
incentive to further develop its capacity to provide high quality 
specialized care. VA's four lead Poly-trauma Rehabilitation Centers 
have achieved and maintained, without qualification, accreditation from 
the Commission on the Accreditation of Rehabilitation Facilities for 
acute inpatient TBI rehabilitation programs; however, to date and to 
our knowledge not a single VA facility has achieved accreditation for 
outpatient, home-based, residential or community based TBI 
rehabilitation. We urged this Committee then, as we do now, to 
encourage VA to seek such accreditation at Level II and Level III poly-
trauma sites.
    Section 216. This section would make federally-recognized tribal 
organizations eligible to participate in VA's State extended care grant 
programs, including the treatment of existing beds in tribally-owned 
health facilities as State veterans home beds for purposes of the per 
diem subsistence program administered by VA.
    DAV does not have a resolution from its membership on this specific 
matter, but as a part of the Fiscal Year 2010 Independent Budget, DAV 
has expressed concerns about the status of the State extended care 
construction grant program, and in particular, with respect to the fact 
that nearly $1 billion in backlogged construction, new home and 
renovation grants are pending in VA Central Office, affecting existing 
State veterans homes in nearly every State. Given this backlog and 
Congress's inability to appropriate sufficient funding annually to 
properly maintain this system, we are concerned that adding as many as 
500 tribal organizations to the competition for these severely limited 
funds will only serve to diminish the existing State home program. 
Therefore, we ask that the Committee withhold approval on this section 
to enable our staffs to work toward an acceptable compromise to enable 
tribal organizations to participate more directly in this unique VA-
State partnership.
    Section 217. We appreciate the intent of the bill which would 
require VA to contract with a dental insurer to administer a new dental 
plan provided under a three-year pilot program. Moreover, each 
individual covered by the dental insurance plan would be required to 
pay the entire premium for coverage under the dental insurance plan, in 
addition to the full cost of any copayments. DAV Resolutions 167 and 
172 support legislation to amend title 38, United States Code, section 
1712, to provide outpatient dental care to all enrolled veterans, but 
without any additional costs to be borne by the veteran or their 
survivors and dependents.
    Title III--Women Veterans Health Care. For Title III of this 
measure, sections 301-309, we refer this Committee to our views on 
S.597, the Women Veterans Health Care Improvement Act of 2009, 
contained herein. We believe the small differences in the two bills can 
be worked out by your able staffs. We strongly support improved 
services for women veterans, are deeply grateful to the Chairman and 
Members of this Committee for their interest in women's health, and 
urge the Committee to report an appropriate compromise bill during this 
session.
    Sections 401 and 402. DAV provided previous testimony during the 
last Congress on Sections 2 and 3 of S.2963, which have been 
incorporated as Sections 401 and 402 of this bill. While DAV has no 
resolutions from our membership supporting the specific matters 
entertained by these sections, we believe each of these proposals would 
be helpful to survivors of military servicemembers and veterans whose 
lives are lost to suicide. Therefore, DAV supports the purposes of 
these sections and would have no objection to their enactment.
    Section 403. DAV provided testimony during the last Congress on 
Section 3 of S.2899, which has been incorporated as Section 403 of this 
bill. DAV has no adopted resolution from our membership dealing 
specifically with suicides in the veteran population. However, we agree 
that full and accurate data on the issue of suicide is crucial to VA's 
ability to reduce veterans' suicides. Also, and more importantly in our 
view, DAV believes strongly that improving, expanding and enhancing 
VA's mental health programs across the board, including those dealing 
with depression, adjustment disorders, PTSD, mild-to-moderate Traumatic 
Brain Injury, marital and family relations (including readjustment from 
long deployment separations), and substance-use disorders--particularly 
with early interventions, will not only provide more effective care but 
can stem suicidal ideation in untreated or poorly treated populations.
    Section 404. We note that Public Law 110-329, the Consolidated 
Security, Disaster Assistance, and Continuing Appropriations Act, 2009, 
includes provisions (Section 227) very similar to Section 404 of this 
measure, so we are concerned that this provision may be unnecessary or 
duplicative of current law. Nevertheless, DAV does not have a 
resolution from our membership on this specific matter; therefore, we 
take no position.
    Title V--Homeless Veterans. DAV provided testimony during the last 
Congress on S.2273, which has been incorporated as Title V of this 
bill. The Independent Budget for Fiscal Year 2010 included a series of 
recommendations that are consistent with the five sections under this 
title; therefore, we support its purposes and urge its enactment.
    Title VI--Nonprofit Research and Education Corporations. DAV 
provided previous testimony last Congress on S.2969, which has been 
incorporated as Title VI of this bill. While DAV has no adopted 
resolution on this particular matter, DAV is a strong supporter of a 
robust VA biomedical research and development program. We believe 
enactment of this Title would be in that program's best interest, and 
therefore, we urge its enactment.
    Sections 701 and 702. These sections are derived from Sections 401 
and 402 of S.2984 from the 110th Congress. These provisions would 
expand certain authorities set out in title 38, United States Code, 
relating to VA police officers so as to better reflect the current 
scope of their duties and responsibilities, and would modify the 
authority of VA to pay an allowance to VA police officers for the 
purchase of police uniforms. DAV has no resolution from its membership 
on this specific matter; therefore, we have no position on this 
measure.
 s.821--a bill to amend title 38, united states code, to prohibit the 
 secretary of veterans affairs from collecting certain copayments from 
  veterans who are catastrophically disabled, and for other purposes.
    Mr. Chairman, thousands of veterans survive catastrophic traumas in 
civilian life. Some of them have been able to surmount the tremendous 
challenges imposed on them by accidents or disease, and have been able 
to rejoin the workforce to be productive citizens. We believe they 
should not face the double jeopardy of catastrophic disability and an 
additional financial penalty of paying VA copayments in order to access 
VA health care and services. These veterans, many permanently 
wheelchair bound and spinal cord injured, already spend thousands of 
their own dollars annually on health-related supports and services that 
able-bodied veterans do not need to bear, or even think about. If a 
catastrophically ill or spinal-cord injured veteran succeeds in the 
daunting personal quest to remain in, or re-join, the labor force, we 
believe the government where possible ought to provide that veteran 
proper incentives to remain employed, in this case by forgiving VA 
copayments.
    In conjunction with DAV's national resolution from our membership 
calling for legislation to repeal all copayments for military retirees 
and veterans' medical services and prescriptions, and as a partner 
organization constituting Fiscal Year 2010 Independent Budget, the DAV 
fully supports this provision. It matches the Independent Budget's 
recommendation that veterans designated by VA as being catastrophically 
disabled for the purpose of enrollment in health care eligibility 
priority group four (4) should be made exempt from health care 
copayments and other fees. We note this legislation was passed by the 
House in the past Congress but was not considered by the Senate. We 
urge this Committee to approve and move this provision to enactment 
during this Congress.
   s.793--department of veterans affairs vision scholars act of 2009
    This measure would direct the Secretary of Veterans Affairs to 
establish and carry out a scholarship program of financial assistance 
for individuals who: (1) are accepted for, or currently enrolled in, a 
program of study leading to a degree or certificate in visual 
impairment or orientation and mobility, or both; and (2) enter into an 
agreement to serve, after program completion, as a full-time VA 
employee for three years within the first six years after program 
completion. It would set maximum assistance amounts of $15,000 per 
academic year and $45,000 in total per participant. The legislation 
would require pro-rata repayment for failure to satisfy education or 
service requirements, while allowing the Secretary to waive or suspend 
such repayment whenever noncompliance is due to circumstances beyond 
the control of the participant, or when waiver or suspension is in the 
best interests of the United States.
    DAV has no resolution on this issue adopted by our members; 
however, the Independent Budget for Fiscal Year 2010 contains a series 
of recommendations for VA improvements in its vision care programs. One 
such recommendation urges VA to require its health care networks to 
restore clinical staff resources in inpatient blind rehabilitation 
centers and increase the number of full-time Visual Impairment Services 
Team coordinators. This measure would improve recruitment for these 
positions. On that basis, DAV fully supports the intent of this bill.
 s.772--honor act of 2009, a bill to enhance benefits for survivors of 
   certain former members of the armed forces with a history of post 
    traumatic stress disorder or traumatic brain injury, to enhance 
availability and access to mental health counseling for members of the 
           armed forces and veterans, and for other purposes.
    This bill would create a scholarship program within VA to produce 
graduate-level behavioral sciences practitioners among qualified 
veterans, in exchange for specified obligated Federal service in either 
the VA or the Department of Defense health care systems. It would also 
create a Defense program of employment, training and deployment of 
combat veterans as psychiatric technicians and nurses, to serve in 
future combat zones as determined by the Secretary of Defense. The bill 
would reauthorize Vet Centers to refer former military servicemembers 
with character of discharges that make them ineligible as veterans, to 
community resources for counseling and other mental health services, 
and it would specifically authorize serving members of the Armed Forces 
to be eligible for counseling and related mental health services at 
VA's Vet Centers. The bill would deem certain post-deployment suicides 
among combat veterans to have been deaths in the line of duty. Finally, 
this bill would require a series of reports to Congress dealing with 
its provisions.
    DAV has no resolution adopted by our membership specific to these 
issues; however, we believe this to be a helpful bill, particularly 
with respect to the Vet Center related provisions. Therefore, we would 
offer no objection to its enactment.
   s.498--a bill to amend title 38, united states code, to authorize 
dental insurance for veterans and survivors and dependents of veterans, 
                        and for other purposes.
    This measure is similar to Section 217 of S.252 with the exception 
that under this measure the provision of dental insurance by VA would 
not be a pilot program with respect to duration and location of 
availability. As discussed in our views on section 217, we appreciate 
the intent of this bill. However, DAV Resolutions 167 and 172 support 
legislation to amend title 38, United States Code, section 1712, to 
provide outpatient dental care to all enrolled veterans but without any 
additional costs to be borne by the veteran or their survivors and 
dependents.
              s.669--veterans 2nd amendment protection act
    Under the terms of this bill, in absence of a judicial 
determination of mental incompetency, VA would be prohibited from 
reporting an individual veteran's identity or competency status to any 
authority that could restrict that veteran from his or her Second 
Amendment rights to bear arms.
    The DAV has no resolution from its membership on this issue and, 
therefore, we take no position on this bill.
                             VHA Work Force
  s.246--a bill to amend title 38, united states code, to improve the 
quality of care provided to veterans in department of veterans affairs 
 medical facilities, to encourage highly qualified doctors to serve in 
   hard-to-fill positions in such medical facilities, and for other 
                               purposes.
    Mr. Chairman, this bill is very similar to S.2377, introduced in 
the 110th Congress. We appreciate and strongly support the intent of 
the bill to stimulate recruitment and to promote VA physician careers 
with various new incentives, and, while it seems clear that additional 
oversight in physician appointments is necessary, we trust that the new 
reporting, State licensure and certification requirements in the bill 
would not serve as obstacles to physicians in considering VA careers in 
the future.
    We noted in testimony on May 21, 2008 to the Senate Committee on 
Veterans' Affairs on S.2377, the predecessor version of this bill, VA 
raised a number of valid concerns with respect to State licensure 
limitations this bill would impose on VA physicians. We ask the 
Committee to take those concerns into account as you consider the 
merits of this bill.
  s.362--a bill to amend title 38, united states code, to improve the 
   collective bargaining rights and procedures for review of adverse 
actions of certain employees of the department of veterans affairs, and 
                          for other purposes.
    Mr. Chairman, this bill would restore bargaining rights for 
clinical care employees of the VHA that were eroded over the past eight 
years by the former Administration. A similar version of the bill was 
introduced in both bodies in the 110th Congress but did not advance.
    DAV does not have an approved resolution from our membership on the 
specific VA labor-management dispute that prompted the introduction of 
this bill. However, we believe labor organizations that represent 
employees in recognized bargaining units within the VA health care and 
benefits systems have an innate right to information and reasonable 
participation that result in making VA a workplace of choice, and 
particularly to fully represent VA employees on issues impacting 
working conditions and ultimately patient care.
    Congress passed section 7422, title 38, United States Code, in 
1991, in order to grant specific bargaining rights to labor in VA 
professional units, and to promote effective interactions and 
negotiation between VA management and its labor force representatives 
concerned about the status and working conditions of VA physicians, 
nurses and other direct caregivers appointed under title 38, United 
States Code. In providing this authority, Congress granted to VA 
employees and their recognized representatives a right that already 
existed for all other Federal employees appointed under title 5, United 
States Code. Nevertheless, Federal labor organizations have reported 
that VA has severely restricted the recognized Federal bargaining unit 
representatives from participating in, or even being informed about, 
human resources decisions and policies that directly impact conditions 
of employment of the VA professional staffs within these bargaining 
units. We are advised by labor organizations that when management 
actions are challenged, VA officials (many at the local level) have 
used subsections (b), (c) and (d) of section 7422 as a statutory shield 
to obstruct any labor involvement to correct or ameliorate the negative 
impact of VA's management decisions, even when management is allegedly 
not complying with clear statutory mandates (e.g., locality pay surveys 
and alternative work schedules for nurses, physician market pay 
compensation panels, etc.).
    Facing VA's refusal to bargain, the only recourse available to 
labor organizations is to seek redress in the Federal court system. 
However, recent case law has severely weakened the rights of title 38 
appointees to obtain judicial review of arbitration decisions. Title 38 
employees also have fewer due process rights than their title 5 
counterparts in administrative appeals hearings.
    It appears that the often hostile local environment consequent to 
these disagreements diminishes VA as a preferred workplace for many of 
its health care professionals. Likewise, veterans who depend on VA and 
who receive care from VA's physicians, nurses and others can be 
negatively affected by that environment.
    We believe this bill, which would rescind VA's refusal to bargain 
on matters within the purview of section 7422, through striking of 
subsections (b), (c) and (d), and that would clarify other critical 
appeal and judicial rights of title 38 appointees, is an appropriate 
remedy, and would return VA and labor to a more balanced bargaining 
relationship on issues of importance to VA's professional workforce. VA 
clearly has indicated vigorous disagreement with the intent of the 
measure, but has not to date been willing to compromise its position in 
refusing to bargain across a wide group of issues that are dubiously 
defined by VA as ``direct patient care.'' Given the stalemate, our only 
recourse is to endorse the intent of the bill, yet continue to hope 
that VA and Federal labor organizations can find a basis for 
compromise.
  s.734--a bill to amend title 38, united states code, to improve the 
 capacity of the department of veterans affairs to recruit and retain 
  physicians in health professional shortage areas and to improve the 
  provision of health care to veterans in rural areas, and for other 
                               purposes.
    Section 2 of this bill would enhance VA's existing education debt 
reduction program by removing the current dollar limitation ($44,000 
per participant) and equating it to the actual level of debt and 
interest payable by individual employees of the Department, with 
amended procedures for offers and acceptances of such debt reduction 
employment incentives. Section 3 of the bill would include certain VA 
medical facilities, located in health professional shortage areas, in 
the list of facilities eligible for assignment of participants in the 
National Health Service Corps scholarship program administered by the 
Department of Health and Human Services (HHS). The section would 
require VA to transfer to HHS $10 million to carry out the purposes of 
the section. Section 4 of the bill would require VA's Office of Rural 
Health to develop and submit to Congress a five-year strategic plan, 
with specifications of the content of this report.
    Section 5 of the bill would enhance VA's Vet Centers to meet needs 
of veterans of OIF/OEF through the establishment, training and 
deployment of volunteers, paraprofessionals and veteran-students to 
provide counseling and other mental health services to OIF/OEF veterans 
in established Vet Centers. Section 6 of the bill would establish a new 
section 1709, title 38, United States Code, to establish consultation 
and teleretinal imaging functions in the VHA, including the 
establishment of clinical and technical standards to carry out these 
programs; and amendments to VA's internal allocation (VERA) and 
workload reporting data systems to accommodate and give creditable 
resources to VA facilities conducting such programs.
    Section 7 of the bill would improve oversight and administration of 
contract and fee basis care authorized by the Department. It would 
require VA to consolidate contracting for community-based outpatient 
clinics (CBOC) at the VHA Network (VISN) level to the maximum extent 
practicable; establish rural outreach coordinators at each CBOC with a 
majority of enrolled veterans who reside in ``highly rural'' areas; 
establish incentives to obtain accreditation of participating fee-basis 
private providers, and to encourage these providers to participate in 
VA's peer review system. Section 8 of the bill would amend section 111, 
title 38, United States Code, to provide reimbursement for airfare and 
other actual necessary expenses to certain enrolled veterans when air 
travel is the only practical way for such veterans to gain access to 
direct VA health care, with conforming changes to section 111.
    Section 9 of the bill would establish a pilot program wherein full-
time VA physicians would be authorized to assume attending 
responsibilities for primary care or mental health services at 
community hospitals located in health professional shortage areas, with 
financial incentives for them to assume these responsibilities, and 
including establishment of a series of rules to govern and control such 
participation.
    Mr. Chairman, this bill largely conforms with recommendations of 
the IB for Fiscal Year 2010, particularly in respect to the provisions 
related to rural health, continuity of care, innovations, quality of 
care, and improving access to direct VA health care. Also, it comports 
with the IB recommendations with respect to better coordinating and 
improving the quality of contract and fee-basis care. On this basis, 
DAV fully supports the intent of this bill and urges the Committee to 
approve it.
                             VHA Facilities
   s.226--to designate the department of veterans affairs outpatient 
clinic in havre, montana, as the merril lundman department of veterans 
                       affairs outpatient clinic.
    This is a local matter, and DAV takes no position on this bill.
  s.239--a bill to amend title 38, united states code, to ensure that 
   veterans in each of the 48 contiguous states are able to receive 
 services in at least one full-service hospital of the veterans health 
administration in the state or receive comparable services provided by 
                         contract in the state.
    Mr. Chairman, while the bill is a general mandate that every state 
have a ``full-service'' VA medical center within its borders, the 
circumstances surrounding the bill make clear that its intent is to 
restore the VA Medical Center in Manchester, New Hampshire. As such, 
this is a local matter, and DAV takes no position on this bill.
s.509--to authorize a major medical facility project at the department 
 of veterans affairs medical center, walla walla, washington, and for 
                            other purposes.
    This is a local matter, and DAV takes no position on this bill.
 s.699--to provide for the construction of a full service hospital in 
         far south texas by the secretary of veterans affairs.
    This is a local matter, and DAV takes no position on this bill.

    Mr. Chairman, this concludes DAV's testimony. We appreciate the 
opportunity to have provided our views on these bills. I will be 
pleased to respond to any questions that you or other Members of the 
Committee may have.

    Senator Sanders. Thank you very much.
    Ms. Hilsabeck?

STATEMENT OF AMMIE HILSABECK, R.N., OSCAR G. JOHNSON VA MEDICAL 
  CENTER, IRON MOUNTAIN, MICHIGAN, ON BEHALF OF THE AMERICAN 
          FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO

    Ms. Hilsabeck. Mr. Chairman and Members of the Committee, 
my name is Ammie Hilsabeck and I am a Registered Nurse at the 
Oscar G. Johnson Iron Mountain VA Medical Center in the Upper 
Peninsula of Michigan. It is a great honor for me to be here to 
testify on behalf of S. 362 on behalf of my union, the American 
Federation of Government Employees, and also the veterans that 
I take care of each and every day.
    In Iron Mountain, I am a union steward for the AFGE Local 
2280 and I work the evening shift in the emergency room. I am 
also the evening NOD, or the nursing officer of the day. I 
provide direct patient care to the veterans who come into the 
emergency room. I also manage additional services that are 
needed to take care of these veterans. I work with the nurses 
and the doctors within the entire hospital, making sure that 
all units are properly staffed on the evening shift. I handle a 
wide range of duties and tasks from within the hospital, and 
calls from veterans from the outside of the hospital.
    The AFGE greatly appreciated the chance to meet with 
Secretary Shinseki on this issue 2 days ago. The Secretary gave 
us his commitment that he would look into the issue and 
continue the dialog with us through a future meeting before 
finalizing his position. Therefore, it was especially 
disappointing to read the VA's testimony for today's hearing 
and see all the inaccurate statements about how bargaining 
rights work and how we want to use them are back again.
    All we are saying is that Title 38 employees deserve equal 
rights to voice their concerns in the workplace. To accuse us 
of wanting to use these rights to interfere with patient care 
is unfair and not based on law or fact. To accuse us of wanting 
to block supervisors from quickly removing employees who are 
abusing patients from the workplace is also unfair and not 
based on law or fact.
    I can't deny the fact that I provide patient care. That is 
my job. I take care of veterans every day. So, of course, every 
concern I have about doing my job relates to patient care in 
some way, but that is not interfering with direct patient care. 
That is not telling management how to treat diabetes or PTSD or 
which specialist to hire or how much to spend on a new imaging 
machine. Collective bargaining is about resolving labor-
management disputes about conditions of employment.
    The right to a grievance is not a temporary restraining 
order forcing immediate action by supervisors or absolute right 
for employees to walk off the job. It is only the right to 
require management to come to the table to discuss what is 
already happening in the workplace, or a policy that has been 
proposed, or to hear the employee's side of the story if he or 
she has been accused of improper conduct or poor performance.
    All we are saying is that it makes no sense to treat one 
part of the VA health care workforce differently than another. 
If a psychologist can bargain over these issues, why can't a 
psychiatrist? If an LPN can negotiate over these issues, why 
can't a Registered Nurse? If military hospital nurses or 
physicians can file grievances on employment matters that 
impact patient care, why can't we at the VA have these rights 
when we do the same jobs?
    I want to tell you what it is really like to work without a 
voice and without a chance to address concerns when you are 
caring for veterans in an emergency room every day and why we 
could provide better care for our veterans if management was 
willing to sit down and negotiate over employment issues.
    My managers recently made a decision that critically ill 
veterans would no longer be stabilized in our critical care 
unit but rather in the emergency room where I work. They would 
not negotiate, however, with us about what the ER nurses would 
need to take care of these veterans and the amount of 
responsibility in terms of training the emergency room nurses, 
equipment that was needed, medications, and supplies. We were 
also kept in the dark when management decided that our imaging 
reading services would sometimes be contracted out and 
sometimes not be contracted out, which means delayed care for 
our veterans. All we want is to negotiate things like this so 
we can meet our guidelines and provide the right care in a 
timely manner.
    Dr. Cross complains that we want to negotiate over what 
constitutes an emergency for mandatory overtime. He suggests 
that we would use the grievance process to stop managers from 
responding to emergencies with extra nurse coverage. All we 
wanted was VA central office to define ``emergency'' in advance 
of future emergencies and with one national definition so that 
over time, policies did not vary from hospital to hospital. 
Over a dozen States have that definition, so why won't the VA 
protect the safety of its veterans in the same way?
    VA's testimony also states that if we have the right to 
negotiate over management policies on compressed work 
schedules, which means three 12-hour days a week, which is 
common in other hospitals, that we are once again interfering 
with shift changes needed for medical emergencies. We can't 
prevent urgent shift changes, but we could be able to plan in 
advance with management about shifts that will make our nurses 
want to stay at the VA.
    Speaking of wanting to stay at the VA, things have changed 
a lot since I arrived in 2002. We are no longer--
    Senator Sanders. If you could please wrap up.
    Ms. Hilsabeck. OK. We are no longer treated like 
professionals whose views on anything matter. We are always in 
fear of arbitrary and unfair discipline or terminations. We are 
seeing doctors and nurses get hired by the VA and leave within 
1 week. I would like to stay at the VA; yet, me and my 
colleagues have so many pressures--to care for veterans without 
adequate support, coupled with hostile managers telling us 
Section 7422 does not let us speak up about anything--it is 
becoming harder and harder not to leave.
    [The prepared statement of Ms. Hilsabeck follows:]
   Prepared Statement by Ammie Hilsabeck, Registered Nurse, Oscar G. 
   Johnson VA Medical Center, Iron Mountain, Michigan, on Behalf of 
          American Federation of Government Employees, AFL-CIO
    Mr. Chairman and Members of the Committee: The American Federation 
of Government Employees (AFGE) appreciates the opportunity to testify 
today on pending health-related legislation. AFGE represents nearly 
160,000 employees in the Department of Veterans Affairs (VA), more than 
two-thirds of whom are Veterans Health Administration (VHA) medical 
professionals on the front lines treating the physical and mental 
health needs of our veteran population.
                                 s.362
Overview
    AFGE strongly supports S.362 to amend the law that provides Title 
38 medical professionals with collective bargaining rights: Section 
7422 of Title 38 (hereinafter ``Section 7422''). Bargaining rights 
enable labor-management disputes over matters that affect working 
conditions to be resolved efficiently through grievances, arbitrations 
and negotiations.
    S.362 is needed to clarify which workplace issues are covered by 
Section 7422. VA human resource policy interprets Section 7422 to 
deprive Title 38 employees of the same bargaining rights used every day 
by other VHA employees covered by Title 5 bargaining rights law.\1\
---------------------------------------------------------------------------
    \1\ Most VHA employees are covered by one of three major personnel 
systems:
          Title 38 covers eight positions: registered nurses 
(RN), physicians, dentists, physician assistants, optometrists, 
chiropractors, podiatrists and expanded duty dental auxiliaries.
          Title 5 covers the most VHA positions and includes 
nursing assistants and medical technicians. All Title 5 employees at 
VHA have full bargaining rights.
          Hybrid Title 38, the newest system, applies Title 38 
rules to hire and appoint employees and Title 5 rules to bargaining. 
Therefore, hybrids, including psychologists, social workers, LPNs and 
pharmacists have full bargaining rights.
---------------------------------------------------------------------------
    For example, registered nurses currently have far fewer bargaining 
rights than licensed practical nurses (LPN) and nursing assistants (NA) 
working at the same facility; psychiatrists cannot grieve over routine 
working conditions while social workers and psychologists working at 
the same mental health clinic can do so.
    S.362 also would give VA registered nurses, doctors and dentists 
the same bargaining rights as registered nurses, doctors and dentists 
performing the same type of work at military hospitals and Federal 
prison facilities, who are covered by Title 5 bargaining rights.
    Last year, VHA testified before this Committee that enacting this 
legislation would ``jeopardiz[e] the lives of our veterans.'' We 
believe that what jeopardizes patient care is arbitrarily preventing 
certain clinicians from speaking up about working conditions that 
impact the quality and safety of patient care. What hurts patient care 
is management's unfettered discretion to ignore laws recently enacted 
by Congress to improve VHA recruitment and retention of registered 
nurses and physicians, especially in the face of growing national 
shortages. (In 2008, VHA ranked RNs and physicians as the top two 
``mission-critical occupations for recruitment and retention.'')
    VHA policy did not always single out Title 38 employees for unequal 
treatment. In fact, in 1996, labor and management entered into an 
agreement about how to interpret Section 7422 to limit the number of 
disputes over what matters could be negotiated. They agreed to 
interpret ``direct patient care'' narrowly and allow grievances over 
routine matters such as nurse schedules and pay surveys. During that 
period, VHA also recognized the importance of affording full collective 
bargaining rights to all employees. In a 2002 VHA directive, that 
``applie[d] to all categories of employees in VA,'' the agency stated 
that collective bargaining ``safeguards the public interest'' and 
``facilitates and encourages the amicable settlement of disputes 
between employees and their employers involving conditions of 
employment.'' A year later, the new administration began singling out 
Title 38 employees and severely curtailing their bargaining rights.
    We agree with VHA that collective bargaining is a valuable 
safeguard. AFGE urges passage of S.362 so that access to this safeguard 
and effective dispute resolution tool does not depend of which 
personnel system applies, or whether the patients are veterans, active 
duty personnel or Federal prisoners. In addition, this legislative 
change will ensure the use of consistent personnel policies even when 
administrations change. (Opponents of this legislation have not 
expressed objection to the other two bill provisions. Section 2 of the 
bill would provide Title 38 employees with the right to appeal 
arbitrator decisions to court and Section 3 would strengthen their 
right to a hearing transcript following agency personnel hearings.)
Exceptions to Title 38 Bargaining in Current Law
    Current VA policy severely limits Title 38 bargaining rights by 
applying the three exclusions to bargaining in Section 7422 very 
broadly: direct patient care, peer review, and compensation.
    Contrary to Congressional intent, since 2003, VHA has applied an 
overly broad interpretation of the ``direct patient care'' exception to 
prohibit bargaining over a wide range of indirect patient care matters 
related to routine working conditions such as scheduling and 
assignments. Congress clearly intended to narrowly define the ``direct 
patient care'' exception as limited to medical procedures physicians 
follow in treating patients. In contrast, Congress cited guidelines for 
RNs wishing to trade vacation days as falling outside the exception. 
(H. Rep. No. 101-466 on H.R. 4557, 101st Cong., 2d Sess., 29 (1990).)
    VHA's interpretation of the compensation exception is also overly 
broad and contrary to Congressional intent. VHA applies this exception 
not just to negotiation over the setting of pay scales (which is 
clearly prohibited already by Title 5 for all Federal employees), but 
also entitlements to ``additional pay'' such as overtime, weekend pay 
and retention pay that Congress has specifically enacted to ensure a 
fair and desirable workplace.
How collective bargaining rights are used in the healthcare workplace
    Collective bargaining is an efficient dispute resolution process 
that requires management and labor to participate in grievance 
hearings, arbitrations and negotiations over conditions of employment. 
For example, collective bargaining requires labor and management to 
participate in grievance hearings about nurse overtime pay is paid 
according to law, and negotiations over training for new computer 
systems. Otherwise, management can simply walk away, leaving employees 
with no recourse to resolve a dispute, even when it involved a matter 
that could hurt patient care, such as excessive mandatory nurse 
overtime or assignment of nurses to new hospital units without adequate 
training.
    Contrary to what opponents have contended, collective bargaining 
cannot be used to:

     Require management to negotiate over disputes related to 
the agency's mission such as medical procedures or the qualifications 
of medical professionals;
     Prevent the employer from removing an unfit employee from 
the workplace;
     Allow employees to ``walk off the job'' and abandon 
patients in order to participate in a grievance hearing or negotiation 
session.
VHA ``7422'' Policy Wastes Health Care Dollars on Unnecessary Disputes
    The ambiguous exceptions in Section 7422 need to be eliminated. 
They are unnecessary because Title 5 already clearly prevents Title 38 
employees from interfering with management's mission. This policy also 
wastes patient care dollars because it results in many costly, time-
consuming and demoralizing labor-management disputes. Opponents point 
to the number of Undersecretary of Health (USH) decisions published 
each year. They fail to point out that the actual number of disputes is 
far greater for two reasons. First, not every USH decision is 
published. Second, even though the USH has the sole authority to make 
these determinations, local human resource personnel regularly make 
unauthorized decisions denying employees their rights to grieve and 
negotiate. (The fact that VHA has not curbed this widespread, 
unauthorized practice is also troubling.) Many employees never 
challenge decisions made at the facility level because they are 
discouraged by the unlikelihood of success. The USH ruled in favor of 
management in 100% of the published cases in 2003, 2005, 2006 and 2007, 
and in all but two cases in 2004.
    Employees and their representatives are also discouraged from 
seeking USH review because of the lengthy process required. Many cases 
take several years to reach the USH. VHA waited seven years to invoke 
Section 7422 to block a challenge by Asheville, North Carolina 
operating room nurses over unfair policies on weekend pay.
    Opponents of S.362 contend that Title 38 employees will use their 
expanded bargaining rights to interfere with patient care, but they 
have not, and cannot, point to a single example of attempts to 
interfere in this matter or in the setting of pay scales. A review of 
all published USH decisions since 2003 reveals that the vast majority 
involve routine disputes over matters such assignments, schedules and 
noncompliance with pay rules, and none relate to medical procedures or 
pay scales.
    Elimination of the exclusions in Section 7422 will not result in 
employee interference with patient care or setting of pay scales 
because Title 5 already sets clear limits on the scope of bargaining 
for all VHA employees, as discussed shortly. Section 7106(a) (which 
also covers Title 38 employees) clearly states that management rights--
the determination of the agency mission, budget and organization--are 
not subject to bargaining. Similarly, employees cannot interfere with 
pay rates; Chapters 53 and 71 of Title 5 have always barred all Federal 
employees from bargaining over the setting of pay scales. In contrast, 
Section 7103(a)(14) of Title 5 makes it clear that Federal employees 
can only bargain over ``conditions of employment.''
    Multiple decisions by the Federal Labor Relations Authority (FLRA) 
confirm that Title 5, standing alone, would prohibit Title 38 employees 
from interfering with direct patient care. More specifically, the FLRA 
has ruled that the union cannot require negotiations on even when 
services are to be provided to the public for ``mission'' reasons. It 
follows that Title 5 prevents a union from forcing negotiations over 
the substance of patient care.
Collective bargaining increases accountability and improves patient 
        care
    Current policy prevents RNs, physicians and other Title 38 
employees from challenging workplace policies that lessen the quality 
and safety of patient care. For example, research on nurse overtime has 
clearly shown that exhausted nurses are more likely to make medical 
errors. In 2004, Congress enacted legislation to limit mandatory 
overtime except in cases of emergency. When local directors invoked the 
``emergency'' exception to cover up for poor staffing policies, AFGE 
tried to negotiate with VHA for a nationally uniform definition of the 
term, but VHA refused.
    Bargaining rights play a valuable role in agency innovation. A 
decade ago, VHA implemented two new health care information technology 
(IT) systems: Computerized Patient Record Systems and Bar Code 
Medication Administration. These health care IT innovations helped 
transform the VA into a world-class health care system and national 
model. When these systems were introduced, labor used its bargaining 
rights to negotiate over training and IT support to ensure that Title 
38 nurses could provide patient care effectively and without 
interruption during computer breakdowns. Sadly, under current VHA 
policy, these negotiations would be prohibited as interfering with 
``direct patient care.'' Full bargaining rights for VHA doctors and 
nurses will allow them to once again make valuable contributions as the 
new administration undertakes major IT changes.
    In contrast, nurses and doctors who work at Department of Defense 
(DOD) and Bureau of Prison (BOP) healthcare facilities have been able 
to use their full rights to positively impact patient care. For 
example, physician assistants (who would fall under Title 38 at the VA) 
participated in negotiations over all 19 BOP health services program 
statements currently in effect, including ``Health Services Quality 
Improvement,'' ``Infectious Disease Management,'' and ``Health 
Information Management.''
    In summary, AFGE urges this Committee to support S.362 to provide 
all VHA clinicians with the same bargaining rights. This legislation 
will vastly reduce the number of wasteful, demoralizing labor-
management disputes at medical facilities and allow all of VHA's 
dedicated clinicians to make positive contributions to health care 
delivery.
                                 s.252
Overview
    AFGE thanks Chairman Akaka for his leadership in introducing 
legislation again this year to address the needs of front-line VHA 
nurses for more competitive pay and schedules, increased loan 
assistance and equal rights for part-time nurses, and we urge passage 
of these provisions. However, we strongly oppose the provision to 
expand the Hybrid Title 38 personnel system, and therefore urge the 
Committee to strike this language from the bill and substitute a 
provision for further study of this poorly functioning, nascent 
personnel system. Age's objections to other provisions in this bill are 
discussed below.
    Section 101(a): This provision would immediately transfer over 
11,000 nursing assistants from Title 5 to Hybrid Title 38 status, and 
allow the Secretary to transfer over 20,000 more Title 5 employees to 
Hybrid status. Further expansion of this broken system could be 
disastrous. Therefore, we urge lawmakers to strike Section 101 (a) from 
the bill and substitute language to request a comprehensive study of 
the Hybrid Title 38 system to determine if and how can be fixed prior 
to further expansion.
    The Hybrid Title 38 personnel system has failed to meet its top 
objective: flexible, expedited hiring of healthcare personnel at the 
facility level. The system is currently plagued by so many delays 
during the initial boarding process and ongoing hiring and promotion 
processes that VHA has had to hire additional staff just to deal with 
current backlogs and problems. For example, it took more than four 
years for social workers and some psychologists to be ``boarded'' 
(transferred to the Hybrid system from Title 5). VHA social workers 
report that it can take more than six months to hire new social 
workers. Hiring is so cumbersome and slow that in many cases, it is 
still faster to hire under Title 5. Proponents of Hybrid expansion 
contend that the Title 5 hiring process is too slow, but it is worth 
noting that the VA recently hired 4,000 new Title 5 disability claims 
processors without delay.
    In addition, veterans' employment rights appear to be weaker under 
Hybrid Title 38 than under Title 5, depriving hundreds of veterans 
employed by VHA of the ability to enforce their rights through the 
Merit System Protection Board and Labor Department. Further study is 
needed to clarify the scope of veterans' preference under different VHA 
personnel systems prior to placing more employees under the Hybrid 
system.
    Promotion policies are less equitable under the Hybrid system as 
well, which impacts VHA recruitment and retention. Currently, Hybrid 
Title 38 employees have little or no recourse if management refuses to 
allow them to go before professional standards board to be considered 
for promotion ``above the journeyman level.'' Even when promotion is 
recommended, management can refuse to promote. This has greatly 
impacted social workers and psychologists, among others.
    In summary, AFGE urges further study of the Hybrid Title 38 system 
prior to further expansion, to determine if and how the system can be 
improved, or whether Title 5 (and possibly new Title 5 streamlined 
procedures) would better serve VHA's workforce needs. It will also be 
worthwhile to examine how VHA recruitment and retention of specific 
professions is faring under the Hybrid system, for example, mental 
health providers, licensed practical nurses and pharmacists.
    Section 101(b) and (c): AFGE strongly supports these provisions. 
Part-time VA registered nurses (RN) have ``fallen through the cracks'' 
of Title 38 for too long. Under current law, a RN hired on a full-time 
basis can become a permanent employee after two years. In contrast, RNs 
who are hired as part-time can never obtain personnel rights and 
benefits associated with permanent status. It is equally unfair that 
RNs who worked for years on a full-time basis lose all their rights 
when they convert to part-time, for example, to start a family or care 
for elderly relatives. These provisions provide a simple, equitable 
fix: After the equivalent of two years of work, part-time nurse achieve 
the same status as their full-time counterparts, and nurses who have 
already achieved permanent status retain it when they change to a part-
time schedule.
    Section 101(d)-(f): AFGE takes no position on these provisions
    Section 101(g): AFGE opposes this provision to pay $40,000 
recruitment and retention bonuses to pharmacist executives. These large 
bonuses should only be put into law after a showing of clear evidence 
of a national recruitment and retention problem for all VHA pharmacist 
positions (including pharmacists and pharmacist techs working directly 
with patients). For example, this Committee recently relied on a 
comprehensive study of recruitment and retention problems for Certified 
Registered Nurse Anesthetists to support pay adjustments for them. We 
estimate that this proposed pay increase change would allow a pharmacy 
executive in Washington State to earn over $173,000 and a pharmacy 
executive in Salem, Virginia, to earn $183,000.
    Section 101(h): We take no position on Section 1(h)(1) on non-
foreign COLAs.
    We object to Section 1(h)(2) that would allow VHA to set the market 
pay differently for management physicians and dentists than 
practitioners providing hands-on care. We see no justification for 
exempting no practicing physicians and dentists from the same peer-
based compensation panel system used by practitioners providing direct 
care. Congress enacted this elaborate system in 2004 (Pub. L. 108-445) 
specifically to ensure that market pay was set fairly and at a level 
that was competitive with pay offered by other local health care 
employers. Exempting management clinicians from this statutory pay 
process will undermine Congressional intent and increase pay decisions 
based on favoritism rather than market conditions. We urge the 
Committee to strike this provision and instead, conduct oversight of 
the 2004 law prior to making any further amendments to it.
    We strongly object to Section 1(h)(3) that would allow pay 
reductions based on changes in board certification or reduction of 
privileges. The board certification provision will disproportionately 
impact newer physicians and dentists who are required to qualify for 
renewal of their board certification every ten years (unlike older 
practitioners whose board certification is permanent). VHA should 
create new incentives, not disincentives, to recruit and retain new 
clinicians. Many VA clinicians have difficulty securing the leave to 
renew their certification in a timely manner. Therefore, this will also 
disproportionately impact clinicians in rural hospitals and other 
facilities that are short-staffed. Similarly, we object to tying pay to 
privileges as they are completely within management's discretion. 
Currently, management can provide themselves with full privileges even 
though they do not see patients, but arbitrarily restrict or deny 
privileges of hands-on physicians and dentists in retaliation for 
voicing their concerns through avenues such as union grievances, 
lawsuits and complaints to the Inspector General.
    Sections 101(l) and (n): AFGE supports this provision to adjust the 
pay caps for Cranes (as already discussed) and Lens (whose modest wages 
often hit the pay cap when annual Federal pay raises are provided).
    Sections 101(j) and (l): AFGE opposes these provisions to provide 
significant increases in base pay and retention bonuses (``special 
pay'') to nurse executives. This represents a 400 percent increase over 
five years. (In 2004, Congress enacted a $25,000 ceiling on nurse 
executive retention bonuses.) We estimate that in North Carolina, this 
would allow some nurse executives to earn almost $240,000, and in 
Washington State, $243,000. AFGE opposes such a large increase absent 
sufficient evidence of a national recruitment and retention problem for 
VHA nurse executive positions.
    Section 101(k): AFGE supports this provision to provide additional 
director training on the RN third party locality pay survey process. 
This will assure that surveys are conducted properly and will result in 
VHA pay that is competitive with the private sector. Providing 
employees and their representatives with survey data about their own 
pay is also a common-sense fix that will lead to greater 
accountability.
    Sections 101(m): AFGE supports this provision to ``fine tune'' the 
rules for overtime and shift differential pay of all VHA nurses to 
ensure fair and consistent payment of additional pay, and keep VHA 
competitive with other employers applying similar rules.
    Section 102 (a-b): AFGE supports this provision to provide clearer 
language to limit mandatory overtime for RNs and extend this limit to 
other nursing positions, as well as protect against retaliation for 
refusal to work a prohibited schedule. The definition of ``emergency'' 
is consistent with state nurse overtime laws that already protect other 
nurses from excessive mandatory overtime. AFGE notes, however, that 
under current VHA policy on Title 38 collective bargaining, RNs will 
not be able to enforce their rights to refuse to work prohibited 
schedules (but Lens and NAs with Title 5 bargaining rights will be able 
to seek enforcement through grievances).
    Section 102(c): AFGE supports this provision to encourage greater 
use of alternative work schedules (AWS) by VHA. AWS is valuable nurse 
recruitment and retention tool as it is widely offered in the private 
sector. AFGE notes, however, that under current VHA policy on Title 38 
collective bargaining, RNs will be unable to enforce their rights to 
AWS if VHA continues to refuse to offer it (in contrast to LPNs and NAs 
with full bargaining rights.)
    Section 103: AFGE supports these improvements to VHA loan 
assistance programs including greater access to this assistance by 
current employees seeking additional training.
    Section 104: AFGE generally supports strong standards for physician 
appointments but notes that most of these proposed requirements are 
already in practice at VHA. AFGE opposes VISN approval of physician 
appointments: this will bog down an already slow hiring process and 
further impede the VA's ability to hire physicians. AFGE calls for 
further study of the impact of tying performance to board certification 
prior to implementing this provision; it could have an adverse impact 
on VHA's ability to recruit physicians without enhancing quality of 
care. More generally, as already discussed, AFGE urges the Committee to 
conduct oversight of a broad range of physician issues, including 
implementation of the base, market and performance pay provisions in 
the 2004 physician and dentist pay bill, the ``24/7'' rule and other 
scheduling matters, panel sizes, continuing medical education 
reimbursement and board certification.
    Section 201: AFGE strongly opposes elimination of this modest 
annual reporting requirement that holds VHA accountable to Congress for 
its nurse locality pay policies. We see no benefit, and only problems, 
with allowing VHA to conduct critical nurse recruitment and retention 
policies in secrecy, especially given the need for highly effective pay 
policies during this growing national nursing shortage. More generally, 
the process of setting front-line nurse locality pay or nurse executive 
retention bonuses should be far more transparent.
    Sections 202-214: AFGE takes no position on these sections.
    Section 215: AFGE supports increased access to TBI care but is 
concerned about the minimal oversight provisions in this section. 
Therefore, AFGE urges the Committee to conduct regular oversight into 
all contract care arrangements, including the ongoing Project HERO 
pilot operating in four VISNs, to ensure that veterans' needs are well 
served by non-VA providers in terms of quality of care, coordination of 
care, timeliness of care and geographic accessibility. In addition, 
oversight of all contract care arrangements should include 
consideration of the impact of diverting patients and patient care 
dollars on the VA's capacity and budget for providing in-house care, a 
comparison of the cost and quality of patient care with care provided 
through increased in-house capacity and providing care through VHA's 
extensive telehealth system. The long range impact of contract care on 
the VA's role as a leading researcher and training ground for 
practitioners across the country should also be evaluated.
    Section 216: AFGE has not taken a position on this section
    Section 217: AFGE opposes this provision to pilot a contract dental 
care program. AFGE supports instead VA-provided outpatient dental care 
to all enrolled veterans without imposing additional costs on them or 
their families.
    Title III: AFGE takes the same position on Title III of this bill 
and S.597. We fully support provisions to improve and expand health 
care services to women veterans and their families.
    Title IV: AFGE has not taken a position on this section.
    Title V: AFGE has not taken a position on this section.
    Title VI: AFGE has not taken a position on this section.
    Title VII: AFGE supports these provisions for VA police officers. 
AFGE also recommends the additional language providing that in the 
event that an offense takes place in the presence of the officer while 
off Department property, he or she may take appropriate action to--
protect life, and may exercise any authority authorized by an express 
grant of authority under applicable Federal, State or local law.
                                 s.821
    AFGE supports this legislation to eliminate copayments from 
veterans who are catastrophically disabled.
                                 s.801
    AFGE supports this legislation to provide assistance to family 
caregivers.
                                 s.793
    AFGE supports this legislation to increase tuition assistance for 
individuals training for positions to care for the visually impaired.
                                 s.772
    AFGE has not taken a position on this bill.
                                 s.734
    AFGE supports this bill, including much needed provisions to 
increase oversight of contract care. As already discussed (see Section 
215 of S.252), AFGE urges the Committee to conduct comprehensive 
oversight of all contract care arrangements and should coordinate 
activities under this program with oversight of Project HERO that 
already operates in four VISNs.
                                 s.699
    AFGE has not taken a position on this bill.
                                 s.658
    AFGE supports this legislation to improve access to health care for 
rural veterans. In Section 6, AFGE urges greater oversight of contract 
care consistent with our recommendations in our comments on Section 215 
of S.252 and S.734.
                                 s.597
    AFGE supports this legislation to improve health care services for 
women veterans and their families.
                                 s.543
    AFGE has not taken a position on this bill.
                                 s.509
    AFGE supports this bill for construction of new facilities and 
other improvements at the Walla Walla, WA VAMC.
                                 s.498
    AFGE has not taken a position on this bill.
                                 s.423
    AFGE supports this legislation to authorize advance appropriations 
for VA health care.
                                 s.404
    AFGE supports this legislation to expand eligibility for emergency 
medical care.
                                 s.246
    AFGE has not taken a position on this bill.
                                 s.239
    AFGE has not taken a position on this bill.
                                 s.226
    AFGE has not taken a position on this bill.

    Senator Sanders. Thank you very much.
    Ms. Heady?

 STATEMENT OF HILDA R. HEADY, MSW, ASSOCIATE VICE PRESIDENT OF 
   RURAL HEALTH, ROBERT C. BYRD HEALTH SCIENCES CENTER, WEST 
VIRGINIA UNIVERSITY, AND PAST PRESIDENT, NATIONAL RURAL HEALTH 
                          ASSOCIATION

    Ms. Heady. Thank you. I am thrilled to be able to present 
to the distinguished members of the panel. I am the Associate 
Vice President for Rural Health at the Robert C. Byrd Health 
Sciences Center at West Virginia University and I was honored 
last summer to have been appointed by former Secretary Peake to 
the National Advisory Committee on Rural Health in the VA.
    NRHA is the rural voice for 62 million Americans who call 
rural their home; and NRHA has focused on the issue of rural 
veterans and studied policy matters since 1997. We particularly 
want to address some of the measures in S. 734 and S. 658 
today.
    Rural Americans have responded every time the country has 
gone to war. I am from a very small rural Southern community 
and a family that can trace its generations in American wars 
all the way back to the American Revolutionary War, and with 
the exception of the War of 1812 and the Spanish-American War, 
I have had members in all of these combats.
    One of my uncles served with General Patton in World War II 
and stormed the beaches of Normandy, returned home to become a 
sharecropper in Northern Alabama, and died of a heart attack at 
the age of 41 as a rural veteran who never received VA 
benefits. He left a young widow and five children. If Senator 
Akaka's bill, S. 734, had been the law of the land in those 
years following World War II, perhaps access to health care 
would have been closer to his small rural community and perhaps 
high-quality trained primary care physicians, whose training 
was supported by the incentives in the bill such as the 
National Health Services Corps, the Education Debt Reduction 
Program, and training in post-deployment health issues, may 
have enabled a physician to detect his heart disease and 
prevent his premature death, and perhaps his children would not 
have grown up with a single mother struggling to provide for 
them.
    In brief, NRHA supports the increase of access and building 
on the current successes of the CBOCs, mobile clinics, and 
outreach clinics, and certainly the Vet Centers. We need more 
rural outreach coordinators in each VISN that serve high 
numbers of rural veterans, as pointed out in this bill, because 
these individuals are involved in contracting fee-for-services 
with existing rural providers. And we need to focus special 
efforts on recruiting existing rural providers in these areas 
to work under these contracts with the VA.
    Linking quality of VA services with quality rural civilian 
services just simply makes sense, and as long as quality 
standards of care and evidence-based medicine guide the 
treatment for rural veterans, then we strongly support these 
collaborations with community health centers, critical access 
hospitals, other rural hospitals, and rural health clinics.
    We need to increase the access to mental health care 
services, particularly for those with PTSD and Traumatic Brain 
Injury. We need more TBI case managers. The current load of TBI 
case managers do not adequately address those individuals who 
are in rural areas. Rural areas suffer from very limited health 
care professionals, and where 75 percent of primary care HPSAs 
are located in rural areas, 85 percent of our shortage areas in 
mental health are in rural areas. The provisions of S. 734 that 
call for the increases in training of mental health providers 
and volunteer counselors would go a long way to helping in that 
area.
    Travel reimbursement will also address some critical needs, 
especially air service for those individuals that are in highly 
rural areas.
    We also call for an increase in the collaboration around 
research that will look at non-enrolled veterans. Most of the 
research that is currently done by the VA is only done on 
secondary databases of veterans who are enrolled, and since we 
know that the VA only serves 39 percent of veterans, then we 
are leaving out 61 percent of those veterans, and we know that 
a number of those individuals are in rural areas. This would be 
a natural tie-in to the Centers of Excellence that are called 
for in Senator Tester's bill, S. 658.
    I want to commend Senator Murray for introducing the women 
veterans bill and I think that we need to point out that among 
the 15 percent total number of women that are in the military 
service right now, 37.5 percent of those women are African-
American women and we need to pay special attention to this 
population as they become veterans and in need of our services.
    Thank you very much for the legislation. This is a huge 
agenda, and with very little exceptions, the National Rural 
Health Association is very pleased to support most of these 
efforts. Thank you.
    [The prepared statement of Ms. Heady follows:]
Prepared Statement of Hilda R. Heady, MSW, Associate Vice President of 
    Rural Health at the Robert C. Byrd Health Sciences Center, West 
 Virginia University, National Rural Health Association, Past President
    Chairman, Akaka, Ranking Member Burr, and Members of the Senate 
Committee on Veterans' Affairs: Thank you for the honor and the 
opportunity to speak to you today about the health care needs of our 
rural veterans. I am Hilda Heady, Associate Vice President of Rural 
Health at the Robert C. Byrd Health Sciences Center at West Virginia 
University, a committee member of the VA Veterans Rural Health Advisory 
Committee, and past president of the National Rural Health Association 
(NRHA). The NRHA provides leadership on the issues that affect the 
health of the 62 million Americans who call rural home and has long 
focused efforts on improving the physical and mental health of our 
rural veterans.
    Since our Nation's founding, rural Americans have always responded 
when our Nation has gone to war. Whether motivated by their values, 
patriotism, or economic concerns, the picture has not changed much in 
230 years. Simply put, rural Americans serve at rates higher than their 
proportion of the population. Though only 19% of the Nation lives in 
rural areas, 44% of U.S. Military recruits are from rural America. And, 
sadly, according to a 2006 study of the Carsey Institute, the death 
rate for rural soldiers in our current war in Iraq is 60% higher than 
the death rate for those soldiers from cities and suburbs. Given this 
great commitment to service from our rural communities, we need to do 
more to resolve the health care barriers that face rural veterans.
    There is a national misconception that all veterans have access to 
comprehensive care. Unfortunately, this is simply not true. Access to 
the most basic primary care is often difficult in rural America. Access 
for rural veterans can be daunting. Combat veterans returning to their 
rural homes in need of specialized care due to war injuries (both 
physical and mental) will likely find access to that care extremely 
limited. Scarcity of mental health and family counseling services is 
also a problem for rural veterans in need of these services.
    Simply put, because there are a disproportionate number of rural 
Americans serving in the military, there is a disproportionate need for 
veteran's care in rural areas. While the VA has increased the number of 
Community Based Outpatient Clinics (CBOCs), Outreach Health Centers, 
Home Based Care, or other outreach service programs in rural 
communities, it is not reasonable to expect that the VA can put a CBOC 
or one of these other services in every community where our rural and 
highly rural veterans live. We can, however, increase access to 
approved sources of care to overcome the difficulty rural veterans 
experience in attempting to receive timely, appropriate care.
    In West Virginia, more than half of all our veterans live in rural 
areas. Veterans represent over 14% of our population and that is 
growing: the state of West Virginia supports a military complex of Army 
and National Guard, Army and Air Reserve Components, plus Navy and 
Marine Reserve Units. Many of our soldiers in these units are serving 
their second or third tour of duty in Iraq or Afghanistan, but 
hopefully will return home soon. A vast number will return home to 
rural communities scattered across the state, often several hours' 
drive from veteran health care facilities. Many will simply forego care 
because this access is so difficult.
    The NRHA strongly supports specific solutions to meet the 
challenges of providing quality care to our rural veterans. The NRHA 
believes that improving access to care for our Nation's rural veterans 
must be a priority for both the Administration and Congress, and 
submits the following recommendations:
1. Increase Access by Building on Current Successes
    Community Based Outreach Centers (CBOCs) open the door for many 
veterans to obtain primary care services within or close to their home 
communities. Additionally, Outreach Health Centers and mobile clinics 
meet the needs of many rural veterans. NRHA applauds the success of 
these programs as well as recent increases in Federal appropriations. 
Expansion of these critical services is needed.
2. Increase Access by Collaborating with Non-VHA Facilities
    Approximately 20% of veterans who enroll to receive health care 
through the VHA live in rural communities. In addition, the VA 
currently serves only 39% of all veterans, so we know that a number of 
rural veterans rely upon their local, civilian health care system for 
services and some may not receive any care. With an ever-growing number 
of veterans returning home to their rural communities after military 
service, these rural health care systems must be prepared to meet their 
needs. While CBOCs and Veteran Outreach Centers provide essential 
points of access, there are not enough of these facilities in rural 
communities. Furthermore, CBOCs do not provide a full range of care and 
the low volume of veterans in some communities may never be able to 
support one of these centers. Simply put, more providers, specifically 
trained in post-deployment health conditions and care, are needed to 
serve the increasing number of rural veterans. Collaboration with 
existing rural health care facilities provides a cost-effective, timely 
and quality solution to this problem.
    Linking the quality of VA services with rural civilian services can 
vastly improve access to quality health care for rural veterans. Our 
goal is not to mandate care to our veterans, but to provide them a 
choice, a local choice. As long as quality standards of care and 
evidence-based medicine guide treatment for rural veterans, the NRHA 
supports collaboration with:

     Community Health Centers. These centers serve millions of 
rural Americans and provide community-oriented, primary and preventive 
health care. More importantly, FQHCs are located where rural veterans 
live. A limited number of collaborations between the VHA and Community 
Health Centers already exist and have proven to be prudent and cost-
effective solutions to serving eligible veterans in remote areas. These 
successful models should be expanded to reach all of rural America.
     Critical Access Hospitals and other rural hospitals. These 
facilities provide comprehensive and essential services to rural 
communities and are specific to rural states. If these facilities are 
linked with VHA services and models of quality, access to care would be 
greatly enhanced for thousands of rural veterans.
     Rural Health Clinics. These clinics serve populations in 
rural, medically-underserved areas and comprise a vital piece of the 
safety-net system. In many rural and frontier communities, RHCs are the 
only source of primary care available.

    The above rural health facilities are the cornerstone of primary 
and preventive quality health care in rural America. Each is required 
to meet Federal requirements for quality, provider credentialing and 
the use of health information technology. Current collaborations with 
the VHA in Wisconsin, Missouri and Utah are strong examples of success. 
Expanding the levels of collaboration will vastly increase access to 
care in a cost-effective manner.
    The NRHA is pleased that the Rural Veterans Access to Care Act was 
signed into law last October. This act establishes a three-year pilot 
program in several rural regions of the country to allow the most 
underserved rural veterans to take advantage of existing quality rural 
health providers, such as Critical Access Hospitals, community health 
centers and rural health clinics. The pilot project is relatively small 
and requirements to qualify are rigid a veteran must live at least 60 
miles from a VA primary care facility like an outpatient clinic, 120 
miles from a VA hospital or 240 miles from a VA specialized-care 
facility when seeking that care. Despite these defects, this 
legislation is an important step in the right direction, but so much 
more must be done.
    S.658, the Rural Veterans Health Care Improvement Act, is an 
important next step because it will allow even greater access to care 
or rural veterans. Specifically, one section authorizes the Office of 
Rural Health to improve or expand care for rural veterans through a 
series of demonstration projects that includes coordination with 
Community Health Centers, Critical Access Hospitals and Indian Health 
Services. We thank Senator Tester for introducing this bill and for 
this Committee's examination of it.
    Additionally, S.734, the Rural Veterans Health Care Access and 
Quality Act of 2009, is yet another crucial step. This Act establishes 
a pilot project that would provide financial incentives for physicians 
who serve in a Health Professional Shortage Area to provide primary 
care or mental health services to rural veterans. Such a program could 
go far in improving access to care for rural veterans, especially 
meeting the great unmet mental health needs of our Nation's veterans. 
The NRHA applauds Chairman Akaka for introducing this important bill. 
Care must be taken that laudable efforts to increase provider care for 
our veterans does not exacerbate the current provider shortage in rural 
areas. Because access to primary care in rural America is at crisis 
levels for all both civilian and non-civilian patients, it is also 
important to be mindful that any incentives do not inadvertently reduce 
providers at non-VA facilities.
3. Increase Access to Mental Health and Brain Injury Care
    Currently, it appears that Traumatic Brain Injury (TBI) will most 
likely become the signature wound of the Afghanistan and Iraqi wars. 
Such wounds require highly specialized care. The current VHA TBI Case 
Managers Network is vital, but access to it is extremely limited for 
rural veterans--expansion is needed.
    Additionally, mental health needs of combat veterans deserve 
special attention and advocacy as well. Access to mental health 
services is a problem in many small rural communities. In fact, 85% of 
all mental health shortages are found in rural America. A lack of 
qualified mental health professionals, shortage of psychiatric hospital 
beds and the negative stigma of mental illness, often result in many 
rural residents not getting the care they so desperately need. These 
problems are exacerbated for veterans who live in rural communities--
too often members of our military return home to a civilian community 
where the cultural expectation is self-reliance and to solve one's own 
problems. In a civilian health care system where few may understand 
military experience or the special needs of combat veterans, we need to 
do more to prepare our primary care providers who will serve these 
veterans.
    Although Vet Centers provide mental health services, they are not 
consistently available at the local, rural level. More resources are 
needed in order to contract with local mental health providers, hire 
additional mental health providers and/or contract with Critical Access 
Hospitals (CAHs) and other small rural hospitals. The provisions in 
S.658 that give the VA the clear authority to contract-out mental 
health services for certain rural veterans is strongly supported by the 
NRHA. However, without addressing the national need for more mental 
health providers in rural areas and include post-deployment and/or 
combat related mental health disorders, the greater impact of S.658 may 
be hampered.
4. Target Care to Rural Veterans
    A. Needs of the Rural Family. Rural veterans have an especially 
strong bond with their families. Returning veterans adjusting to 
disabilities and the stresses of combat need the security and support 
of their families in making their transitions back into civilian life. 
The Vet Centers do a tremendous job of assisting veterans, but their 
resources are limited. The NRHA supports increases in funding for 
counseling services for veterans' and their families.
    B. Needs of Rural Women Veterans. More women serve in active duty 
than at any other time in our Nation's history. And more women are 
wounded or are war casualties than ever before in our Nation's history.
    Targeted and culturally competent care for today's women veterans 
is needed. Rural providers should also be trained to meet the unique 
needs of rural, minority, and female veterans.
5. Improving the VA Office of Rural Health
    The NRHA calls on Congress and the VA to fully implement the 
functions of the newly created VA Office of Rural Health to develop and 
support an ongoing mechanism to study and articulate the needs of rural 
veterans and their families.
    Additionally, efforts to increase service points for rural veterans 
have, in large part, not been fully supported by the VA Administration 
itself. The VA has not consistently supported attempts to collaborate 
with rural health. It is my hope that with a new Administration and the 
newly formed VA Rural Health Advisory Committee, previous barriers will 
be eradicated and the VA Office of Rural Health will lead the way in 
expanding access options for rural veterans. Furthermore, the NRHA 
strongly encourages greater coordination between the Rural Health 
Consultants housed in each VISN and state-level rural health officials 
in their region. Specifically, quarterly meetings with State Office of 
Rural Health and State Rural Health Association officials would be 
prudent.
    S.734 provides important direction for the VA Office of Rural 
Health. The requirement of establishing a strategic plan to implement 
specific workforce recruitment and retention goals is imperative for 
increasing access to care for rural veterans. However, we must again be 
mindful that any strategic plan to increase providers at VA facilities 
does not inadvertently increase the current shortage crisis at non-VA 
facilities. To this end, collaboration between the Federal Office of 
Rural Health Policy within HRSA and the VA Office of Rural Health is 
critical and must be established to best take advantage of the many 
efforts to reduce provider shortages in rural areas already underway 
within HRSA.
6. Explore ways to coordinate benefits for dual eligible veterans
    As the veteran population ages, a growing number of veterans are 
eligible for both VHA health benefits and Medicare. The combination of 
two partial benefits packages should ensure the best possible care for 
our veterans, but the co-payments and Medicare Part D requirements may 
not be affordable for many veterans. Coordination of benefits would 
allow veterans to utilize the different resources offered to them 
effectively to receive high quality care close to home.
7. Increase research on defining the rural veteran population
    Without good research about the rural veteran population, we cannot 
possibly expect to ensure their good health. Epidemiological studies 
are needed to identify the locations and populations of veterans in 
various rural areas of the country. These studies must provide 
information about race, gender, place of residence, health care needs, 
service-related health issues and service utilization. With only 39 
percent of veterans enrolled in VA health care benefits, and most VA 
research conducted on secondary bases of enrollees, we know that non-
enrollees who may be rural, less than honorably discharged, and other 
veterans in need, are not included in this research. We need to broaden 
avenues for quality research which would provide information about how 
to best serve the veteran population who are currently not enrolled. 
The NRHA would encourage the VA to collaborate with the six Federal 
Office of Rural Health Policy/HRSA-funded Rural Health Research Centers 
to explore this research.
                               Conclusion
    While many opportunities for improvement exist in providing care to 
veterans in rural communities, the VA is to be commended for the 
excellent service provided in many of its facilities. However, we must 
never forget that many veterans forgo care entirely because of access 
difficulties to VA facilities. Providing health care in rural 
communities requires unique solutions, whether it is to veterans and 
their families or the general population. Additionally, we must all be 
mindful of long-term needs and costs of our sailors and soldiers. The 
wounded veterans who return today won't need care for just the next few 
fiscal years; they will need care for the next half century.
    Both S.734 and S.658 are crucial pieces of legislation that will 
vastly improve the access to health care for our Nation's rural 
veterans. Adopting the legislation and other strategies referenced in 
this written testimony will vastly improve the lives of the millions of 
veterans who live in rural America. Their service to their Nation 
affords them no less.

    Thank you again for this opportunity.

    Senator Begich [presiding]. Thank you for your testimony. 
The Chair keeps rotating, so you have to bear with us.
    Mr. Ibson, please.

  STATEMENT OF RALPH IBSON, SENIOR FELLOW FOR HEALTH POLICY, 
                    WOUNDED WARRIOR PROJECT

    Mr. Ibson. Thank you. Mr. Chairman and Members of the 
Committee, thank you for inviting Wounded Warrior Project to 
testify about pending legislation, particularly S. 801, a 
measure that would direct VA to develop a nationwide 
comprehensive wounded warrior family caregiver program; and S. 
543, which calls for a pilot program to assess the feasibility 
of providing such support.
    Both bills recognize the extraordinary burdens being 
shouldered by family caregivers. Like wounded warriors 
themselves, family caregivers must adjust to a new normal in 
taking on what may be a lifetime of committed care.
    Wounded Warrior Project knows firsthand the challenges 
these family members face and believes the time has come to 
create a comprehensive nationwide program to sustain that 
caregiving. The establishment of such a program is our top 
legislative priority and we offer our overwhelming support for 
S. 801, the Family Caregiver Program Act of 2009.
    We applaud Chairman Akaka's leadership in taking up this 
important issue and working so closely with Ranking Member Burr 
to craft this strong bill.
    S. 801 incorporates all the elements we believe are 
essential to helping families sustain the caregiving needed by 
our wounded warriors. We have reached that view based on 
exhaustive research on family caregiving needs documented in a 
paper we would like to submit for the record. [Please find 
``Sustaining Family Caregiving for Wounded Warriors: The Need 
for a Comprehensive Caregiver Program'' after Mr. Ibson's 
prepared statement]
    S. 543, also before the Committee, would provide some of 
the supports we view as critical, but the measure falls short, 
in our view. It would not provide the full range of needed 
supports and is limited in scope to a 2-year pilot involving 
relatively few facilities. We believe the time for pilot 
programs is long past.
    Family caregivers are a vital link in the rehabilitation of 
severely wounded warriors, but these families have no assurance 
of ongoing governmental support. That lack of support threatens 
to take its toll. Studies show that family caregivers 
experience an increased likelihood of stress, depression, and 
mortality as compared to their non-caregiving peers. Caregiving 
takes an economic toll, as well.
    Let me share just two examples from among the many 
caregivers with whom we have worked closely. Jennifer was 
forced to leave her teaching job to care for her husband, who 
was struck by an IED in Iraq in 2005. His injuries resulted in 
total blindness and severe TBI and he is on medications to 
control seizures and many other problems. In her 3 years of 
full-time caregiving, Jennifer has received no training of any 
kind and no supplemental income. She had not been made aware of 
any VA respite care program when we interviewed her recently.
    Charlene, another caregiver, lost her job after 2 months of 
caring for her wounded warrior son, who sustained severe TBI in 
2003 and requires full-time care. She has health care coverage, 
but only through her husband's health program, and they pay 
significant premiums for that care, having gone from a two-
income to a single income family. Charlene recently underwent a 
heart biopsy and heart catheterization and states plainly that 
her caregiving activities are extremely stressful.
    Without ongoing support, many of these family caregivers 
will simply find themselves unable to cope. The ultimate cost 
of failing to address their urgent needs is surely to increase 
the risk of veterans being needlessly institutionalized at 
great cost.
    I was struck, and perhaps others of you on the Committee 
were, as well, that VA expresses its opposition to S. 801 in 
part on the ground that it would, quote, ``divert from the 
primary mission of treating veterans and training clinicians.'' 
I can think of no higher calling in law or policy than the 
care, rehabilitation, and well-being of wounded warriors. That 
is the essence of what S. 801 is about and it is disappointing 
that the Department's testimony misses that point.
    Further, the Department offers as a solution a position 
that I think Senator Burr ably demolished, but a position 
articulated last September in hearings on the House side, 
proposing that caregivers might be employed by home health 
agencies. Senator, as you ably pointed out, the VA has no 
evidence to show that that is a workable solution. In the 
months since last September, nothing has changed and no 
evidence was put on the table to suggest that this is at all 
plausible. It simply isn't a mechanism by which to support 
family caregivers. S. 801 is just such a mechanism and it has 
our full support.
    We would welcome the opportunity to discuss the elements of 
the bill in greater detail, including what some families see as 
a need for somewhat greater flexibility in the bill's oversight 
provisions. But above all, we urge the Committee to make 
enactment of S. 801 a top priority.
    Thank you for taking up this important issue. I would be 
pleased to address any questions you might have.
    [The prepared statement of Mr. Ibson follows:]
  Prepared Statement of Ralph Ibson, Senior Fellow for Health Policy, 
                        Wounded Warrior Project
    Chairman Akaka, Ranking Member Burr, Members of the Committee: 
Thank you for inviting Wounded Warrior Project (WWP) to testify about 
pending legislation, particularly S.801, a measure that would direct 
the Department of Veterans Affairs to develop a nationwide, 
comprehensive wounded warrior family caregiver program, and S.543, 
which calls for a pilot program to assess the feasibility of providing 
such support.
    Both bills recognize the extraordinary burdens being shouldered by 
family caregivers of our Nation's latest generation of wounded 
warriors, and both seek to support these critical stakeholders in the 
rehabilitative process. Family caregivers, like their wounded warrior, 
often must adjust to their own ``new normal'' as they embark on what 
may be a lifetime of committed care for their veteran. The time has 
surely come to create a robust, nationwide wounded warrior family 
caregiver program to address the urgent needs of these family members. 
The establishment of such a program is Wounded Warrior Project's top 
legislative priority, and we offer our overwhelming support for S.801.
    Wounded Warrior Project knows firsthand the challenges these family 
members face. We work daily with thousands of our alumni to ensure they 
become the most successful and well adjusted wounded warriors in the 
Nation's history. Through our nationwide family caregiver outreach and 
retreat program, Wounded Warrior Project is gathering vital data needed 
to more appropriately support family caregivers in the rehabilitation 
of their wounded warriors. This program provides these caregivers much 
needed respite, counseling, and training. Family caregiver retreats are 
comprised of participants facing similar challenges based on their 
unique family roles and experiences. Separate retreats are organized 
for wives, mothers, and fathers of wounded warriors. Also, we will be 
holding a caregiver summit in Washington, DC, in late June, and we 
expect that our family caregivers will visit many of you on the 
Committee.
                 wounded warrior project supports s.801
    WWP strongly supports S.801, ``The Family Caregiver Program Act of 
2009.'' This bill reflects a keen understanding of the needs of both 
severely wounded warriors and the devoted loved ones who selflessly 
care for them. That understanding is reflected in the establishment of 
a program that would fully address the long unmet needs of family 
caregivers while ensuring the well-being of our most profoundly wounded 
warriors. Mr. Chairman, we applaud your leadership in taking up this 
important issue and working with the Ranking Member to craft this 
strong bill. Not only does S.801 meet a dire and well-established need, 
but it builds on an array of services--some of which are already 
provided at many, but not all, VA facilities. These services are simply 
not currently integrated in a comprehensive manner to support family 
caregivers.
    The Department of Veterans Affairs (VA) has mounted a number of 
pilot programs to assist family caregivers, and various elements of the 
VA system already provide many of the services family caregivers need. 
Thus, there already exists a strong foundation to take the next logical 
step and establish a nationwide program of comprehensive support. 
S.543, ``The Veteran and Servicemember Caregiver Act of 2009,'' would 
provide some of the supports we view as critical to sustain family 
caregiving. But the measure falls short. It would not provide family 
caregivers the full range of needed supports (providing simply for 
study with regard to needed respite and health care), and it is limited 
in scope to a two-year pilot program to be carried out at not fewer 
than six facilities. We believe that the time for pilot programs is 
past.
    S.801, in contrast, proposes just the type of comprehensive 
solution Wounded Warrior Project recommends and fully supports. Our 
wounded warriors and those family members who care for them have 
compelling needs. S.801 meets those needs head on. We commend the 
Chairman, the Ranking Member, and all the Committee co-sponsors for 
introducing this urgently needed legislation.
The Need for Family Caregiver Support
    While many wounded warriors substantially recover from their wounds 
and are able to live independently, some have sustained such profound 
injuries that they will likely need ongoing personal care and 
assistance for a very long time. These individuals usually want to 
return to, or remain in, their homes, and strongly resist being 
institutionalized. In-home care by a loved one also affords the wounded 
warrior greater access to community-based care, a right that has 
already been affirmed by the Supreme Court in its Olmstead v. L.C. 
decision. Most warriors want to be cared for by their loved ones, if 
possible, rather than by agency personnel. Most families want the same 
for their wounded warrior. But the extraordinary demands of caregiving 
invariably take a toll on family caregivers--physically, 
psychologically, emotionally, and financially.
    Our research makes one thing abundantly clear--very little 
institutional attention is being paid to family caregivers though they 
are a vital link in the veteran's rehabilitation process. The 
President's Commission on Care for America's Returning Wounded 
Warriors, the Dole-Shalala report, provided powerful data on the nature 
and magnitude of the problem. Among its findings, the Commission 
reported that:

     Among OEF/OIF servicemembers surveyed, ``33% of active 
duty, 22% of reserve component and 37% of retired/separated 
servicemembers report that a family member or close friend relocated 
for extended periods of time to be with them while they were in the 
hospital.''
     Among OEF/OIF servicemembers surveyed, ``21% of active 
duty, 15% of reserve component, and 24% of retired/separated 
servicemembers say friends or family gave up a job to be with them or 
act as their caregiver.''
The Well-Established Burden on Family Caregivers
    The impact of long-term caregiving on the families of severely 
disabled individuals in the general population has been extensively 
studied. These findings underscore the need wounded warrior family 
caregivers have for the array of services provided for in S.801.
    Studies indicate, for example, that proper caregiver training can 
reduce the chances of injury for both the caregiver and the recipient. 
They show further that well-trained caregivers are less likely to use 
costly, formal supports.
    Highlighting the need for access to counseling and other health 
care services, the studies also show that family caregivers experience 
an increased likelihood of stress, depression, and mortality as 
compared to their non-caregiving peers. Those who provide care 36 hours 
or more per week are more likely than non-caregivers to experience 
depression and anxiety. Women who provide that level of care to a 
disabled spouse are six times more likely to experience symptoms of 
depression and anxiety. Studies also suggest that with each incremental 
increase in assistance with activities of daily living (ADLs), spousal 
caregivers experience a greater risk for serious illness. Caregivers 
report poorer levels of perceived health, more chronic illnesses, and 
poorer immune responses to viral challenges.
    Finally, economic issues associated with caregiving cannot be 
ignored. The literature suggests that informal (unpaid) caregiving is 
incompatible with full-time employment. Research shows that even small 
reductions in work hours to provide unpaid care can result in 
significant lost wages and a reduction in the caregiver's future 
pensions and retirement savings. Also, while not specifically addressed 
in the research, a reduction in long-term wages will obviously result 
in a reduction in future social security benefits.
    Wounded Warrior Project works closely with the family caregivers of 
our wounded warriors and sponsors frequent caregiver retreats. We have 
learned firsthand that our caregivers experience the same profound 
challenges so thoroughly documented in the literature.
    Let me share just two examples from among the many with whom we 
work closely. In late 2005, one of our alumni was struck by an 
Improvised Explosive Device while serving in Iraq. He was permanently 
and totally blinded, has severe TBI, and is on medications to control 
seizures and a host of related issues. His wife was forced to leave her 
teaching job permanently to care for her husband. She is assisted daily 
by her mother. In the three years she has been a full-time caregiver, 
she has received no training of any kind, no supplemental income, and 
has health care coverage only because she is covered by TRICARE which 
does not extend to her mother. She was completely unaware of any VA 
respite care program when we interviewed her. She lives 90 miles from 
the nearest VA facility.
    The mother of one of our alumni lost her job after two months of 
caring for her son, a severely wounded warrior injured in April 2003, 
who requires full-time care. She only has health care coverage because 
she is covered by her husband's health care program, but they pay 
significant premiums for that care. They have gone from a two-income 
family to a one-income family. She has had a heart biopsy and heart 
catheterization done recently and states plainly that her caregiving 
activities are extremely stressful. She worries about their finances 
and health care coverage.
    The impact on family members such as these of having to care for 
severely wounded veterans for extended periods of time--and in many 
cases, for life--can be overwhelming. From the moment one or more 
family members meet their returning wounded warrior, they come face-to-
face with their ``new normal.''
    From the moment they are injured, the wounded warrior and their 
family members are forced to make decisions about who will provide 
routine, daily care. While the decision to care for a loved one--a 
commitment vital to that wounded warrior's recovery--may come easily, 
the burden of caregiving itself can take an enormous toll on the 
family. Family caregivers may be forced to take extended leaves of 
absence or permanently leave their jobs, losing retirement plans, 
health care plans, savings plans, and benefits plans in the process. In 
many cases, the wounded warrior requires personal assistance around the 
clock and may need specialized, daily care which the family caregiver 
is neither trained nor emotionally equipped to handle. At present, few 
family caregivers receive training, and they have no formal support 
network. Many have no access to health care, respite care, counseling, 
or a way to replace lost income.
The High Cost of Doing Nothing
    These family caregivers are, in many cases, the ``first 
responders'' to wounded veterans in need. They are often the first ones 
to detect new challenges to the veteran's rehabilitation and the ones 
most capable of implementing a positive response to those challenges. 
Without an appropriate level of support, many of these family 
caregivers will simply find themselves unable to cope. Over the long-
term, such a tragic outcome will ultimately result in an enormous cost 
to our wounded warriors, their families, and to the health care system 
which will likely be called upon to care for them.
    Setting aside the obligation we owe these warriors and their loved 
ones, the ultimate cost of failing to address the urgent needs of 
wounded warrior family caregivers is almost certainly much greater than 
the cost of establishing a comprehensive wounded warrior family 
caregiver program for all who need ongoing support. S.801 clearly 
recognizes this reality.
There is Currently no Comprehensive, Nationwide Wounded Warrior Family 
        Caregiver Program
    While S.801 envisions a comprehensive nationwide program, it is 
important to note that many VA medical centers already provide some of 
the very services and supports proposed in the bill, including respite 
care and family education and counseling. But none provide all of these 
services. Nor do they focus in a comprehensive, coordinated way on 
family caregivers. Family caregivers need more than piecemeal services 
and support. They have a profound need for the kind of robust national 
program proposed in S.801. Based on the experience of our wounded 
warriors, we believe such a program would contribute enormously to the 
recovery and rehabilitation of severely wounded warriors. Moreover, we 
believe it would avert what is otherwise likely to be a growing need 
for long-term institutional care. In short, establishing a 
comprehensive family caregiver program such as the one envisioned by 
S.801 is not only the right thing to do for our wounded warriors, but a 
fiscally prudent one.
    Given the handful of very limited and inconsistent wounded warrior 
family caregiver programs and support services now available, families 
are coping largely on their own. VA testified last year that it 
provides home health services to veterans in many areas through 
contract arrangements with some 4,000 home health agencies. But many of 
the families of our newest generation of wounded warriors consider such 
services--even if they are available locally--a poor alternative to the 
care provided by a devoted parent, sibling, spouse, or friend. Local 
services vary greatly in both quality and quantity. There is no 
nationwide training standard and no cultural training for local 
agencies addressing the unique needs of young, severely wounded 
veterans, particularly those with TBI, PTSD or other psychological 
health issues. Additionally, for family caregivers who need financial 
support to enable them to care for their wounded loved ones, VA has no 
answer other than to refer them to these same local agencies for 
possible employment.
    Legislation is now urgently needed to avert foreseeable family 
tragedies through creation of a nationwide, comprehensive wounded 
warrior family caregiver program such as the one proposed in S.801. At 
its core, this legislation would meet a vital need for those seriously 
wounded warriors who require extensive personal care. This legislation 
would provide an option not now available to many severely injured 
veterans whose families cannot meet or sustain their loved ones' 
caregiving needs.
S.801 Provides the Kind of Comprehensive Support that Family Caregivers 
        Need
    Informed by the experience of our wounded warriors and their 
families, Wounded Warrior Project enthusiastically supports passage of 
S.801. It lays a comprehensive and needed foundation for a VA-
administered family caregiver program comprised of three basic 
elements: training and certification, provision of support services, 
and a modest monthly allowance. Participation would be predicated on an 
objective, clinical determination of a veteran's need for extensive 
daily caregiving, and the family caregivers' capacity to provide the 
needed assistance.
    Under S.801, an individual who, with the veteran's assent, agrees 
to serve as the veteran's Primary Personal Care Attendant, and who 
successfully undergoes training and achieves certification, would be 
provided the support and services needed to sustain that role. This 
support and these services would include counseling and needed mental 
health services; technical support, including access to a Web portal 
linked to a wide range of nationwide family caregiver support services; 
30 days of annual respite care; CHAMPVA health care coverage; and a 
modest monthly allowance. Other family members can also receive basic 
family caregiver training, and, upon certification, have access to 
counseling and technical assistance.
    S.801 provides the full array of support needed by family 
caregivers while establishing a framework that balances the needs of 
the wounded warrior and the family caregiver. The legislation provides 
VA the needed latitude to design and administer the program, but also 
directs VA to consult with wounded warriors, family caregivers, VSO's 
and other pertinent organizations during the design and initial 
implementation phases.
    We anticipate that VA would employ an interdisciplinary process to 
determine the need for caregiving assistance. Such a process would 
include an objective assessment of the veteran's need for caregiving 
assistance in performing such routine activities of daily living as 
feeding, dressing, bathing and other personal hygiene needs. This 
assessment and a VA family caregiver recommendation would in no way 
obligate the family. It would simply provide the veteran and family an 
additional option where feasible and appropriate.
    VA would provide all training and certification at no expense to 
the servicemember or designated family caregiver. VA's responsibility 
to these family caregivers would not end with training and 
certification. S.801 sets the framework to provide direct technical 
support, including information, assistance, and counseling, and to 
address routine, emergency, and specialized caregiving needs in a 
timely manner.
    To be effective and sustaining, a family caregiver program design 
must address the intense burden of daily caregiving. S.801 does so by 
including such program elements as respite care of not less than 30 
days annually, to include 24-hour per day respite, tailored to meet 
each Primary Personal Care Attendant's needs.
    A viable program must also provide a means of protecting the health 
of a family caregiver who undertakes the weighty commitment of 
providing ongoing primary care of a wounded warrior. S.801 meets that 
important need by making Primary Personal Care Attendants eligible for 
medical care under the CHAMPVA program.
    Finally, cognizant that many family members must forego employment 
and often relocate to provide care to a loved one, the authors of S.801 
have met a critical need by providing the Primary Personal Care 
Attendant a modest monthly stipend based on the level of daily care 
provided. S.801 would direct VA to establish a schedule of allowances 
tied to the amount the Department would pay a commercial home health 
care agency to provide a commensurate level of personal, daily care 
authorized for that veteran.
    We should note that our focus on the importance of family caregiver 
assistance outlined in Section 3 of S.801 does not, in any way, 
indicate a lack of support for the other provisions of S.801. Section 2 
waives charges for humanitarian care provided to family members 
accompanying certain severely injured veterans receiving care at a VA, 
VA-contracted, or ``fee-basis'' facility. Section 4 authorizes VA to 
pay lodging and subsistence to attendants who travel with a disabled 
veteran to receive treatment at a VA facility. These additional 
proposals serve as logical, additional components of a nationwide 
family caregiver program, and have our full support.
    We welcome the opportunity to discuss the elements of S.801 in more 
detail, including what some families see as a need for greater 
flexibility in the bill's oversight provisions. But, above all, we urge 
the Committee to make enactment of S.801, ``The Family Caregiver 
Program Act of 2009,'' a top priority.

    Thank you for your interest in this important issue. I'm pleased to 
address any questions you or other Members of the Committee have at 
this time.

    [The paper referenced by Mr. Ibson follows:]

GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT


    Senator Begich. Thank you very much, Mr. Ibson.
    Mr. Ortner, before you start, I want to say I enjoyed 
playing in the poker tournament the Paralyzed Veterans 
Association had. I am glad I came in second. [Laughter.]
    Mr. Ortner. Well, we were glad to have you there.
    Senator Begich. It was a pleasure to be there. Please, your 
testimony.

  STATEMENT OF BLAKE C. ORTNER, SENIOR ASSOCIATE LEGISLATIVE 
            DIRECTOR, PARALYZED VETERANS OF AMERICA

    Mr. Ortner. Paralyzed Veterans of America would like to 
thank Chairman Akaka, Ranking Member Burr, and Members of the 
Committee for the opportunity to present our views on pending 
legislation before the Committee. Due to the number of bills 
today, I will limit my remarks to only a few, but want to 
assure the Committee that we are interested in all legislation 
dealing with our Nation's veterans.
    First, on behalf of Paralyzed Veterans of America and our 
20,000 members, I want to thank the Chairman, Ranking Member 
Burr, and other Members of the Committee for introducing and 
cosponsoring S. 423, the Veterans Health Care Budget Reform and 
Transparency Act of 2009. This legislation will reform the VA 
budget process by providing advance appropriations for veterans 
health care, ensuring timely and predictable funding for VA. We 
look forward to working with you to pass this critical 
legislation.
    PVA supports S. 821 to prohibit the Secretary of VA from 
collecting copayments from catastrophically disabled veterans, 
legislation critical to PVA members, many of whom receive 85 to 
90 percent of their care from VA. As Senator Sanders mentioned, 
PVA worked hard to ensure that those veterans with catastrophic 
disabilities were allowed to enroll in Priority Group 4, even 
though their disabilities were non-service-connected and 
regardless of income. However, unlike Category 4 veterans, they 
would still be required to pay fees and copayments. PVA 
believes this is unjust.
    VA recognizes these veterans' unique specialized status on 
the one hand by providing specialized service for them in 
accordance with its mission to provide for special needs. 
Unfortunately, these veterans are not casual users of VA health 
care. Because of the nature of their disabilities, they require 
a great deal of care and a lifetime of services. In most 
instances, the VA is the only and the best resource for a 
veteran with spinal cord injury. Because of the amount of care 
required, these copays rapidly add up.
    In the last Congress, a House bill received unanimous 
support from Republicans and Democrats as well as VA. 
Unfortunately, the Senate never took action on the measure and 
the legislation was never enacted. On March 5, 2009, Mrs. 
Halvorson introduced legislation in the House, H.R. 1335, that 
will again attempt to remove this burden. Together with S. 821, 
we hope to finally resolve this issue during the 111th 
Congress.
    Regarding family caregiver services, we applaud the 
introduction of both S. 801, the Family Caregiver Program Act 
of 2009, and S. 543, the Veteran and Servicemember Caregiver 
Support Act of 2009, and strongly support this legislation. 
This training and assistance is a critical aspect of preparing 
caregivers to care for a family member. The only concern that 
PVA would like to address is the significant use of the word 
``may'' instead of ``shall'' in requirements of the Secretary. 
Our fear is that if VA is faced with the budget challenges that 
inevitably will occur, the value of the caregiver programs may 
be lost as they fall under the budget axe.
    There are approximately 44 million individuals across the 
United States that serve as caregivers on a daily basis. Their 
contributions are invaluable economically as they obviate 
rising costs of traditional institutional care. The services 
rendered by caregivers are also priceless socially and 
emotionally as they allow ailing and disabled veterans to live 
more independently and often in their comfort of their own 
homes with friends and family.
    Many of the pieces of legislation being considered today 
have to do with increasing the number of health care 
professionals in the VA system, in particular, those in hard-
to-serve areas. PVA's primary concern and the basic reason for 
our existence is the health and welfare of our members and our 
fellow veterans. The thousands of VA health care professionals 
and those individuals necessary to support their efforts are 
the core of VA's primary mission.
    PVA appreciates the comprehensive nature of S. 252 and 
supports the overall provisions of the legislation. It clearly 
outlines multiple approaches to increasing the competitiveness 
of VA for hiring health care providers. These programs will 
provide incentives for new hires or to keep already skilled 
employees in the VA system.
    Contributing to the problem for veterans is the need for 
care in rural America. Forty percent of nearly two million VA 
health care users reside in rural areas and 44 percent of newly 
returning veterans from OEF and OIF live in rural areas. PVA 
supports the provisions of S. 246, S. 734, and S. 658.
    Finally, the number of rural veterans is increasing, but in 
addition, there has been a dramatic increase in the number of 
women veterans now using VA facilities. PVA fully supports S. 
597, the Women's Veterans Health Care Improvement Act of 2009, 
language that has been incorporated into S. 252. Women have 
played a vital part in the military service throughout our 
history and current estimates indicate that there are 1.8 
million women veterans, comprising nearly 8 percent of the U.S. 
veterans population. VA must act now to prepare to meet the 
specialized needs of women who have served.
    PVA sincerely appreciates the opportunity to provide our 
views on this important legislation and would also like to 
point out that much of the legislation presented today is 
discussed in greater detail in the current edition of the 
Independent Budget.
    This concludes my testimony. I would be happy to answer any 
questions you may have.
    [The prepared statement of Mr. Ortner follows:]
  Prepared Statement of Blake C. Ortner, Senior Associate Legislative 
                Director, Paralyzed Veterans of America
    Chairman, Akaka, Ranking Member Burr, and Members of the Committee, 
on behalf of Paralyzed Veterans of America (PVA), I would like to thank 
you for the opportunity to present our views on pending legislation 
before the Committee. We hope that the Senate Committee on Veterans' 
Affairs will take our concerns under consideration as it moves its 
legislation forward in the 111th Congress. Mr. Chairman, we appreciate 
the legislative successes that veterans have realized under your 
leadership and we look forward to continued success in the future. PVA 
continues to work on issues important to our members, veterans with 
spinal cord injury or dysfunction, specifically, and to all veterans.
          s.423--the ``veterans health care budget reform and 
                       transparency act of 2009''
    Chairman, Akaka, on behalf of PVA and our 20,000 members, I want to 
thank you and the other Members of the Committee, for introducing 
S.423, the ``Veterans Health Care Budget Reform and Transparency Act of 
2009,'' that will reform the Department of Veterans Affairs (VA) budget 
process by providing advance appropriations for veterans' health care. 
Your legislation was developed in consultation with the Partnership for 
Veterans Health Care Budget Reform (the Partnership)--a group that 
consists of nine major veterans service organizations, including 
Paralyzed Veterans of America. For more than a decade, the Partnership 
has worked to achieve a sensible and lasting reform of the funding 
process for veterans' health care. While the Partnership has long 
advocated converting VA's medical care funding from discretionary to 
mandatory funding, there has been virtually no movement in Congress in 
this direction.
    The Veterans Health Care Budget Reform and Transparency Act would 
ensure that the goals of the Partnership--sufficient, timely, and 
predictable funding--are met. Historically, advance appropriations have 
been used to make a program function more effectively, better align 
with funding cycles of program recipients, or provide insulation from 
annual partisan political maneuvering. By moving to advance 
appropriations, veterans' health care programs will accrue all three of 
these benefits.
    To enhance the budget process even further, the legislation 
includes provisions to add transparency and oversight to VA's internal 
budget forecasting model. Due to the complex nature of VA's 
actuarially-based Model, S.423 will require GAO to conduct an annual 
audit and assessment of the Model to determine its validity and 
accuracy, as well as assess the integrity of the process and the data 
upon which it is based. GAO would submit public reports to Congress 
each year that would assess the Model and include an estimate of the 
budget needs for VA's medical care accounts for the next two fiscal 
years. Providing Congress with access to the Model and its estimates of 
VA health care's resource needs, would create greater confidence in the 
accuracy of advance appropriations for veterans' medical care, as well 
as validate future requests for emergency supplemental appropriations.
    Additionally, the Senate budget committee agreed with the value of 
advance appropriations for VA and included language in their recent 
budget resolution calling for advance appropriations for the VA medical 
care appropriation. Moreover, President Obama recently reaffirmed his 
support for advance appropriations. PVA strongly supports S.423.
    s.821--elimination of co-payments for priority group 4 veterans
    PVA supports S.821, to prohibit the Secretary of VA from collecting 
co-payments from catastrophically disabled veterans and we applaud 
Senator Sanders for introducing this important and overdue legislation. 
This legislation is critical to PVA members, many of whom receive 85 to 
90 percent of their care from the VA.
    In 1985, Congress approved legislation which opened the VA health 
system to all veterans. In 1996, Congress again revised that 
legislation with a system of rankings establishing priority ratings for 
enrollment. Within that context, PVA worked hard to ensure that those 
veterans with catastrophic disabilities would be placed in a higher 
enrollment category. To protect their enrollment status, veterans with 
catastrophic disabilities were allowed to enroll in Priority Group Four 
even though their disabilities were non-service-connected and 
regardless of their incomes. However, unlike other Category Four 
veterans, if they would otherwise have been in Category Seven or Eight, 
due to their incomes, they would still be required to pay all fees and 
co-payments, just as others in those categories do now for every 
service they receive from VA.
    PVA believes this is unjust. VA recognizes these veterans' unique 
specialized status on the one hand by providing specialized service for 
them in accordance with its mission to provide for special needs. The 
system then makes them pay for those services. Unfortunately, these 
veterans are not casual users of VA health care services. Because of 
the nature of their disabilities they require a lot of care and a 
lifetime of services. In most instances, VA is the only and the best 
resource for a veteran with a spinal cord injury, and yet, these 
veterans, supposedly placed in a higher priority enrollment category, 
have to pay fees and co-payments for every service they receive as 
though they had no priority at all.
    We were pleased that the House Committee on Veterans' Affairs 
approved and the House of Representatives eventually passed 
legislation--H.R. 6445--to eliminate this financial burden placed on 
catastrophically disabled veterans during the 110th Congress. In fact, 
the House bill received unanimous support from Republicans and 
Democrats as well as the VA. Unfortunately, the Senate never took 
action on the measure and the legislation was never enacted. On March 
5, 2009, Mrs. Halvorson introduced legislation in the House of 
Representatives, H.R. 1335, that will again attempt to remove this 
unjust burden. Together with S.821, we hope that with your leadership, 
we will finally be able to resolve this issue during the 111th 
Congress.
          s.801--the ``family caregiver program act of 2009''
 s.543--the ``veteran and servicemember caregiver support act of 2009''
    Regarding family caregiver services, we applaud the introduction of 
both S.801, the ``Family Caregiver Program Act of 2009'' and S.543, the 
``Veteran and Servicemember Caregiver Support Act of 2009'' and 
strongly support the legislation. While we believe S.543 certainly 
expands caregiver assistance opportunities, we prefer the provisions of 
S.801 because it is more broadly focused. This training and assistance 
is a critical aspect of preparing caregivers to care for a family 
member. PVA would like to thank the congressional staffs for their work 
on both S.801 and S.543 to insure these critical issues are properly 
addressed. The only concern that PVA would like to address in the 
legislation is the significant use of the word ``may'' instead of 
``shall'' in areas identifying requirements of the Secretary. Our fear 
is that if VA is faced with the budget challenges that inevitably will 
occur, will all the value of the caregiver programs be lost as they 
fall to the budget ax. This must not be allowed to happen.
    There are approximately 44 million individuals across the United 
States that serve as caregivers on a daily basis. The contributions of 
caregivers in today's society are invaluable economically as they 
obviate the rising costs of traditional institutional care. The 
services rendered by caregivers are also priceless socially and 
emotionally, as they allow ailing and disabled veterans to live more 
independently and often in the comfort of their own homes with their 
friends and family.
    As the veteran community is aware, family caregivers also provide 
mental health support for veterans dealing with the emotional, 
psychological, and physical effects of combat. Many PVA members with 
spinal cord injury also have a range of co-morbid mental illnesses, 
therefore, we know that family counseling and condition specific 
education is fundamental to the successful reintegration of the veteran 
into society. Providing education and training to family caregivers 
will pay dividends in care well beyond any costs associated with the 
program.
    The aspects of personal independence and quality care are of 
particular importance to veterans with spinal cord injury/dysfunction. 
Paralyzed Veterans has over 60 years of experience understanding the 
complex needs of spouses, family members, friends, and personal care 
attendants that love and care for veterans with life long medical 
conditions. As a result of today's technological and medical advances, 
veterans are withstanding combat injuries and returning home in need of 
medical care on a consistent basis. Such advances are also prolonging 
and enhancing the lives and physical capabilities of injured veterans 
from previous conflicts. No matter the progress of modern science, 
these veterans need the health-care expertise and care from a health 
team comprised of medical professionals, mental health professionals, 
and caregivers. As a part of the health care team, caregivers must 
receive ongoing support to provide quality care to the veteran. It is 
for this reason, we are happy to see that S.801 includes provisions for 
conducting caregiver assessments that identify the needs and problems 
of caregivers currently caring for veterans. The VA must also work to 
enforce and maintain an efficient case management system that assists 
veterans and family caregivers with medical benefits and family support 
services.
    Our experience has shown that when the veteran's family unit is 
left out of the treatment plan, the veteran suffers with long 
reoccurring medical and social problems. However, when family is 
included in the health plan through services such as VA counseling and 
education services, veterans are more apt to become healthy, 
independent, and productive members of society.
                    s.772--the ``honor act of 2009''
    PVA supports this legislation and would like to thank Senator Bond 
for his introduction of S.772, the ``Honor Act of 2009.'' Mental health 
issues continue to be a growing problem for those who have witnessed 
the horrors and traumatic events of war. Evidence continues to show 
that the prevalence of mental illness is high in veterans who have 
served in Iraq and Afghanistan. Combat exposure coupled with long and 
frequent deployments are associated with an increased risk for Post 
Traumatic Stress Disorder (PTSD) and other forms of mental illness. In 
fact, the VA reports that Operation Enduring Freedom and Operation 
Iraqi Freedom (OEF/OIF) veterans have sought care for a wide array of 
possible co-morbid medical and psychological conditions, including 
adjustment disorder, anxiety, depression, PTSD, and the effects of 
substance use disorder.
    The impact of a veteran's mental illness is far reaching and 
obviously has serious consequences for the individual veteran being 
affected, but perhaps less obvious are the serious consequences, 
stemming from a veteran's mental illness, that confront his or her 
spouse, their children and other family members. With this in mind, 
Paralyzed Veterans believes that Congress should formally authorize, 
and VA should provide, a full range of psychological and social support 
services as an earned benefit to family and non-family caregivers of 
severely injured and ill veterans.
    The scholarships and other provisions of S.772 create opportunities 
to increase the number of mental health professionals to provide for 
veterans with mental health challenges. Additionally, we applaud 
provisions expanding Vet Center opportunities for those who would not 
be authorized counseling services. But PVA believes that Vet Centers 
should also increase coordination with VA medical centers to accept 
referrals for family counseling; increase distribution of outreach 
materials to family members with tips on how to better manage the 
dislocation; improve reintegration of combat veterans who are returning 
from deployment; and provide information on identifying warning signs 
of suicidal ideation so veterans and their families can seek help with 
readjustment issues. PVA believes that an effective mental illness 
family counseling and education program can improve treatment 
outcomes for veterans, facilitate family communication, increase 
understanding of mental illness, and increase the use of effective 
problem solving and reduce family tension.
          s.669--the ``veterans 2nd amendment protection act''
    Regarding S.669, the ``Veterans 2nd Amendment Protection Act,'' PVA 
has not taken a position on this legislation.
     s.252--the ``veterans health care authorization act of 2009''
      s.246--the ``veterans health care quality improvement act''
    PVA's primary concern, and the basic reason for our existence, is 
the health and welfare of our members and our fellow veterans. The 
thousands of VA healthcare professionals and all of those individuals 
necessary to support their efforts are at the core of VA's primary 
mission. These individuals serve on the front line every day, caring 
for America's wounded veterans from Iraq and Afghanistan and seeing to 
the complex medical needs of our countries older veterans from previous 
wars. PVA believes that VA's most important asset is the people it 
employs to care for those who have served our Nation. By the number of 
bills today regarding the subject of staffing of VA, we can see it is 
of concern to the Committee as well.
    Mr. Chairman, PVA appreciates the comprehensive nature of S.252, 
the ``Veterans Health Care Authorization Act of 2009'' and supports the 
overall provisions of the legislation. It clearly outlines multiple 
approaches to increasing the competitiveness of VA for hiring health 
care providers including changes to pay computation, exemptions from 
limitations on competitive pay and opportunities for additional nurse 
pay. In addition, changes to educational assistance programs and 
employee retention programs will provide incentives to keep those 
already skilled employees in the VA system.
    Given the Veterans Health Administration's (VHA) leadership 
position as a health system, it is imperative that VA aggressively 
recruit health care professionals and work within established 
relationships with academic affiliates and community partners to 
recruit new employees. In order to make gains on these needs, VA must 
update and streamline its human resource processes and policies to 
adequately address the needs of new graduates in the health sciences, 
recruits, and current VA employees. Today's health care professionals 
and other staff who work alongside them need improved benefits, such as 
competitive salaries and incentives, child care, flexible scheduling, 
and generous educational benefits. VA must actively address the factors 
known to affect current recruitment and retention, such as fair 
compensation, professional development and career mobility, benevolent 
supervision and work environment, respect and recognition, technology, 
and sound, consistent leadership, to make VA an employer of choice for 
individuals who are offered many attractive alternatives in other 
employment settings.
    The United States is currently in the tenth year of a critical 
nursing shortage which is expected to continue through 2020. The 
shortage of registered bed-side nurses and registered nurse specialists 
is having an impact on all aspects of acute and long-term care. 
America's nursing shortage has created nurse recruitment and retention 
challenges for medical care employers nationwide and is making access 
to quality care difficult for consumers.
    VA's ability to sustain a full complement of highly skilled and 
motivated personnel will require aggressive and competitive employment 
hiring strategies that will enable it to successfully compete in the 
national labor market. VA's employment success within the VHA will 
require constant attention by the very highest levels of VA leadership. 
Additionally, Members of Congress must understand the gravity of VA 
personnel issues and be ready to provide the necessary support and 
oversight required to ensure VA's success. The legislation presented 
today demonstrates without doubt that the Committee understands these 
issues.
    PVA is concerned about the VA's current ability to maintain 
appropriate and adequate levels of physician staffing at a time when 
the Nation faces a pending shortage of physicians. Recent analysis by 
the Association of American Medical Colleges (AAMC) indicates the 
United States will face a serious doctor shortage in the next few 
decades. The AAMC goes on to say that currently, ``744,000 doctors 
practice medicine in the United States, but 250,000--one in three are 
over the age of 55 and are likely to retire during the next 20 years.'' 
The subsequent increasing demand for doctors, as many enter retirement, 
will increase challenges to VA's recruitment and retention efforts.
    Contributing to the problem for veterans is the need for care in 
rural America. The tremendous increase in veterans due to the wars in 
Afghanistan and Iraq is leading to greater numbers of veterans located 
in rural areas where only 10 percent of physicians practice. 
Additionally, those living in rural areas generally are more likely to 
live below the poverty line.
    Because 40 percent of nearly 2 million VA health care users reside 
in rural areas, including 80,000 who live in highly rural areas, they 
often have worse physical and mental health quality-of-life. 
Exacerbating the problem is that 44 percent of newly returning veterans 
from OEF/OIF live in rural areas. While VA may be working in good faith 
to address its shortcomings in rural areas, it clearly still faces 
major challenges and hurdles.
    PVA supports the provisions of S.246, including loan repayment, 
tuition reimbursement and other incentives, if fully implemented, 
should help alleviate some level of this challenge by providing 
incentives to physicians to accept service in hard-to-fill positions. 
We applaud Senator Durbin for his far reaching initiative to provide 
for all veterans, even though they may live far from our urban centers.
    Mr. Chairman, we also applaud the inclusion of language from S.246 
in S.252 to insure the disclosure of certain physician information 
before their appointment to VA regarding lawsuits and civil actions 
against the individual for medical malpractice. Physicians providing 
care to our honored veterans must be of the highest quality. PVA 
understands that in this era of often frivolous medical lawsuits, 
physicians may be challenged and may settle lawsuits for which there 
was no medical wrongdoing. PVA believes the best way to guarantee the 
highest quality of physician in the VA system is to be forthright with 
information and allow the full examination of the record to prevent any 
future doubts. Additionally, the establishment of Quality Management 
Officers as outlined in both S.252 and S.246 should help insure the 
highest quality of care is provided to our veterans.
    PVA strongly supports provisions of S.252 regarding Nonprofit 
Research and Education Corporations. This legislation will modernize 
and clarify the existing statutory authority for VA-affiliated 
nonprofit research and education corporations (NPCs). This bill will 
allow the NPCs to fulfill their full potential in supporting VA 
research and education, which ultimately results in improved treatments 
and high quality care for veterans, while ensuring VA and congressional 
confidence in NPC management.
    Since passage of Public Law 100-322 in 1988 (codified at 38 U.S.C. 
Sec.  7361-7368), the NPCs have served as an effective ``flexible 
funding mechanism for the conduct of approved research and education'' 
performed at VA medical centers across the Nation. NPCs provide VA 
medical centers with the advantages of on-site administration of 
research by nonprofit organizations entirely dedicated to serving VA 
researchers and educators, but with the reassurance of VA oversight and 
regulation. During 2007, 85 NPCs received nearly $230 million and 
expended funds on behalf of approximately 5,000 research and education 
programs, all of which are subject to VA approval and are conducted in 
accordance with VA requirements.
    NPCs provide a full range of on-site research support services to 
VA investigators, including assistance preparing and submitting their 
research proposals; hiring lab technicians and study coordinators to 
work on projects; procuring supplies and equipment; monitoring the VA 
approvals; and a host of other services so the principal investigators 
can focus on their research and their veteran patients.
    Beyond administering research projects and education activities, 
when funds permit, these nonprofits also support a variety of VA 
research infrastructure expenses. For example, NPCs have renovated 
labs, purchased major pieces of equipment, staffed animal care 
facilities, funded recruitment of clinician-researchers, provided seed 
and bridge funding for investigators, and paid for training for 
compliance 
personnel.
    Although the authors of the original statute were remarkably 
successful in crafting a unique authority for VA medical centers, 
differing interpretations of the wording and the intent of Congress, 
gaps in NPC authorities that curtail their ability to fully support VA 
research and education, and evolution of VA health care delivery 
systems have made revision of the statute increasingly necessary in 
recent years. S.252 will allow the NPCs to better serve VA research and 
education programs while maintaining the high degree of oversight 
applied to these nonprofits.
    The legislation reinforces the idea of ``multi-medical center 
research corporations'' which provides for voluntary sharing of one NPC 
among two or more VA medical centers, while still preserving their 
fundamental nature as medical center-based organizations. Moreover, 
accountability will be ensured by requiring that at a minimum, the 
medical center director from each facility must serve on the NPC board. 
This authority will allow smaller NPCs to pool their administrative 
resources and to improve their ability to achieve the level of internal 
controls now required of nonprofit organizations.
    The legislation also clarifies the legal status of the NPCs as 
private sector, tax-exempt organizations, subject to VA oversight and 
regulation. It also modernizes NPC funds acceptance and retention 
authorities as well as the ethics requirements applicable to officers, 
directors and employees and the qualifications for board membership. 
Moreover, it clarifies and broadens the VA's authority to guide 
expenditures.
    PVA has been a strong supporter of the NPCs since their inception, 
recognizing that they benefit veterans by increasing the resources 
available to support the VA research program and to educate VA health 
care professionals.
    s.597--the ``women veteran health care improvement act of 2009''
    As stated above, the number of rural veterans is increasing, but in 
addition, there has been a dramatic increase in the number of women 
veterans now using VA facilities. PVA fully supports S.597, the ``Women 
Veterans Health Care Improvement Act of 2009,'' language that has been 
incorporated into S.252. Women have played a vital part in the military 
service throughout our history. In the last 50 years their roles, 
responsibilities, and numbers have significantly increased. Current 
estimates indicate that there are 1.8 million women veterans comprising 
nearly 8 percent of the United States veteran population. According to 
Department of Defense (DOD) statistics, women servicemembers represent 
15 percent of active duty forces, 10 percent of deployed forces, 20 
percent of new recruits, and are a rapidly expanding segment of the 
veteran population.
    Historically, women have represented a small numerical minority of 
veterans who receive health care at VA facilities. However, if women 
veterans from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/
OIF) continue to enroll at the current enrollment rate of 42.5 percent, 
it is estimated that the women using VA health care services will 
double in two to four years.
    As the population of women veterans undergoes exponential growth in 
the next decade, VA must act now to prepare to meet the specialized 
needs of the women who served. Overall the culture of VA needs to be 
transformed to be more inclusive of women veterans and must adapt to 
the changing demographics of its women veteran users--taking into 
account their unique characteristics as young working women with 
childcare and eldercare responsibilities. VA needs to ensure that women 
veterans' health programs are enhanced so that access, quality, safety, 
and satisfaction with care are equal for women and men.
    This legislation is meant to expand and improve health care 
services available in the VA to women veterans, particularly those who 
have served in OEF/OIF. More women are currently serving in combat 
theaters than at any other time in history. As such, it is important 
that the VA be properly prepared to address the needs of what is 
otherwise a unique segment of the veteran population.
    Title I of S.597 would authorize a number of studies and 
assessments that would evaluate the health care needs of women 
veterans. Furthermore, these studies would also identify barriers and 
challenges that women veterans face when seeking health care from the 
VA. Finally, the VA would be required to assess the programs that 
currently exist for women veterans and report this status to Congress. 
We believe each of these studies and assessments can only lead to 
higher quality care for women veterans in the VA. They will allow the 
VA to dedicate resources in areas that it must improve upon.
    Title II of the bill would target special care needs that women 
veterans might have. Specifically, it would ensure that VA health care 
professionals are adequately trained to deal with the complex needs of 
women veterans who have experienced sexual trauma. Furthermore, it 
would require the VA to develop a pilot program to evaluate the 
feasibility and advisability of providing reintegration and 
readjustment services to recently separated women veterans in a retreat 
setting. Additionally, the legislation calls for the inclusion of 
recently separated women veterans on advisory committees to allow them 
to provide their unique perspective as veterans issues are considered. 
This together with programs to subsidize child care for certain women 
veterans receiving health care and those receiving maternity care, will 
provide an excellent environment that considers the unique needs of 
women veterans. While many veterans returning from OEF/OIF are 
experiencing symptoms consistent with PTSD, women veterans are 
experiencing unique symptoms also consistent with PTSD. It is important 
that the VA understand these potential differences and be prepared to 
provide care.
    PVA views this proposed legislation as necessary and fully supports 
the Chairman's decision to include the language of S.597 within S.252. 
The degree to which women are now involved in combat theaters must be 
matched by the increased commitment of the VA, as well as the 
Department of Defense, to provide for their needs when they leave the 
service. We cannot allow women veterans to fall through the cracks 
simply because programs in the VA are not tailored to the specific 
needs that they might have. Finally, we would encourage the Committee 
to review the extensive policy section in the FY 2010 edition of The 
Independent Budget--``Women Veterans' Health and Health Care 
Programs.''
  s.793--the ``department of veterans affairs vision scholars act of 
                                 2009''
    As in previous bills, S.793, the ``Department of Veterans Affairs 
Vision Scholars Act of 2009,'' provides increased services for an 
additional at-risk group, veterans with vision impairments. PVA has 
consistently supported the protection of specialized services and 
supports S.793. As with other specialty fields, VA suffers from a 
shortage of blind rehabilitation specialists. The scholarship program 
proposed in this legislation should encourage individuals to enter this 
field to provide rehabilitation services to veterans with visual 
impairments. However, it is critical that the provisions of the 
legislation concerning outreach and the publication of the program be 
aggressively pursued. Those who may take advantage of the scholarship 
program will be unable to if they do not know about it.
     s.362--to improve collective bargaining rights and procedures
    PVA supports S.362 introduced by Sen. Rockefeller that will more 
quickly resolve adverse actions and set deadlines for final decisions.
   s.734--the ``rural veterans health care access and quality act of 
                                 2009''
   s.658--the ``rural veterans health care improvement act of 2009''
    PVA recognizes that there is no easy solution to meeting the needs 
of veterans who live in rural areas. These veterans were not originally 
the target population of men and women that the VA expected to treat. 
However, the VA decision to expand to an outpatient network through 
community-based outpatient clinics reflected the growing demand on the 
VA system from veterans outside of typical urban or suburban settings. 
As discussed previously regarding S.246, 40 percent of nearly 2 million 
VA health care users reside in rural areas, with 44 percent of newly 
returning veterans from OEF/OIF living in rural areas.
    PVA supports S.734, the ``Rural Veterans Health Care Access and 
Quality Act of 2009,'' and its provisions to increase the number of 
health care professionals in rural areas. Enhancement of the education 
debt reduction program at VA for those who accept placement in rural 
areas is an efficient method, though it is only one method. In 
addition, the pilot program on incentives for physicians who assume 
inpatient responsibilities may also encourage health care professionals 
to locate in rural areas. But these are short term fixes. For this 
reason we welcome the legislation's call for a five-year strategic plan 
by VA with goals for recruitment and retention of health care personnel 
in rural areas. The challenge of this problem must be met by multiple 
solutions. The inclusion of legislative provisions to expand 
teleconsultation and telemedicine can help to provide services that may 
not be generally available to rural communities.
    PVA supports S.658, the ``Rural Veterans Health Care improvement 
Act of 2009,'' which includes additional methods for improving rural 
health care. The creation by VA of Centers of Excellence for rural care 
research, education and clinical activities may help shed light on how 
best to provide services in rural areas. PVA supports the oversight of 
these centers by the Director of the Office of Rural Health (ORH) and 
encourage close coordination among the centers and the ORH if more than 
one center is established. The most important provision may be to 
develop and implement innovative clinical activities and systems of 
care for veterans in rural areas. In addition, demonstration projects 
on alternatives for expanding care may be beneficial. While all these 
ideas are welcome, the greatest need still is for qualified health care 
providers to be located in rural settings. Only significant incentives 
and opportunities for these professionals will bring them to these 
often remote areas.
    PVA also supports the provisions of S.658 dealing with our Native 
American veterans by establishing Indian Veterans Health Care 
Coordinators as well as provisions for a program of readjustment and 
mental health care services to veterans who have served in Operation 
Iraqi Freedom and Operation Enduring Freedom.
      s.404--the ``veterans' emergency care fairness act of 2009''
    Mr. Chairman, PVA strongly supports S.404, the ``Veterans' 
Emergency Care Fairness Act of 2009'' which will remove an unfair 
burden on our veterans. The legislation will expand eligibility for 
emergency medical care for some veterans. Currently, veterans who have 
a third-party insurance provider that pays a portion of medical 
expenses in the event of an emergency, do not have the balance of their 
medical expenses covered by the VA. Having the VA function as a 
secondary payer should eliminate that situation. It will prevent the VA 
from denying payment for emergency service at non-VA hospitals when a 
veteran is partially covered by their third-party insurance.
   s.498--authorize dental insurance for veterans and survivors and 
                               dependents
    Regarding S.498, legislation to authorize dental insurance for 
veterans and survivors and dependents of veterans, PVA recommends 
caution in pursuing this legislation. We are concerned with the 
provisions which appear to establish VA as an insurance company, with 
the Secretary providing dental insurance, identifying dental benefits 
and treatment, establishing premium rates and managing enrollment and 
disenrollment. S.252 includes similar language, but establishes the 
program as a pilot. This is a direction that PVA believes is 
inappropriate for VA. If this need is sufficiently significant for VA 
to establish an insurance program, PVA recommends that existing VA 
facilities and capability be expanded to meet this need.
           s.239--the ``veterans health equity act of 2009''
    The intent of S.239, the ``Veterans Health Equity Act of 2009,'' is 
to ensure veterans receive care close to their homes to avoid the time 
and health hazards of traveling long distances for care. Though the 
idea of contract care for those displaced from VA facilities appears 
like the simple and obvious choice, there are many drawbacks with the 
use of VA contracting authority.
    VA already has contracting ability, but it is generally limited to 
care VA cannot provide at its facilities. Allowing an expansion of this 
authority to provide for general care has the potential to result in 
the decline of VA as a system of care for veterans as more and more 
locations seek to provide care closer to the veteran and away from VA 
facilities. PVA believes that while this may be useful for some 
veterans, those with the greatest need for VA care, those with 
catastrophic spinal cord injuries and disease and other specialized 
services that depend on a well funded VA system, will see reduced 
availability of services provided most effectively by VA.
    While PVA is seriously concerned about the ability of VA to 
continue providing high quality specialized services, we also recognize 
the serious challenges faced by veterans in states with limited VA 
facilities. PVA acknowledges something must be done, and it is VA's 
responsibility to determine what steps should be taken to address this 
problem. Mr. Chairman, we would encourage VA to examine possible 
alternatives to provide care that will not damage or interfere with the 
care system and services currently provided to veterans. Though PVA 
believes that any outside contract care which meets the standard of VA 
services will be more expensive, an examination of this option, with 
appropriate coordination of care to ensure veterans are receiving the 
best care possible, may be an option for a future program. However, any 
pilot or demonstration program implemented by VA should use separately 
designated and appropriated funds outside of VA's normal budget and 
must ensure coordination with VA to maintain a continuity of records 
between contract care providers and VA to protect veterans when they 
return to a regular VA care facility.
    In a time of tight budgets and increasing need due to returning 
Afghanistan and Iraq combat veterans, the pressures on VA to find less 
expensive and more widely available methods to provide care for these 
veterans can become overwhelming. But any modifications to VA care must 
ensure that veterans most in need of the specialized care provided best 
by VA do not suffer from any changes made to the system.
 s.226--merril lundman department of veterans affairs outpatient clinic
      s.509--authorize medical facility in walla walla, washington
       s.699--far south texas veterans medical center act of 2009
    PVA has no position on these proposed bills. All deal specifically 
with local issues or needs and we believe they should be considered 
within the local needs for facilities and the ability to provide 
veterans' services. PVA believes naming issues should be considered by 
the local community with input from veterans organizations within that 
community. For construction projects and the authorization of new 
facilities, PVA believes that if a demonstrated need exists, VA should 
establish facilities that will provide the best care for veterans in 
the area.
    Mr. Chairman, PVA sincerely appreciates the opportunity to provide 
our views on this important legislation and would be pleased to provide 
any additional information. We would also point out that much of this 
legislation is discussed in much greater detail in the 23rd edition of 
The Independent Budget.

    This concludes my testimony and I will be happy to answer any 
questions you may have.

    Senator Begich. Thank you very much.
    Senator Burr, do you want to start with questions?
    Senator Burr. Thank you, Mr. Chairman.
    I would like to thank all of our witnesses on the second 
panel for your valuable testimony and the insight that all 
bring to the table on the issues. I am going to focus on two 
areas very quickly, and I am going to pick on you, Adrian. I 
could ask the guys at the end of the table down here, but I am 
going to spare them.
    Does the DAV think it is appropriate that the names of 
service-disabled veterans are sent to NICS when Social Security 
recipients aren't for the same circumstances?
    Mr. Atizado. Well, sir, I appreciate the question in light 
of my colleagues at the end of the table. In our testimony, if 
you will note that we don't have a resolution on this issue. 
Whether or not our organization would support or oppose a bill 
really depends on what our membership passes at our national 
convention, and since we don't have a resolution on this 
specific matter, we can't take a position on the bill, Senator.
    Senator Burr. And I appreciate that. I know how the member 
organizations operate up here--let me just say for the benefit 
of all three--because there were no positions from any.
    I think that when you have a population that entrusts you 
with the issues that are of great importance to them, when you 
have one that I think is a constitutional question, I think you 
have to go above and beyond to sell to the members why their 
voice should be heard. I am not sure that there is any veteran 
of the 117,000 that are out there that are sitting at home 
saying, ``You know what? This was appropriately applied to 
me.'' And I am not sure that members of all the organizations 
aren't sitting at home saying, ``I hope that never happens to 
me.'' I am not sure that anybody is wishing this to happen.
    This needs to be reversed. It does. And I think that every 
organization that represents veterans should look at this as a 
potential loss of their individual rights and engage their 
membership. Granted, it is not number 1 on everybody's list; I 
understand that. But I don't think we have the ability to pick 
and choose which ones we are going to be engaged in and which 
ones we are not. So, I hope you will take it back to the annual 
meeting and propose that you do take a position as strongly as 
you can. And Blake, also with you; and Ralph, if appropriate, 
with you.
    If I didn't miss anything, I think most of you were 
supportive of the Family Caregiver Act and I believe that this 
is vitally important that we move forward.
    I will defend the VA for a little bit. They had many more 
responsibilities and they have got to make sure that the 
overall architecture that they set up continues to work and 
function. And I think that it puts a higher threshold on the 
Chairman and me to work with VA to make sure that what we are 
attempting to do works within that framework, and I pledge to 
them to continue to do that.
    But I also pledge to you that at the end of the day, we are 
going to have a caregiver program that provides for those 
family members that choose to take care of their loved ones. I 
think it is in the best interest of those veterans who have 
been injured. It is in the best interest of the family that 
feels the closest to them and desires the most--as much of a 
recovery that they possibly can have. And clearly, since we 
offer this to other populations in America--typically that care 
is extended through Medicaid in different fashions determined 
by States--I don't know why the Veterans Administration should 
be excluded from it.
    So, I appreciate the comments all of you have made. Where 
you still have issues that are thorny or rough, I look forward 
to working with you on any language where we might need to make 
changes to smooth that out. Once again, I thank you.
    Senator Begich. Thank you very much, Senator Burr.
    I have a 4:30, so I am going to ask a couple of questions, 
and then, Senator Burr, I will come back to you for any 
additional questions; and then I will close it off.
    I do have a couple of questions that the Chairman wanted to 
ask, so I am going to ask them on his behalf. The first one is 
to Mr. Ortner. The PVA testified in 2007 against the VA 
partnering with the Centers for Medicare and Medicaid Services 
to utilize critical access hospitals. Does the organization 
still object to that or have they modified their position, or 
are you aware of that?
    Mr. Ortner. I am not aware. I would be happy to take that 
for the record and I will go back and we will get an answer for 
the Chairman.
    Senator Begich. That would be great. That was a couple of 
years ago and there may have been a change since then. But if 
you could follow that up and give it to the Committee, that 
would be fantastic.
    Mr. Ortner. And I wasn't present at PVA at the time that 
was testified.
    Senator Begich. I love it. We newbies. I get to say, that 
all happened last year; I wasn't here. So I am with you on 
that. But thank you very much.
    [Response to the request follows:]

                             Paralyzed Veterans of America,
                                      Washington, DC, May 20, 2009.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: Thank you for the opportunity to respond to 
questions from Paralyzed Veterans of America's (PVA) April 22, 2009 
testimony on pending legislation before the Committee.
    Regarding Mr. Begich's question on your behalf in reference to 
PVA's 2007 testimony against VA partnering with the Centers for 
Medicare and Medicaid Services to utilize critical access hospitals, 
PVA would like to offer the following response for the record.
    I believe the Chairman was referring to PVA's June 14, 2007, 
testimony to the House Committee on Veterans' Affairs Subcommittee on 
Health. PVA expressed its concerns about demonstration projects between 
VA and the Centers for Medicare and Medicaid Services. PVA believed 
that congressional legislation may have been ``jumping the gun'' and 
getting ahead of the Office of Rural Health's ability to assess 
demonstration projects.
    PVA's position has not changed. The Office of Rural Health (ORH) 
was established to develop policies and identify and disseminate best 
practices and innovations to improve health-care services to veterans 
who reside in rural areas. This is a noble goal and ORH is now 
established and working its mandated activities, but it is still 
relatively new and at the threshold of tangible effectiveness. But more 
specifically, PVA does not believe it is the proper role of Congress to 
legislate specific solutions to rural health problems. It is much more 
critical that Congress provide aggressive oversight to ensure VA is 
providing the high quality of care veterans are due, regardless of 
their location. It is not simply enough to increase the access to care. 
VA increasing its fee based care will provide greater access, but at 
what long-term cost to the veteran.
    ORH must concentrate on its coordination role. Public Law 109-461, 
the ``Veterans Benefits, Health Care, and Information Technology Act of 
2006,'' which established the Office of Rural Health and its mission 
requirements, in Section 213 of the law requires VA to work at the 
local level with, among other institutions, critical access hospitals 
located in rural areas. The intent was to increase the awareness of 
veterans and their families of the availability of VA health care and 
how they can access such care from VA. Congress should emphasize this 
coordination role and demand from ORH specific examples of its success 
or progress toward success. This is where Congress can provide the 
greatest overall impact on rural care.
    Additionally, the Office of Rural Health should have the 
opportunity to develop programs that will help provide high quality 
health care to the rapidly increasing number of rural veterans. 
Congress needs to provide the stringent oversight to insure ORH is 
meeting the goals of policies and practices on care which is of the 
same quality or better than that provided at VA facilities. ORH must 
not only disseminate the practices and innovations, but should monitor 
that its recommendations are being implemented and if not, why.
    The Office of Rural Health has a daunting mission. With over 40 
percent of veterans living in rural areas and almost 80,000 living in 
``highly rural'' locations, VA must develop new and innovative 
techniques to care for these veterans. But these challenges in no way 
permit providing lesser quality care than these deserving veterans 
would receive from any other VA facility. This must be ORH's first 
mission.
    More information on the concerns of PVA and other VSOs regarding 
rural health care issues is contained in The Independent Budget for 
Fiscal Year 2010 produced by AMVETS, Disabled American Veterans, 
Paralyzed Veterans of America and the Veterans of Foreign Wars.
            Sincerely,
                                           Blake C. Ortner,
                                Sr. Associate Legislative Director.

    Senator Begich. Mr. Ibson, many of the VA's current 
caregiver pilot programs do not include--and I know some of you 
already testified on this, but I want to put his question on 
the record so the answer is crystallized here. Current 
caregiver pilot programs do not include financial support for 
the caregiver--something you talked about as well as others. 
Can you tell the Committee why caregivers need the monetary 
stipend in addition to counseling, training, and other forms of 
support? Specifically, why monetary is important, if you could 
add to that and then we put that into the record, that would be 
fantastic.
    Mr. Ibson. Surely. I think the experience we have seen with 
caregivers is, as I indicated, that their lives have been 
completely irrevocably altered. Family members have left their 
jobs to be at the bedside of their loved ones and have not left 
that bedside. Economic concerns have been set aside in what 
becomes a self-sacrificing mode. Ultimately, that burden will 
take its toll, not only in terms of mental health, emotional 
health, overall health, but economically, as well. We see a 
need to sustain that caregiving, and in order to do so, it is 
our view that a broad array of services is needed to provide 
adequate supports--not simply emotional support, not simply 
respite, not simply counseling and training, but a financial 
stipend, as well--to sustain the caregiving.
    Senator Begich. Thank you for that.
    I will just give you 2 seconds here. I have a nephew who 
has spina bifida and Medicaid; I have another nephew who is his 
caregiver and gets a stipend. I just wanted to make sure the 
Chairman had his question, but I also am very sensitive to the 
issue and making sure that the economic opportunities are there 
because it does put lots of stress for all the reasons you have 
just said.
    Let me ask, if I can, just one more. I will not do well 
with your name. I will do my best. Mr. Atizado and also Ms. 
Hilsabeck, this is for both of you. The Chairman noted your 
testimony, which indicates the DAV's and the AFGE's full 
support of S. 743, the Rural Veterans Health Care Access and 
Quality Act of 2009, in part because it improves oversight of 
contract and fee-based care. Could you comment on why you see 
the need to improve oversight in this area? If you could be 
just brief, but just again emphasize a little bit of your 
testimony, again, crystallizing it for this question, either 
one of you.
    Ms. Hilsabeck. Thank you for the question, but I wouldn't 
be really prepared to answer that. I would have the AFGE--the 
union--get that information.
    Senator Begich. OK. That would be fair. If you can get that 
information to the Chairman, that would be fantastic.
    Ms. Hilsabeck. OK.
    Senator Begich. Thank you.
    [Response to the request follows:]
Response to Requests Arising During the Hearing by Hon. Daniel K. Akaka 
        to American Federation of Government Employees, AFL-CIO
    At the April 22, 2009 hearing, Senator Begich requested that AFGE 
elaborate on the statement in its written testimony on S.734 about the 
need for oversight of VA contract and fee basis health care, especially 
the Project HERO pilot project,
    Generally, AFGE is deeply concerned about the lack of adequate 
oversight of all VA contract health care arrangements, in terms of

     Lack of cost effectiveness;
     Inferior quality of care for specialized veterans' needs;
     Lack of coordination between contract providers and VA 
providers; and
     Long range impact on contract care on VA's internal 
capacity to meet veterans' health care needs through direct care, 
research and academic affiliations.
                           i. fee basis care
    With regard to fee basis care specifically, we believe that many VA 
medical facilities are over relying on fee basis care, in violation of 
the statutory requirement that these arrangements only be made when VA 
in-house care is ``scarce'' i.e. not available. Our members regularly 
report that managers at their facilities turn to costly fee basis care 
rather than make effective staffing plans or utilize the recruitment 
and retention tools enacted by Congress to fill nurse and physician 
vacancies (e.g. nurse locality pay and alternative work schedules, 
physician market pay and performance pay). Overreliance on fee basis 
care also threatens the quality of care: fee basis providers lack the 
expertise and specialization of VA providers who exclusively treat 
veterans within the VA system, and they are less familiar with unique 
combat related injuries such as Traumatic Brain Injury.
    We have heard that a number of facilities are currently facing 
budget shortfalls--despite unprecedented budget increases from 
Congress--because they are providing and more of their care through 
expensive fee basis arrangements.
    Recommendation: We urge Congress to conduct oversight into the 
current status of VA's fee basis program, including expenditures by 
each VA medical facility on fee basis care, credentials of fee basis 
providers, effectiveness of coordination between contract providers and 
VA providers, and the adequacy of VA personnel needed to arrange and 
oversee fee basis arrangements.
                            ii. project hero
    Project HERO has been touted as the cure for all the woes of fee 
basis care. Nothing could be further from the truth. This pilot project 
was implemented without adequate Congressional authority.\1\ It has 
been conducted in near secrecy. It is draining VA medical centers of 
substantial portions of their budgets and resulting in reductions of 
the very in-house personnel needed to effectively arrange and oversee 
contract care. It is costing the VA more than fee basis care arranged 
directly by VA personnel. It has not resulted in greater access for 
rural veterans and in fact, is impeding access for many veterans who 
are being forced to go to HERO providers and travel further when they 
prefer to receive their care within the VA.
---------------------------------------------------------------------------
    \1\ The conference report for the 2006 VA appropriations law is the 
only source of authority for Project HERO. The following 196 words 
addressed the need for contract care management, and were never 
intended to serve as the basis for this vast pilot project:

    Contract Care Coordination--The conferees support expeditious 
action by the Department to implement care management strategies that 
have proven valuable in the broader public and private sectors. It is 
essential that care purchased for enrollees from private sector 
providers be secured in a cost effective manner, in a way that 
complements the larger Veterans Health Administration system of care, 
and preserves important agency interest, such as sustaining a 
partnership with university affiliates. In that interest, the VHA shall 
establish through competitive award by the end of calendar year 2006, 
at least three managed care demonstration programs designed to satisfy 
a set of health system objectives related to arranging and managing 
care. The conferees encourage the Department to formulate demonstration 
objectives in collaboration with industry and academia, and the 
Secretary will report objectives to the Committees on Appropriations of 
both Houses of Congress within 90 days of the enactment of this Act. 
Multiple competitive awards and designs may be employed that may 
incorporate a variety of forms of public-private participation. The 
demonstrations, in satisfying the objectives to be enumerated, must be 
established in at least three VISNs, be comprehensive in scope, and 
serve a substantial patient population.
---------------------------------------------------------------------------
    The reach of Project HERO is enormous: the pilot covers 33 states 
in 4 VISNs (8, 16, 20 and 23) and by the VA's own admission, now covers 
thirty percent of all veterans enrolled in the VA.\2\ Yet, on the HERO 
webpage, it describes HERO as ``a pilot program that helps Veterans 
access the health care they need when specific medical expertise or 
technology isn't available inside the VA health care system'' (emphasis 
added). Clearly, a 30% penetration rate is directly contrary to HERO's 
own stated goal of supplementing, not supplanting, VA's in-house 
services.
---------------------------------------------------------------------------
    \2\ See statement by VA National Program Manager Greg Eslinger in 
February 2009 news report. http://wcco.com/health/
project.hero.veterans.2.939294.html
---------------------------------------------------------------------------
    Based on reports from the field, it appears that HERO may not be 
consistently fulfilling other key commitments it made on its VA 
webpage:

     ``When Veterans need care that's not available at their 
local VA medical center . . . Project HERO supplements VA care with 
credentialed quality medical and dental providers to quickly meet their 
needs.''
     ``HVHS (Humana Veterans Health Services) is committed to 
contacting Veterans for appointments within five days, and both HVHS 
and Delta Dental arrange for Veterans to see specialists within 30 
days. Veterans also wait less than 20 minutes to see the doctor or 
dentist once they've checked in for their appointments.''
     ``Veterans have peace of mind knowing their medical and 
dental records are returned to VA so their primary doctors and dentists 
can provide more informed, continuous care over time.''
     ``Veterans can trust VA is using resources wisely while 
maintaining high quality care. With Project HERO, HVHS and Delta Dental 
offer consistent, competitive pricing and they send invoices directly 
to VA for payment.''

    The VA has also not kept its commitment to keep labor organizations 
adequately informed about HERO, which it identifies as a ``partner''. 
They have not met AFGE's multiple requests for a face-to-face briefing, 
and at best, have supplied a few very general PowerPoint presentations 
to the AFGE VA Council leadership at group meetings. Our members on the 
front lines of health care have been given no role in overseeing or 
consulting on the use of HERO care.
    We have brought our concerns to Senator Johnson, Chair of the 
Senate Mil-Con-VA Appropriations Subcommittee. South Dakota is also one 
of the states most heavily impacted by HERO to date. (Generally, the 
HERO pilot is VISN 23 is the most developed but we also are aware of 
HERO activity in VISNs 8, 16, and 20.)
    Recommendation: The following are the questions that we have raised 
with appropriators. We hope this Committee will also conduct oversight 
to secure answers to these questions.

    I. Source of funding for HERO
          a. Which designated accounts are used to fund HERO 
        administrative costs at each level (VA Central Office (VACO), 
        VISN office and facility)?
          b. Which accounts are used for payments to HVHS and Delta 
        Dental for the services they arrange, related referral fees, 
        etc.
          c. Are fee basis dollars used to cover any HERO costs? If 
        yes, what statutory authority does the VA rely on to use fee 
        basis dollars?

    II. Cost Effectiveness\3\
---------------------------------------------------------------------------
    \3\ AFGE has information that Humana may be charging the VA 105% of 
Medicare plus a referral fee per patient. In contrast, it is our 
understanding that when VA arranges its own contract (``fee basis'' 
care) it pays the providers 100% of Medicare and there are no other 
fees involved.
---------------------------------------------------------------------------
          a. What is the fee arrangement between VA and contractors for 
        different types of care, and how do these fees relate to the 
        Medicare fee schedule?
          b. What other costs are billed to the VA, e.g. referral fees?
          c. Provide data on all payments to contractors since the 
        inception of the pilot project.
          d. Provide data on all administrative costs incurred at each 
        level for the VA to operate this pilot project since HERO's 
        inception.

    III. Impact on Medical Center budgets\4\
---------------------------------------------------------------------------
    \4\ AFGE has received reports that several local facilities, 
including Minneapolis, Black Hills and Seattle have gone into budget 
shortfalls because of increasing costs for HERO and other contract 
care.
---------------------------------------------------------------------------
          a. For each facility participating in HERO, provide data 
        indicating the percentage of the facility's budget that has 
        been used to cover HERO fees, administrative costs and other 
        HERO expenses.
          b. For each facility participating in HERO, provide data 
        indicating staffing levels for positions relating to care 
        coordination (with HERO contractors and other contract care 
        providers) including clinical care coordinators.
          c. For each facility participating in HERO, provide data on 
        staffing policies (e.g. hiring freezes), vacancies and other 
        staffing changes since the date that the facility began 
        participation in HERO.

    IV. Impact on quality of patient care
          a. Provide copies of all provider networks established by 
        HVHS and Delta Dental to date.
          b. What criteria are used to screen candidates for the HVHS 
        and Delta Dental provider networks?
          c. What if any complaints has the VA received regarding HVHS 
        and Delta Dental providers?
          d. What type of orientation is required for providers 
        participating in HVHS and Delta Dental networks?
          e. How does the VA (at each level) oversee the quality of 
        care provided by HERO network providers?
          f. What procedures are in place to ensure that contract 
        providers make proper referrals (to the VA or outside the VA) 
        when veterans need specialty care or other referrals?
          g. Provide data indicating the number and type of referrals, 
        and provider name and address, for each referral made by 
        contract providers since the inception of the pilot project.
          h. Are the contractors required to provide the same level of 
        care provided for equivalent services at the VA, e.g. physician 
        or nurse, primary care or specialist?
          i. What are the skill levels of personnel employed by the 
        contractors who coordinate referrals and care with the VA?

    V. Other care coordination issues
          a. Provide a copy of procedures for sharing of medical 
        records between the VA and the contractors, and their network 
        providers.
          b. What safeguards are in place to ensure that sharing of 
        records protects veterans' personal health information?
          c. Provide all reports received to date regarding problems 
        with medical record exchanges between the VA and the HERO 
        contractors.
          d. Provide a copy of procedures used to ensure that 
        contractors provide other medical services timely and properly, 
        including prescriptions and prosthetics.

    VI. Impact on access
          a. What geographic criteria do contractors use to identify 
        and recruit providers to their network?
          b. What percentage of VA referrals have contractors been 
        unable to fill due to lack of geographically accessible 
        providers?
          c. What percentage of VA referrals have contractors been 
        unable to fill due to lack of appropriate specialists?
          d. Provide data indicating travel times required for veterans 
        using HVHS and Delta Dental providers, in comparison to travel 
        times required to equivalent providers within the VA or fee 
        basis providers contracting directly with the VA.
          e. Provide data indicating the HERO contractors' success in 
        meeting HERO's stated commitment of contacting veterans for 
        appointments within five days, arranging for veterans to see 
        specialists within 30 days and limiting the amount of time the 
        veteran waits at the provider's office to less than 20 minutes 
        after checking checked in for their appointments
          f. What reports has the VA received of dissatisfaction by 
        providers who contracted with HVHS or Delta, or evidence of 
        reluctance by medical professionals or other providers 
        (including dialysis facilities) to join the HVHS or Delta 
        Dental networks?
          g. What are the VA's criteria for determining which patients 
        to refer to HVHS and Delta Dental, rather than treat in-house 
        or refer to a fee basis provider arranged directly by the VA? 
        Has the VA imposed any fixed quotas on facility directors as to 
        the number of patients that must be referred to HERO 
        contractors?

    VII. Oversight and Evaluation
          a. Describe all efforts by HVHS and Delta Dental to provide 
        performance data and other information to lawmakers and 
        partners (academic affiliates, VSOs and labor unions)? Provide 
        all materials provided to lawmakers and partners.
          b. What criteria were used to award the initial contract to 
        HVHS and Delta Dental? Was the award made competitively? 
        Provide a copy of first year contracts with HVHS and Delta 
        Dental.
          c. What criteria were used to award the second year contract 
        to Humana and Delta Dental? Provide a copy of the second year 
        contract.
          d. What criteria were used to award additional specialty area 
        contracts to Humana and Delta Dental during the first year? 
        Provide copies of all such contracts.
          e. Provide copies of all evaluations completed to date and 
        all pending evaluations conducted by VA to determine the impact 
        of HERO on the quality, timeliness and accessibility of 
        veterans' care, patient satisfaction and cost effectiveness.

    VIII. Patient Satisfaction
          a. What information is provided to veterans regarding 
        referrals to HERO contractors? Are they informed that they have 
        a right to refuse an outside referral? Please provide copies of 
        all documents provided to veterans about HERO and the referral 
        process.
          b. Have any veterans been told that if they refuse a referral 
        to HVHS or Delta Dental, that they will be denied VA care? Are 
        facilities permitted to impose this requirement?
          c. What oversight has the VA conducted to ensure that 
        veterans are fully informed of their rights in the referral 
        process?
          d. Provide data on the out-of-pocket medical costs incurred 
        by all veterans using HERO providers who faced these additional 
        costs.
          e. What information is given to veterans about the 
        safeguarding of their medical records when their cases are 
        referred outside the VA?

    XI. IMPACT ON RESEARCH: What evaluations has the VA done to 
determine the impact of HERO on VA's research capacity? Is HERO causing 
VA and academic researchers to lose volunteer patients needed for 
research programs?

    XII. IMPACT ON ACADEMIC AFFILIATES: What evaluations has the VA 
done to determine the impact of HERO on VA's relationship with academic 
affiliates and opportunities for medical training? The impact on VA's 
medical school and other health professions training programs at the 
local level when a large portion of subspecialty work is diverted 
outside the VA and university systems? Is HERO causing medical schools 
and the VA to lose the very patients they need for teaching purposes.

    Mr. Atizado. Senator Begich, thank you for the question. 
The DAV believes that oversight for VA's fee-basis program is 
needed simply because this program is fraught with problems: 
anywhere from the IT infrastructure or software that is 
utilized, the training of the people that run the fee-basis 
program; as well as the care that is purchased; the way it is 
not coordinated or lack of coordination. In fact, VA right now 
is conducting a project called Project HERO that is supposed to 
answer most of the concerns that we have about fee-based and 
contract care that VA currently does. We are learning more 
about that program, but if you would like, I can provide you a 
more detailed answer for the record.
Response to Requests Arising During the Hearing by Hon. Daniel K. Akaka 
to Adrian M. Atizado, Assistant National Legislative Director, Disabled 
                           American Veterans
    Question. The Chairman noted your testimony, which indicates the 
DAV's and the AFGE's full support of S.734, the Rural Veterans Health 
Care Access and Quality Act of 2009, in part because it improves 
oversight of contract and fee-based care. Could you comment on why you 
see the need to improve oversight in this area?
    Response. Current law places limits on VA's ability to contract for 
private health care services in instances in which VA facilities are 
incapable of providing necessary care to a veteran: when VA facilities 
are geographically inaccessible to a veteran for necessary care; when 
medical emergency prevents a veteran from receiving care in a VA 
facility; to complete an episode of VA care; and for certain specialty 
examinations to assist VA in adjudicating disability claims. VA also 
has authority to contract to obtain the services of scarce medical 
specialists in VA facilities. Beyond these limits, there is no general 
authority in the law to support broad-based contracting for the care of 
populations of veterans, whether rural or urban with exception to 
Section 403 in Public Law 110-387, the Veterans' Mental Health and 
Other Care Improvements Act of 2008. This provision directs VA to 
conduct a three-year pilot program under which a highly rural veteran 
who is enrolled VA health care and who resides within a designated area 
of a participating VISN may elect to receive covered health services 
through a non-VA health care provider at VA expense.
    According to VA, 41 percent (over 3.2 million) of its enrolled 
veteran population live in rural and highly rural areas, and 
approximately 40 percent of veterans receive some of their care from a 
non-VA health care provider. This represents a significant portion of 
the enrolled veteran population that has an identifiable need for 
expanded access to VA health care.
    However, increased use of VA purchased care whether through 
contract and/or fee-base can silently shift the balance of clinical 
material that will result in unintended consequences for VA, unless 
carefully administered. Chief among these is the diminution of 
established quality, safety, and continuity of VA care for rural and 
highly rural veterans. It is important to note that VA's specialized 
health care programs, authorized by Congress and designed expressly to 
meet the specialized needs of combat wounded and ill veterans, such as 
the blind rehabilitation centers, prosthetic and sensory aid programs, 
readjustment counseling, polytrauma and spinal cord injury centers, the 
centers for war-related illnesses, and the national center for Post 
Traumatic Stress Disorder, as well as several others, would be 
irreparably impacted by the loss of veterans from those programs. Also, 
the VA's medical and prosthetic research program, designed to study 
and, hopefully, cure the ills of injury and disease consequent to 
military service, could lose focus and purpose were service-connected 
and other enrolled veterans no longer physically present in VA health 
care. Additionally, title 38, United States Code, section 1706(b)(1) 
requires VA to maintain the capacity of its specialized medical 
programs and not let that capacity fall below the level that existed at 
the time when Public Law 104-262 was enacted in 1996. Unfortunately 
some of that capacity has dwindled.
    We recommend the principles of our recommendations from the 
``Contract Care Coordination'' section of the Independent Budget (IB) 
for Fiscal Year (FY) 2010 be used as a guide for VA to develop an 
integrated program of contract care coordination for veterans who 
receive care from private health care providers at VA expense, while 
mitigating the aforementioned unintended consequences that diminish VA 
health care.
                      rural outreach coordinators
    The DAV believes much can be done to improve the use of purchased 
non-VA care. For example, components of a coordinated care program 
should include a care and case management system to assist every 
veteran and each VAMC when a veteran must receive non-VA care. Notably, 
a provision in Section 7 of S.734 would require VA to establish rural 
outreach coordinators at each CBOC with a majority of enrolled veterans 
who reside in ``highly rural'' areas.
    Ostensibly, these rural outreach coordinators would fall under VA's 
Office of Rural Health (ORH), whose mission includes identifying and 
implementing new initiatives such as increasing mobile clinics, 
establishing new outreach clinics, expanding fee-based care, exploring 
collaborations with Federal and non-Federal community partners, 
operating the Rural Health Resource Centers, accelerating telemedicine 
deployment, developing workforce recruitment initiatives, developing 
web-based information delivery methods and funding innovative pilot 
programs. Notably, VA's budget submission for FY 2010 projects an 
increase in fee workload of 24 percent from 2008, and an increase in 
rural health spending through the ORH of $380 million from 2009.
    As part of the IB, the DAV believes veterans who receive private 
care at VA expense and authorization should be required to participate 
in the care coordination program, with limited exceptions. This 
provision of S.734 would require the coordinator at a clinic to be 
responsible for coordinating care and collaborating with community 
contract and fee-basis providers with respect to the clinic. We believe 
this is a good first step in care coordination for rural and highly 
rural veterans enrolled in the VA.
 consolidation of community-based outpatient clinic (cboc) contracting
    As part of the IB, the DAV believes consolidated CBOC contracting 
offers VA a way to standardize the health care benefits to veterans 
served by individual VAMCs and provides greater efficiencies and cost 
savings to help meet the increasing health care needs of veterans in 
rural or underserved areas and areas not directly served by a VA 
medical facility.
    Specifically, consolidated CBOC contracting would provide greater 
continuity of care and uniformity of benefit; simplify contract 
administration and oversight allowing for more efficiency; responsive 
capacity by sharing of health care providers based on demand; provide 
consistent and uniform medical care services; consolidate training on 
VA programs and procedures, including use of Veterans Health 
Information Systems and Technology Architecture (VistA); and 
standardized CBOC reporting. We invite the Committee to read more 
details on this issue in the FY 2010 IB article, ``Community Based 
Outpatient Clinics.''
establish incentives to obtain accreditation of participating fee-basis 
 private providers, and to encourage these providers to participate in 
                        va's peer review system
    The DAV believes VA's health delivery system must promote and 
ensure health care quality and value, and protect veterans' safety. The 
Veterans Health Administration (VHA) has created a culture of quality 
by measuring important clinical outcomes, many of which fall within the 
domain of primary care. In addition, part of VA's quality of care 
includes the many safeguards built into the VA system through its 
patient safety program, evidence-based medicine, electronic health 
record and bar code medication administration. Loss of these 
safeguards, ones that are generally not available in private sector 
systems, would equate to diminished oversight and coordination of care, 
and ultimately may result in lower quality of care for those who 
deserve it most.
    An important tool to expand access to VA health care in rural areas 
is its use of fee care. Notably, sections 212(b) and (c) of Public Law 
109-461 requires an extensive assessment of the existing VA fee-basis 
system of private health care, and eventual development of a VA plan to 
improve access and quality of mental health and long-term care for 
enrolled veterans who live in rural areas. To further such 
requirements, section 7 of S.734 seeks to establish incentives to 
obtain accreditation of participating fee-basis private providers, and 
to encourage these providers to participate in VA's peer review system. 
Each VA rural outreach clinic is part of a VA network and maintains 
VA's quality standards. When conducted systematically and credibly, 
peer review can result in both immediate and long-term improvements in 
patient care by revealing areas for improvement in individual 
providers' practice. Mr. Chairman, you mentioned VA currently has no 
standardized procedure in place to ensure non-VA purchased care 
veterans receive in the community are of equal or better quality than 
that which they would receive directly from VA. This provision is 
consistent with the principles of the recommendations from the 
``Contract Care Coordination'' section of the IB for FY 2010.

    Senator Begich. Very good. If you could do that, that would 
be great.
    I just got a note that a vote has started, so I am going to 
just close it up and say thank you all again for your 
testimony, for both panels. Again, for information for all, the 
Committee's markup is scheduled for May 21 and it is the hope 
of the Chairman that at that time, we will move a number of 
these bills presented today.
    For the Administration witnesses, we ask that you review 
all the bills that are going to be up for markup and submit 
your views no later than 1 week prior to markup--by May 14--
especially after the Chairman's commentary today. I would even 
have it back by May 13--be 1 day early. That would be good. He 
would like your commentary on the bills prior to May 14.
    I know many of you have submitted testimony for the record. 
We appreciate that. Again, markup will be on May 21 on several 
of these bills.
    At this time, I will adjourn the meeting and thank you all 
for testifying.
    [Whereupon, at 4:32 p.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


     Prepared Statement of LT. Jerri Geer, USCG (Ret.), Seattle, WA

    Chairman Akaka, Ranking Member Senator Burr and Committee 
Members: I am LT. Jerri Geer, USCG (Ret.) and I am extremely 
grateful to be asked to speak with you today. I am honored to 
be here. Thank you.
    I live in the Seattle, Washington, area and go to the 
Seattle VA Medical Center for my health care.
    To begin, I live with the challenges of Bipolar Disorder. I 
have struggled with this disability for over thirty years and 
have always been responsible for my health and personal aspects 
of my life. Being Bipolar, I have had difficulties with my 
finances over the years, but have always been responsible for 
my debts and have never been late on my payments. I have always 
paid my debts in full. My FICO scores are between 783 and 785, 
which are considered excellent. However, in the fall of 2002, I 
was very afraid that I had gotten into a financial situation 
that I might not be able to handle. I thought I could trust my 
social worker and my psychiatrist at the Seattle VAMC, so I 
finally asked for help. This is when all the trouble started. 
They informed me about a program through the Seattle VA 
Regional Office that helps Veterans with their finances. After 
being told what I thought were all the facts about the program, 
I asked to be put in it. My psychiatrist wrote a letter to 
request this for me. A red flag immediately went up when I read 
the word incompetent in that letter. I asked my social worker 
what that meant and she said it was just a term the VA uses for 
this program; that it was unfortunate the VA couldn't find a 
better term for my situation. I asked her if this had any legal 
consequences outside the VA and she said no. Neither she, nor 
my psychiatrist, ever told me about the Brady Act--National 
Instant Criminal Background Check System (NICS). This letter is 
dated December 2, 2002. I really wanted to get help, so I 
signed the letter.
    I didn't know about the Brady Act until I received my 
proposed rating letter of January 23, 2003, adjudicating me 
incompetent and I was to be assigned a fiduciary. In the letter 
it stated I was permanently barred from purchasing a firearm. 
Because I don't like guns, I didn't pay any attention to it. It 
took until May 2003 before I met my Field Investigator. During 
this time, I had read Suze Orman's books on finances and had 
actually regained control of my finances. When my Field 
Investigator saw what I had done, she said I really didn't need 
to be in the program and would recommend that to my 
psychiatrist. My psychiatrist didn't agree and wanted me to be 
on supervised pay and not have a payee. I only saw my Field 
Investigator twice: in the beginning, May 2003; and at the end, 
a year later in May 2004. During this period I managed my own 
affairs.
    At my last meeting with my Field Investigator I was 
reminded once again I was permanently barred from purchasing a 
firearm. At that point, I realized I needed to know what that 
really meant. I received my competency rating November 19, 
2004. I started researching the Brady Act later in January 
2005. This is when I discovered the real ramifications and 
became concerned and angry that I was not told about this NICS 
when I volunteered to be put into the fiduciary system. I told 
my social worker and psychiatrist of my anger and fears. 
Apparently the VA Regional Office failed to inform the VA 
Medical Center about this NICS-Brady Act. If my psychiatrist 
had known, she would not have put me in this program. I was 
never incompetent and she knew I just wasn't the kind of person 
that should be in this NICS database. She apologized and said 
she was ignorant about this. I think she was genuinely upset 
that she was not informed. Other patients had also been put in 
this system that were not incompetent. In my heart, I feel I 
was deceived, however unintentionally.
    I decided this was an egregious miscarriage of justice. I 
spent at least three months researching on the internet and 
found information and misinformation concerning the Brady Act. 
Since I have no legal background, I tried earnestly to obtain 
information from the VA and the NICS, both of which kept 
pinging me back and forth between the two, saying the other 
could only remove my name from this database. I called the NICS 
for information three times and each time I received three 
different answers to the same question, ``How can I remove my 
name from the NICS.'' They essentially told me the original 
agency that adjudicated me incompetent is the only one that can 
remove my name, which would be the VA.
    I put a claim through the DAV to the Seattle VA Regional 
Office requesting they remove my name from the NICS in April 
2005. I waited until June 2005 for a response, but none came. I 
decided to see Senator Patty Murray's staff member, Ms. Muriel 
Gibson in Seattle for help. She sent a Congressional Inquiry to 
the VA Regional Office in June 2005.
    The VA responded in August 2005 to Senator Murray's 
Congressional Inquiry saying they could not remove my name, but 
sent a pamphlet giving me information on how to contact the 
NICS to remove my name. The pamphlet instructed how to appeal, 
but only after trying to purchase a firearm and the last 
paragraph indicated the original agency would be a key factor 
in the appeal. I felt the NICS appeal process was another path 
that would again put responsibility back on the original 
agency--the VA.
    Therefore, Ms. Gibson and I decided to send a letter to the 
VA Judiciary Council asking them to remove my name from the 
NICS in August 2005. I waited until December 2005 for a 
response. None came. Ms. Gibson then contacted the VA Judicial 
Council which stated a reply had been sent in October 2005. 
Needless to say, I did not receive it. Ms. Gibson was faxed the 
response which again said the NICS was the only agency that can 
remove my name and only after I tried to buy a firearm. Since 
my stance of not wanting to buy a gun would be compromised, a 
letter was again sent to the VA Judiciary Council in December 
2005 explaining my request. The VA sent another response dated 
March 2006 which denied my request once again to Senator 
Murray's office; however, I did not receive this letter until 
May 2007.
    At this point, my spiritual needs were becoming serious and 
I turned to my Chaplain at the VA Medical Center. She called 
the attorney at the VA Regional Office and the attorney said 
she had never heard of this issue and referred my Chaplain to 
the Chief of Security at the VA Medical Center in Seattle.
    Back in July 2005, I began to realize I seemed to know more 
about the NICS than the Federal Government. Even when a mistake 
has been made by the VA, a name cannot be removed. This, in my 
opinion, takes away my right to ``due process'' which is my 
Fifth Admendment Right and my Second Admendment Rights. So, I 
made a desperate move to write Chairman Craig on July 16, 2005. 
I also sent the same letter to the Chairman of the House 
Committee on Veterans' Affairs and Ranking Members of both the 
Senate and House of Representatives. Fortunately, Chairman 
Craig's staff member, Major David Buffaloe, USA, took the 
letter seriously and began researching this issue. He contacted 
me and told me that neither he nor other staff members knew 
about this and together we all began a journey that has led me 
to testify before you today.
    I believe the Brady Act is not only an illegal act 
pertaining to veterans, but an ethical, civil rights, and 
privacy issue. I find it unbelievable that a Federal agency 
such as the Veterans Administration would make an agreement 
with another Federal agency without at least researching the 
various laws concerning the appropriateness of such an 
agreement. I feel the VA did little or no oversight and failed 
to protect the rights of veterans, their children and spouses. 
I later learned from Major David Buffaloe that the VA was also 
putting the names of veteran's children into the NICS when they 
became orphaned or for other reasons. This is unconscionable. 
Anyone with an ounce of sense would know the terrible 
ramifications of such an act when these children become adults. 
It makes me believe that there is no one at the helm in the VA 
and the VA is derelict in its duties.
    The Brady Act was not created to put innocent children's 
names in the NICS nor innocent adults. It is too broad, 
overreaching and is flawed. I do believe it was born out of 
fear, high emotions, feelings of not having control over the 
escalating violence in this country, ignorance, stereotyping 
and a belief system about the mentally ill that is vastly 
untrue and antiquated. It was well intended; however, it has 
cast a very wide net and innocent people have been swept into 
it, simply because they swim in the same ocean.
    Before any citizen has their Constitutional Rights removed, 
it should be done only through a court of law and the right of 
legal council. Now, I do understand there are special 
circumstances, but it should always be done though a court of 
law. Right now felons have more legal rights than veterans.
    After researching this issue, rbecame aware that this quest 
to remove my name from the NICS was not just about me, but 
about all veterans whose names are also sacred. This situation 
has been devastating to me. I feel my name has been stolen and 
my honor has been tainted. My whole sense of safety has been 
destroyed. I need my name removed from the NICS because I am 
not a ``mental defect'' and ``a threat to public safety'' and I 
was never ``incompetent.'' This is very detrimental to my 
health. In the past, I have been open about my Bipolar 
Disorder, however, after this experience, of being plunged into 
the dark abyss of bureaucracy and indifference in the last four 
and a half years, I realize I have been putting myself at risk 
of being unjustly feared, judged and seen as a threat to public 
safety no matter who I shared my life with.
    Mr. Chairman, in creating such a law as the Brady Act with 
its vast misunderstandings, I believe Congress has increased 
the potential violence with firearms. For who would want to 
subject themselves to the stereotyping, stigmatization, 
alienation, fear, loss of friends, family, jobs, and much more 
in voluntarily seeking Mental Health Care? It takes an immense 
amount of courage, responsibility and a wanting to be a 
positive member of society to seek this help. Instead of 
vilifying people who seek help, we need, as a moral society to 
make such people the pillars of society and, in a sense, 
heroes. Then, you will have a safer society. Otherwise, I fear 
we are only creating more Mr. John Hinckley's walking among us.
    The irony of my situation is that I do support gun control 
and advocate for nonviolence. I also understand the concerns of 
law-abiding citizens who enjoy or feel a need to own a firearm.
    Mr. Chairman, I want to thank Senator Larry Craig while he 
was The Chairman of this Committee for his support, and his 
staff members, especially Major David Buffaloe, USA, for his 
exemplary work in researching this issue and helping me along 
the way. His kindness and compassion will always be with me.
    I want to end by saying, ``The benchmark of any society is 
its justice and there can be no freedom and honor without 
justice.''
                                ------                                


        Prepared Statement of Michael Brennan, M.D., President, 
                   American Academy of Ophthalmology

    Chairman Akaka and Ranking Member Burr: I am Michael 
Brennan, President of the American Academy of Ophthalmology. 
The Academy appreciates the opportunity to present its views on 
S.252, the Veterans Health Care Authorization Act of 2009. The 
Academy is the largest national membership association of Eye 
M.D.s with more than 27,000 members, over 17,000 of which are 
in active practice in the United States. Eye M.D.s are 
ophthalmologists, medical and osteopathic doctors who provide 
comprehensive eye care, including medical, surgical and optical 
care. More than 90 percent of practicing U.S. Eye M.D.s are 
Academy members.
    The Academy strongly supports Section 101 of the Veterans 
Health Care Authorization Act of 2009 which would authorize the 
Department of Veterans Affairs (VA) to extend Title 38, United 
States Code (U.S.C.), employment status to certain employees. 
We believe that this authority would enable the conversion of 
eye technicians within the Veterans Health Administration (VHA) 
from their existing non-specific health technician status into 
a Title 38 Hybrid Series specific for eye care technicians. The 
inclusion of eye technicians into the hybrid classification 
system would improve the ability of VA to recruit and retain 
qualified eye technicians by ensuring that personnel are hired 
based on knowledge, training and experience and to compensate 
eye technicians at a level more competitive with the private 
sector.
    Improving VA's ability to recruit and retain qualified, 
experienced eye technicians is more crucial than ever today. 
Over the past decade, the eye care workload in the veterans' 
health care system has dramatically increased. Between 2001 and 
2008, ophthalmology and optometry clinic visits and unique 
patients have increased 80 percent. In Fiscal Year (FY) 2008, 
there were 2.36 million eye clinic visits for 1.39 million 
veterans. As the veteran population ages, their complexity of 
care also increases. Diabetic retinopathy, macular 
degeneration, glaucoma, and cataracts are diseases that are 
highly prevalent in the aging veteran population.
    The complexity of eye care will further increase as 
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom 
(OIF) veterans return home. According to the Office of VA 
Research, combat eye trauma is the second most common injury 
experienced by military personnel serving in Iraq and 
Afghanistan. Veterans with a history of ocular battle injuries 
are at high risk for developing retinal detachments, traumatic 
cataracts, and glaucoma. Delayed Traumatic Brain Injury (TBI) 
neuro-visual complications can occur years after the initial 
injury. The ever increasing prevalence of combat eye trauma and 
TBI-related visual complications will place even greater 
demands on VA's eye care services for years to come.
    Traditionally, eye clinics in the VA health care system 
have been staffed with untrained technicians who are hired as 
Title 5 employees under the Health Technician GS-0640 Series 
which covers a range of health care positions, including such 
diverse jobs as phlebotomist and laboratory technician. The 
ability of VA to recruit trained eye care personnel (including 
eye technicians, ophthalmic photographers and opticians), is 
hampered by a lack of an appropriate eye care personnel series 
and standards. There are no formal position descriptions for 
eye care personnel in the VA, leaving each medical center to 
create its own position description, which reduces consistency 
throughout the veterans' health care system. Moreover, there 
are no established salary ranges for eye care personnel in the 
VA system, making it difficult to recruit qualified applicants. 
Medical centers are forced to post an eye care professional 
position as a ``health technician'' and use convoluted language 
and special qualifications to avoid selecting an unqualified 
applicant. These constraints make it difficult for the VA to 
attract the most talented eye care technicians in the 
community.
    Under Title 5 employment, positions are graded according to 
classification standards and employee pay is determined based 
on the position classification, not on the individual 
qualifications of the person occupying the position. This 
policy has hindered the VA from achieving the highest 
efficiencies of care as the addition of one trained technician 
to one eye care provider has been shown to have a positive 
impact on workload. For example, one technician improves the 
workload of an optometrist an average of 14 percent while one 
technician improves the workload of an ophthalmologist an 
average of 36 percent. In 2009, eye technicians are expected to 
have the knowledge, training and experience to perform highly 
technical, state-of-the-art, diagnostic procedures including:

     Ultrasonography;
     Digital computerized imaging and fluorescein 
angiography;
     Pachymetry;
     Optical coherence tomography;
     Scanning laser ophthalmoscopy; and
     Automated perimetry.

    The addition of trained eye care technicians and 
photographers to an eye clinic is a relatively cost-efficient 
way to improve veteran access to eye care and increase 
productivity.
    The Title 38 Hybrid Conversion Series was developed to help 
recruit and retain employees in highly competitive health care 
occupations. These positions are considered Title 38 positions 
but also retain some features of Title 5 positions. Under Title 
38 Hybrid, the grade and salary of each position is based on 
the duties of the position and how the candidate's 
qualifications compare to the VA Standard. A professional 
standards board determines which candidates are qualified 
through a peer-review process. Education, training and 
experience all can be considered as qualifications. Several 
health care technical series have already been converted to the 
Title 38 Hybrid Series; many of these series involve diagnostic 
testing that is similar to ophthalmic technicians 
(ultrasonography, angiography, electrophysiological testing, 
etc.).
    The demand for quality ophthalmic medical technicians is on 
the rise, and employment opportunities for these technicians 
are only expected to increase. In 2006, the Joint Commission on 
Allied Health Personnel in Ophthalmology, Inc (JCAHPO) applied 
to the U.S. Bureau of Labor and Statistics to list ophthalmic 
medical technicians as a separate occupational classification. 
Earlier this year, the Bureau of Labor and Statistics' 2010 
Standard Occupational Classification (SOC) Committee 
recommendations included a new classification for ophthalmic 
medical technicians (Classification Number: 29-2057). This new 
classification recognizes the more advanced, clinical and 
overall medically detailed skills and knowledge of ophthalmic 
medical technicians and will increase the competitiveness of 
qualified technicians in the job market.
    In closing, the Academy strongly supports the enactment of 
S.252, the Veterans Health Care Authorization Act of 2009, 
because we believe it will provide the VA with the authority it 
needs to properly address the growing demand for eye care 
services. Once enacted, we would urge the Department of 
Veterans Affairs to use its new authority to convert eye 
technicians from their current classification to a Title 38 
Hybrid classification as quickly as possible. Qualification 
standards for eye care technicians already have been developed 
for implementation by the VA through a joint ophthalmology/
optometry collaboration. Creating a Title 38 Hybrid series for 
eye technicians in VA would enable VA to recruit and retain 
qualified eye technicians into the Veterans Health Care 
Administration and would increase the ability of VA to provide 
excellent, yet efficient eye care to our Nation's veterans.

    Thank you for your consideration.
                                ------                                


    Prepared Statement of IAVA Submitted by Patrick Campbell, Chief 
        Legislative Counsel, Operation Iraqi Freedom (2004-2005)

                         ADVANCE APPROPRIATIONS

S.423, Veterans Health Care Budget Reform and Transparency Act of 2009 
        (Akaka)
    IAVA strongly endorses this legislation. For nineteen of 
the last twenty-two years, the VA budget has been passed late, 
forcing the largest health care provider in the Nation to 
ration care. Imagine trying to plan for next month's bills 
without knowing your next paycheck. That's what we ask 
veterans' hospitals to do almost every year. Advance 
appropriations will ensure that the quality of care for 
veterans will no longer be compromised by budget delays. With 
the strong support of the President, bipartisan leadership in 
Congress, and the support of every major veterans organization, 
S.423 can and must move forward this year.

                             MENTAL HEALTH

S.658, Rural Veterans Health Care Improvement Act of 2009 (Tester)
    We are pleased to offer support for S.658. According to the 
GAO, more than 25 percent of veterans enrolled in VA health 
care live over 60 minutes driving time from a VA hospital. This 
legislation would implement a multi-pronged approach to 
delivering quality health care to rural veterans: creating 
rural centers of excellence, funding new transportation grants 
and demonstration projects, and authorizing the VA to build 
local peer outreach and support services. S.658 would also 
expand current counseling capacity by allowing the VA to 
contract with local community health centers. With nearly one 
third of all returning veterans suffering from invisible 
psychological injuries, S.658 will allow veterans to support 
one another and receive the counseling they need.
S.772, Honor Act of 2009 (Bond)
    S.772 will address one of IAVA's top legislative priorities: ending 
the shortage of mental health professionals in the military and at the 
VA. This legislation provides incentives for retiring or separating 
military personnel and combat veterans to pursue an advanced degree in 
behavioral health. It will build a new generation of counselors with 
combat experience, and will help ensure that our men and women in 
uniform receive mental health care from personnel that understand 
military culture. The legislation also gives active-duty servicemembers 
the same access that veterans have to Vet Centers, expanding the pool 
of mental health care options available to our troops. In addition, the 
Honor Act takes a number of other innovative steps to address the 
mental health needs of troops and veterans. It allows servicemembers to 
present their records to the VA for screening, irrespective of their 
discharge, so that veterans do not fall through the cracks. The 
legislation also guarantees survivor benefits for any servicemember who 
commits suicide within 2 years of separation or retirement, provided 
they have a documented history of combat-related PTSD or TBI. Finally, 
by providing comprehensive training to educate troops on Post Traumatic 
Stress Disorder, the legislation will mitigate the confusion and stress 
that servicemembers feel when trying to identify mental health 
resources. For all of these reasons, IAVA wholeheartedly endorses 
S.772.
S.669, Veterans 2nd Amendment Protection Act (Burr)
    Two years ago, this Committee considered critical suicide 
prevention legislation called the Joshua Omvig Suicide Prevention Act. 
When this desperately-needed bill came to the Senate floor for a vote, 
rumors spread that the legislation would cause veterans seeking help 
for PTSD to lose their Second Amendment rights. Although even the NRA 
stated that the Joshua Omvig bill would have no impact on gun rights, 
critical sections of the Suicide Prevention Act were watered down. 
Although there is still no danger a veteran will lose their right to 
carry a firearm for seeking treatment for PTSD, we offer our support 
for this legislation in the hopes it will quell any fears veterans 
might have about seeking treatment for mental health injuries.
                            female veterans
S.597, Women Veterans Health Care Improvement Act of 2009 (Murray)
    IAVA is honored to offer our full support for S.597. By 2020, the 
proportion of women veterans using VA health care is expected to reach 
15 percent. This vital legislation will assess barriers to VA care that 
women face; plan for women's future VA health care needs; ensure full-
time women veterans program managers at every VA medical center; 
authorize the VA to care for the newborn children of female veterans; 
enhance Military Sexual Trauma (MST) training for VA mental health 
professionals; build a pilot program to evaluate providing child care 
subsidies to qualified veterans; and create a pilot program to study 
readjustment counseling for women veterans in group retreat settings.
                           family caregivers
S.801, Family Caregiver Program Act of 2009 (Akaka)
    IAVA is proud to put our full support behind S.801, which will 
ensure that family caregivers who care for their injured loved ones 
receive compensation and benefits that honor their service to their 
wounded warrior. This bill will provide a living stipend, health care 
benefits, training, and support to family caregivers.
S.543, Veteran and Servicemember Caregiver Support Act of 2009 (Durbin)
    S.543 is also a strong caregiver support bill. Like S.801, it 
provides a living stipend and training to family caregivers, but offers 
a narrower scope of services than S.801, and the legislation is limited 
to a 2-year pilot program. We support S.543, but would prefer S.801.
                             va health care
S.699, Far South Texas Veterans Medical Center Act of 2009 (Cornyn)
    The Far South Texas Veterans Medical Center Act is a critical piece 
of legislation that will improve access to health care for many of our 
returning veterans. With more than 114,000 veterans residing in the 
South Texas area, and a high rate of deployment from the Texas National 
Guard and Reserve units stationed there, it is unconscionable that the 
nearest acute inpatient care facility is almost 6 hours away. The 
Capital Asset Realignment for Enhanced Services study found that fewer 
than 3 percent of its enrollees in the Valley-Coastal Bend Market of 
VISN 17 reside within its acute hospital access standards. This bill 
will help correct this dire situation. Veterans in South Texas must be 
provided access to the care they were promised after fighting for this 
Nation.
S.734, Rural Veterans Health Care Access and Quality Act of 2009 
        (Akaka)
    IAVA is proud to support S.734, enhancing retention within the 
Veterans Health Administration, expanding care at Vet Centers, and 
expanding VA health care in rural areas. S.734 ensures that the VA 
recruits and retains the highest quality medical professionals by 
removing the cap on the Education Debt Reduction Program and making VA 
medical centers eligible for assignment in the National Health Service 
Corp Scholarship Program. Additionally, S.734 expands the mental health 
services offered by the Vet Centers by allowing mental health care 
professionals to act as volunteer counselors for the VA. S.734 also 
expands outreach to rural areas by allowing for expanded teleconsulting 
and treatment to veterans who are not able to travel due to distance or 
infirmary, and allows the VA to reimburse a veteran for airfare when 
ground transportation is not feasible.
S.498, Establishing VA Dental Care for Veterans and their families 
        (Burr)
    IAVA is proud to support S.498, extending VA dental care to 
veterans and their families by allowing them to purchase a VA dental 
insurance plan. Dental coverage has long been a gap in the benefits 
offered to veterans of the armed services, and IAVA fully supports 
allowing veterans and their families to take advantage of the high 
quality of care that is offered by their local VA.
                                 ______
                                 
   Statement for the Record Submitted by the National Association of 
         Veterans' Research and Education Foundations (NAVREF)
 s.252, ``veterans health care authorization act of 2009,'' title vi, 
 nonprofit research and education corporations (legislation to update 
    and clarify provisions of the law authorizing the va-affiliated 
  nonprofit research and education corporations, 38 u.s.c. Sec. Sec.  
                               7361-7366)
    The National Association of Veterans' Research and Education 
Foundations (NAVREF) thanks Senator Daniel K. Akaka, Chairman of the 
Committee on Veterans' Affairs, for incorporating title VI, ``Nonprofit 
Research and Education Corporations'' in S.252, the ``Veterans Health 
Care Authorization Act of 2009'' and for holding a hearing on this and 
other important health-related legislation. Upon enactment by Congress, 
title VI of this legislation will update and clarify provisions of the 
law authorizing the VA-affiliated nonprofit research and education 
corporations.
    NAVREF is the membership organization of the 82 VA-affiliated 
nonprofit research and education corporations (NPCs) originally 
authorized by Congress under Public Law 100-322, and currently codified 
at sections 7361 through 7366 of the United States Code. NAVREF's 
mission is to promote high quality management of the NPCs and to pursue 
issues at the Federal level that are of interest to its 
members. NAVREF accomplishes this mission through educational 
activities for 
its members as well as interactions and advocacy with agency and 
congressional officials. Additional information about NAVREF is 
available on its Web site at www.navref.org.
                       background about the npcs
    In 1988, Congress allowed the secretary of the Department of 
Veterans Affairs to authorize ``the establishment at any Department 
medical center of a nonprofit corporation to provide a flexible funding 
mechanism for the conduct of approved research and education at the 
medical center.'' [38 U.S.C. Sec.  7361(a)] At this time, 82 NPCs 
provide their affiliated VA health care systems and medical centers 
with a highly valued means of administering non-VA Federal research 
grants and private sector funds in support of VA research and 
education.
    The fundamental purpose of the nonprofits is to serve veterans by 
supporting VA research and medical education to improve the quality of 
care that veterans receive. For example, a seed grant provided by the 
Palo Alto Institute for Research and Education (PAIRE) to a 
gastroenterology clinician-investigator resulted in his finding that an 
easily overlooked type of abnormality in the colon is the most likely 
type to turn cancerous, and is more common in this country than 
previously thought. This finding, reported on the front page of the 
March 5, 2008, New York Times and in the Journal of the American 
Medical Association, is changing colonoscopy practices and may well 
lead to widespread earlier detection of a cancer that is preventable or 
curable through surgery. During 2008 PAIRE made nine similar awards to 
VA Palo Alto investigators in the hope of equally significant research 
success down the road. Similarly, a few years ago funds administered by 
the Seattle Institute for Biomedical and Clinical Research (SIBCR) 
allowed a psychiatry clinician-investigator to test use of Prazosin, an 
inexpensive, already approved drug, for treatment of veterans with 
debilitating post-traumatic stress-related nightmares. The SIBCR 
funding allowed the investigator to accumulate positive preliminary 
data that then led to DOD and NIH awards to further test this promising 
treatment.
    Last year, the NPCs collectively administered more than $250 
million with expenditures that supported approximately 4,000 VA-
approved research and education programs. These nonprofits are 
dedicated solely to supporting VA and veterans. This includes providing 
VA with the services of nearly 2,500 without compensation (WOC) 
research employees who work side-by-side with VA-salaried employees, 
all in conformance with the VA background, security and training 
requirements such appointments entail.
    Beyond administering research projects and education activities, 
these nonprofits support a variety of VA research infrastructure and 
administrative expenses. As described above, they have provided seed 
and bridge funding for investigators; staffed animal care facilities; 
funded recruitment of clinician researchers; paid for research 
administrative and compliance personnel; supported staff and training 
for institutional review boards (IRBs); and much more.
         legislation would enhance and clarify npc authorities
    The purpose of title VI of S.252 is to modernize and clarify the 
1988 statute after 20 years of experience under its current terms. The 
NPCs have already proven themselves to be valued and effective 
``flexible funding mechanisms for the conduct of approved research.'' 
VA's most recent annual report to Congress regarding the NPCs stated, 
``The VA-affiliated NPCs continue to make a substantial contribution to 
the VA research and education missions.'' This legislation will further 
enhance their value to VA.
    The objectives of this legislation are consistent with the findings 
in the May 2008 VA Office of Inspector General (OIG) review of five 
NPCs and VHA's oversight of them. VHA is working hard to address the 
shortcomings in oversight that the OIG identified. NAVREF and the NPCs 
are working equally hard to ensure that NPCs have appropriate controls 
over funds and equipment (including strengthening the documentation for 
all transactions), and that all NPC officers, directors and employees 
are certifying their awareness of the applicable Federal conflict of 
interest regulations. While NAVREF firmly believes that NPC boards and 
administrative employees strive to be conscientious stewards of NPC 
funds, NAVREF thanks the OIG for its thorough review of those five NPCs 
and for bringing to light these areas in need of improvement.
    It is noteworthy that the OIG report cited no misuse of funds or 
instances of conflicts of interest, no dual compensation of Federal 
employees and no fraud. However, we take very seriously the OIG finding 
that these NPCs nonetheless may not have had adequate controls over 
some of the funds they manage. Two major provisions in title VI of 
S.252 directly address this finding:

          First, section 601 allows voluntary formation of ``multi-
        medical center research corporations.'' That is, two or more VA 
        medical centers may share one NPC, subject to board and VA 
        approval, while preserving their fundamental nature as medical 
        center-based organizations. This provision--the centerpiece of 
        the legislation--will allow interested VA facilities with small 
        research programs to join with larger ones. Or several smaller 
        facilities may pool their resources to support management of 
        one NPC with funds and staffing adequate to ensure an 
        appropriate level of internal controls, including segregation 
        of financial duties.
          Second, the last item in section 604(a)--``(e) Policies and 
        Procedures''--addresses the OIG criticism by broadening VA's 
        ability to guide NPC expenditures. The only constraint on VA is 
        that such guidance must be consistent with other Federal and 
        State requirements as specified in laws, regulations, executive 
        orders, circulars and directives--of which there are many--
        applicable to other 501(c)(3) organizations. The purpose of 
        this limitation is to prevent the possibility of imposing on 
        NPCs conflicting requirements and to ensure that they remain 
        independent ``flexible funding mechanisms.''

    Title VI of S.252 provides a number of other welcome enhancements 
to the NPC authorizing statute.

     Section 603(b)(2) of the bill broadens the qualifications 
for the two mandatory non-VA board members beyond familiarity with 
medical research and education. This will allow NPCs to use these board 
positions to acquire the legal and financial expertise needed to ensure 
sound governance and financial management.
     Section 603(c) deletes the overly broad stipulation in the 
current statute that these non-VA board members may not have ``any 
financial relationship'' with any for-profit entity that is a source of 
funding for VA research or education. This absolute prohibition 
conflicts with regulations applicable to Federal employees with respect 
to conflicts of interest, which are invoked for all NPC directors and 
employees in section 7366(c)(1) of title 38, United States Code. Unlike 
the standard currently applied to NPC board members, Federal conflict 
of interest regulations provide means of recusal as well as de minimus 
exceptions. Additionally, the current prohibition may be applied to any 
individual who has accepted compensation or reimbursement from a for-
profit sponsor of VA research for purposes unrelated to VA research, 
thereby eliminating many otherwise desirable and qualified individuals 
from serving on NPC boards.
     Section 604(a)--(a)(1)(C) increases the efficiency of NPC 
administration of funds generated by educational activities. This 
clause allows NPCs to charge registration fees for the education and 
training programs they administer, and to retain such funds to offset 
program expenses or for future educational purposes. However, it also 
explicitly sustains the existing prohibition against NPCs accepting 
fees derived from VA appropriations.
     Section 604(a)--(a)(1)(D) provides NPCs with authority to 
reimburse the Office of General Counsel (OGC) for legal services 
related to review and approval of Cooperative Research and Development 
Agreements (CRADAs), the form of agreement used to establish terms and 
conditions for industry-funded studies performed at VA medical centers 
and administered by NPCs. Although OGC is already obligated to review 
these agreements without reimbursement, the funds generated under this 
provision would help OGC to staff Regional Counsel offices to 
accommodate the substantial workload these agreements entail and to 
provide training for VA attorneys in CRADA requirements and related VA 
policies. The NPCs support making these reimbursements.
     Section 604(a)--(b)(2) of the legislation provides VA with 
authority to reimburse NPCs for the salary and benefits of NPC 
employees loaned to VA under Intergovernmental Personnel Act (IPA) 
assignments conducted in accordance with section 3371 of title 5, 
United States Code. This provision responds to recent OIG questions 
asking whether such reimbursements are allowable and permits VA to 
continue to benefit from this efficient and cost-effective mechanism to 
acquire the temporary services of skilled research personnel.
     Section 604(a)--(b)(3) establishes explicit authority for 
VAMCs to accept funds provided by NPCs that may fall outside of VA's 
gift acceptance authority. It also allows VAMCs to retain such funds 
locally and to deposit them in the appropriate VA account without 
having to route them through the Treasury, necessitating cumbersome 
steps to get the funds to the right VA account. Finally, this provision 
makes these reimbursements ``no year'' money to give VAMCs needed 
flexibility in timing for use of the funds.
    Although VA has broad authority to accept gifts (38 U.S.C. Sec.  
8301), many NPC payments to VAMCs are more accurately described as 
reimbursements to the VAMC or payments for services and may not be 
consistent with VA's gift acceptance authority. For example, NPCs 
typically reimburse VAMCs for the cost of clinical services provided 
exclusively for research purposes; VA employees' time spent on NPC-
administered programs; and animal per diems. This clause also will 
allow VA to resolve longstanding VAMC uncertainty about how to treat 
such reimbursements and will let the VAMC that incurred the cost retain 
the amounts reimbursed. Currently, VAMCs must send such reimbursements 
to the Treasury and then the Fiscal Office must use a cumbersome 
process to bring the funds back to the VAMC.

    Title VI of S.252 also contains a number of useful clarifications 
of NPC status and purposes.

     Sections 601(b), (c) and (d) codify--without changing--the 
legal status of the NPCs as state-chartered, independent organizations 
exempt from taxation under section 501(c)(3) of the Internal Revenue 
Service (IRS) code and subject to VA oversight and regulation. Clause 
601(c) codifies the congressional intent, previously expressed in the 
House report that accompanied the original NPC authorizing statute (H. 
Rept. 100-373), that nonprofits established under this authority would 
not be corporations controlled or owned by the government. As a result, 
this legislation resolves longstanding differences of opinion among 
stakeholders, overseers and funding sources about the legal status of 
NPCs.
     Section 602(a)(1) of the legislation establishes that in 
addition to administering research projects and education activities, 
NPCs may support ``functions related to the conduct of research and 
education.'' This resolves differences of opinion about the 
appropriateness of NPC expenditures that support VA research and 
education generally, such as purchase of core research equipment used 
by many researchers for multiple projects, and enhances the value of 
NPCs to VA facilities.
     Section 604(a)--(c) ascertains that all NPC-administered 
research projects must undergo ``scientific'' rather than ``peer'' 
review. This change recognizes that peer review is not necessary or 
appropriate for all research projects administered by NPCs. However, 
the legislation leaves in place the overarching requirement for VA 
approval and the medical center's Research and Development Committee 
remains in a position to determine on a case-by-case basis whether a 
project also requires peer review as a condition of VA approval.

    In addition to these enhancements and clarifications, title VI of 
S.252 legislation reorganizes the NPC authorizing statute to put all 
provisions regarding their establishment and status in one section; 
describes their purposes in another; and gathers in one section the 
clauses enumerating their powers. Other revisions are largely technical 
and conforming amendments.
  proposed legislation preserves measures providing oversight of npcs
    Title VI of S.252 makes no changes in VA's power to regulate and 
oversee the NPCs. Further, NPC records remain fully available to the 
Secretary and his designees; to the Inspector General; and to the 
Government Accountability Office (GAO). Likewise, NPCs are still 
required to undergo an annual audit by an independent auditor in 
accordance with the sources--Federal or private--and the amount of 
their prior year revenues, and they must submit to VA an annual report 
that includes the resulting audit report along with detailed financial 
information and descriptions of accomplishments.
    In the wake of the Sarbanes-Oxley Act and changing Federal 
Accounting Standards Board (FASB) auditing standards, even the most 
basic form of nonprofit audit has become an effective means for 
assessing an organization's financial controls. Additionally, the 
percentage of NPC funds subject to audits conducted in accordance with 
OMB Circular A-133, the most rigorous level of applicable auditing 
standards, will continue to increase as more NPCs assume responsibility 
for non-VA Federal grants. According to reports submitted to VA in June 
2008, nearly 80 percent of prior year NPC expenditures were subject to 
an A-133 audit and overall, 99.7 percent of NPC expenditures were 
subject to an audit of one type or another. These audits are 
comprehensive and provide a sound framework for examining an 
organization's controls over funds as well as compliance with program 
requirements.
                               conclusion
    In conclusion, NAVREF urges the Congress to enact title VI of S.252 
at the earliest possible opportunity. The NPCs are already a highly 
efficient means to maximize the benefits to VA of externally-funded 
research conducted in VA facilities, ably serving to facilitate 
research and education that benefit veterans. Additionally, they foster 
vibrant research environments at VA medical centers, enhancing VA's 
ability to recruit and retain clinician-investigators and other 
talented staff who in turn apply their knowledge to state-of-the-art 
care for veterans.
    Twenty years after the VA-NPC public-private partnership was first 
authorized by Congress, this is a timely opportunity to update and 
clarify the NPCs' enabling legislation. This legislation will 
accomplish those objectives. Experience working within the current 
statute has brought to light its many strengths, but also areas that 
will benefit from modification, enhancement and updating, particularly 
in light of the increasing complexity of both research and nonprofit 
compliance. We believe enactment of title VI of S.252 will allow NPCs 
to better achieve their potential to support VA research and education 
while ensuring VA and congressional confidence in their management.
    NAVREF thanks the Senate Committee on Veterans' Affairs and its 
staff members for their work on title VI of S.252. We look forward to 
working with the Members of the Committee toward enactment of this 
bill. Please direct any questions you 
may have to NAVREF Executive Director Barbara West at 301-656-5005 or 
[email protected].
                                 ______
                                 
   Prepared Statement of Barbara Cohoon, Deputy Director, Government 
          Relations, The National Military Family Association
    National Military Family Association is the leading nonprofit 
organization committed to improving the lives of military families. Our 
40 years of accomplishments have made us a trusted resource for 
families and the Nation's leaders. We have been at the vanguard of 
promoting an appropriate quality-of-life for active duty, National 
Guard, Reserve members, retired servicemembers, their families, and 
survivors from the seven uniformed services: Army, Navy, Air Force, 
Marine Corps, Coast Guard, Public Health Service, and the National 
Oceanic and Atmospheric Administration.
    Association Representatives in military communities worldwide 
provide a direct link between military families and the Association 
staff in the Nation's capital. These volunteer Representatives are our 
``eyes and ears,'' bringing shared local concerns to national 
attention.
    The Association does not have or receive Federal grants or 
contracts.
    Our Web site is: http://www.nmfa.org.

    Chairman Akaka and Distinguished Members of this Committee, the 
National Military Family Association would like to thank you for the 
opportunity to present written testimony for the record on ``Family 
Caregiver Program Act of 2009.'' We thank you for this legislation's 
recognition of the integral role caregivers serve in managing both 
medical and non-medical care of our wounded, ill, and injured veterans. 
The proposed legislation ensures access to quality health care and 
mental health care for our wounded, ill, and injured veterans' 
caregivers and provides them the opportunity for training, 
certification, and compensation.
    National Military Family Association applauds Chairman Akaka, 
Senator Burr, and Senator Rockefeller for this legislation. The intent 
of the legislation is to recognize the important role caregivers play 
in caring for our veterans. Research has shown the quality-of-life of 
our wounded, ill, and injured veterans can be directly linked to the 
level of caregiver involvement. It is because of the caregiver's 
dedication our veterans get timely quality care and they are also 
strong advocates who oversee the rehabilitation process.
    The legislation addresses the special conditions and behaviors 
presented by veterans with a wide range of diagnosis. The definition of 
``severe injury'' captures not only physiological conditions and 
psychological, but the inclusion of ``an injury for which a veteran 
needs supervision or protection based on symptoms or residuals of 
neurological or other impairment.'' This provision is key with our 
Traumatic Brain Injury (TBI) injured veterans and the individuals who 
care for them.
    We especially appreciate the fact this proposal has a more 
inclusive view for caregivers then other legislation previously 
introduced. Your legislation includes a provision for medical care, has 
a provision to expand coverage to other veteran caregivers in the 
future, and is more than a pilot study for a select few caregivers.
    However, there are some areas of the legislation with which we have 
concerns and believe need further clarification.
    Section 2 allows for ``emergency'' care for caregivers attending a 
VA facility; however, this is a ``may'' and not a ``shall.'' A true 
emergency must be addressed by a hospital when you are physically 
present on their premises. For example, Congress enacted the Emergency 
Medical Treatment and Labor Act (EMTALA) in 1986 to ensure the public 
access to emergency treatment regardless of ability to pay. Health care 
providers have an ethical requirement to ``do no harm'' and not 
providing care would cause harm. Hospitals are already allowed to 
provide emergency services and then bill if the individual has 
insurance. We understand co-pays and out-of-pocket expenses may be 
involved, but hospitals have the right to waive those fees. Another 
concern is what constitutes ``emergency'' care? Who will decide this, 
especially as the event is unfolding in real time? The National Defense 
Authorization Act for Fiscal Year 2008 (NDAA FY08) Section 1672 
provides for medical care at Department of Defense (DOD) Military 
Treatment Facilities (MTFs) or Department of Veterans Affairs (VA) 
facilities on a space-available basis authorized for certain family 
members, not otherwise eligible for medical care, caring for a 
recovering servicemember. According to a briefing by General Elder 
Granger, Deputy Director and Program Executive Officer for TRICARE 
Management Activity, on April 13, 2009, DOD has implemented this 
Section of the NDAA FY08. This law allows for non-emergent care. How 
has the VA complied with this law in allowing access to care for 
caregivers?
    The long extensive list of ``family members'' is appreciative. Most 
individuals and government agencies recognize and understand the blood 
and marriage connection. However, the list left off ``significant 
other'' and ``fiancee,'' which we frequently hear are part of the 
caregiver structure. We see the added provision for the Secretary of 
the Department of Veterans Affairs to add additional people; however, 
we find that these additional caregivers are often not recognized by 
DOD as eligible. The difference between DOD and VA in regards to a 
caregiver definition and eligibility is important because the choice or 
self selection of the caregiver begins while the wounded, ill, and 
injured servicemember is still on active duty. According to the VA, `` 
`informal' caregivers are people such as a spouse or significant other 
or partner, family member, neighbor or friend who generously gives 
their time and energy to provide whatever assistance is needed to the 
veteran.'' We would like to make sure the definition of caregiver 
eligibility is broad enough to capture additional individuals.
    The provision regarding the date of enactment is confusing. We 
understand the intent to start with a certain population, Sept. 11, 
2001, and then go back and possibly increase the population to earlier 
veterans' caregivers, but it is hard to glean that information from the 
written language. We support the expansion of the program to cover all 
eligible veteran caregivers.
    The provision outlining additional instruction and allowing the 
caregiver to be certified as a personal care attendant is dependent on 
the Secretary. It states, the Secretary ``may'' provide these services. 
Caregivers are not guaranteed the opportunity to become certified and 
be eligible for additional instruction and training. Certification will 
be key in determining the level of care and the scope of practice the 
caregiver can provide and affecting the amount of compensation they 
could 
receive.
    The provision on certified personal care attendant versus 
designates needs further clarification. The legislation provides for a 
``certified'' personal care attendant to receive technical support, 
counseling, and internet access and allows the ``designated'' personal 
care attendant to qualify for mental health services, respite care, 
medical care, and a stipend. We don't understand why one qualifies for 
counseling and the other mental health? What would be the difference in 
services? Adding to the confusion is the fact the designated personal 
care attendant qualifies for health care, which should cover mental 
health services. We would appreciate further clarification on the 
eligibility sequencing. It is hard to determine if there are two levels 
of eligible caregiver services or if both caregiver categories can be 
eligible for one or the other. For example, must the caregiver first 
qualify for one in order to be eligible for the other? If so, then 
which category must they qualify for first? It would make more sense 
for there to be a lower level entry first, which would be your 
``designated'' personal care attendant, and they would then be eligible 
for the higher level, the ``certified'' personal care attendant, and 
receive additional services.
    What constitutes ``protection?'' Is it physical protection from 
physical injury, such as someone who is prone to falls and is in need 
of bed rails? Or, does it encompass a much broader definition that 
would include overall safety concerns, such as crossing the street by 
themselves and navigating their way on public transportation? Our 
Association would support the adoption of a more expansive definition 
involving overall safety concerns for the veteran.
    National Military Family Association will also take the opportunity 
to discuss several issues of importance to wounded, ill, and injured 
servicemembers, veterans, and their families in the following subject 
areas:

        I. Wounded Service Members Have Wounded Families
        II. Who Are the Families of Wounded Service Members?
        III. Caregivers
        IV. Mental Health
             wounded service members have wounded families
    National Military Family Association asserts that behind every 
wounded servicemember and veteran is a wounded family. Spouses, 
children, parents, and siblings of servicemembers injured defending our 
country experience many uncertainties. Fear of the unknown and what 
lies ahead in future weeks, months, and even years, weighs heavily on 
their minds.
    Transitions can be especially problematic for wounded, ill, and 
injured servicemembers, veterans, and their families. DOD and the VA 
health care systems, along with State agency involvement, should 
alleviate, not heighten these concerns. National Military Family 
Association believes the government must take a more inclusive view of 
military and veterans' families. Those who have the responsibility to 
care for the wounded servicemember must also consider the needs of the 
spouse, children, parents of single servicemembers, siblings, and 
especially the caregivers.
            who are the families of wounded servicemembers?
    In the past, the VA and the DOD have generally focused their 
benefit packages for a servicemember's family on his/her spouse and 
children. Now, however, it is not unusual to see the parents and 
siblings of a single servicemember presented as part of the 
servicemember's family unit. In the active duty, National Guard, and 
Reserve almost 50 percent of the members are single. Having a wounded 
servicemember is new territory for family units. Whether the 
servicemember is married or single, their families will be affected in 
some way by the injury. As more single servicemembers are wounded, more 
parents and siblings must take on the role of helping their son, 
daughter, or sibling through the recovery process. Family members are 
an integral part of the health care team. Their presence has been shown 
to improve the servicemember and veteran's quality-of-life and aid in a 
speedy recovery.
    National Military Family Association recently gathered information 
about issues affecting our wounded servicemembers, veterans, and their 
families through our Operation Purple Healing Adventure Camp 
in August 2008 and a focus group held March 2008 at Camp Lejeune. 
Families said following the injury, they find themselves having to 
redefine their roles. They must learn how to parent and become a 
spouse/lover with an injury. Spouses talked about the stress their new 
role as caregiver has placed on them and their families. Often 
overwhelmed, they feel as if they have no place to turn to for help.
                               caregivers
    Caregivers need to be recognized for the important role they play 
in the care of their loved one. Without them, the quality-of-life of 
the wounded servicemembers and veterans, such as physical, psycho-
social, and mental health, would be significantly compromised. They are 
viewed as an invaluable resource to DOD and VA health care providers 
because they tend to the needs of the servicemembers and the veterans 
on a regular basis. Their daily involvement saves DOD, VA, and State 
agency health care dollars in the long run.
    Caregivers of the severely wounded, ill, and injured services 
members who are now veterans have a long road ahead of them. In order 
to perform their job well, they must be given the skills to be 
successful. This will require the VA to train them through a 
standardized, certified program, and appropriately compensate them for 
the care they provide. National Military Family Association is pleased 
with the ``Family Caregiver Program Act of 2009'' legislation that will 
provide for the training, certification, and compensation for injured 
servicemembers or veterans. This legislation places VA in an active 
role in recognizing caregivers' important contributions and enabling 
them to become better caregivers to their loved ones. It is a ``win 
win'' for everyone involved.
    The VA currently has eight caregiver assistance pilot programs to 
expand and improve health care education and provide needed training 
and resources for caregivers who assist disabled and aging veterans in 
their homes. These pilot programs are important, but there is a strong 
need for 24-hour in-home respite care, 24-hour supervision, emotional 
support for caregivers living in rural areas, and coping skills to 
manage both the veteran's and caregiver's stress. These pilot programs, 
if found successful, should be implemented by the VA as soon as 
possible and fully funded by Congress. However, one program not 
addressed is the need for adequate child care. Veterans can be single 
parents or the caregiver may have non-school aged children of their 
own. Each needs the availability of child care in order to attend their 
medical appointments, especially mental health appointments. Our 
Association encourages the VA to create a drop-in child care for 
medical appointments on their premises or partner with other 
organizations to provide this valuable service.
                          relocation allowance
    Active Duty servicemembers and their spouses qualify through the 
DOD for military orders to move their household goods (known as a 
Permanent Change of Station (PCS)) when they leave the military 
service. Medically retired servicemembers are given a final PCS move. 
Medically retired married servicemembers are allowed to move their 
family; however, medically retired single servicemembers only qualify 
for moving their own personal goods.
    National Military Family Association is requesting the ability for 
medically retired single servicemembers to be allowed the opportunity 
to have their caregiver's household goods moved as a part of the 
medical retired single servicemember's PCS move. This should be allowed 
for the qualified caregiver of the wounded servicemember and the 
caregiver's family (if warranted), such as a sibling who is married 
with children or mom and dad. This would allow for the entire 
caregiver's family to move, not just the caregiver. The reason for the 
move is to allow the medically retired single servicemember the 
opportunity to relocate with their caregiver to an area offering the 
best medical care, rather than the current option that only allows for 
the medically retired single servicemember to move their belongings to 
where the caregiver currently resides. The current option may not be 
ideal because the area in which the caregiver lives may not be able to 
provide all the health care services required for treating and caring 
for the medically retired servicemember. Instead of trying to create 
the services in the area, a better solution may be to allow the 
medically retired servicemember, their caregiver, and the caregiver's 
family to relocate to an area where services already exist, such as a 
VA Polytrauma Center.
    The decision on where to relocate for optimum care should be made 
with the Federal Recovery Coordinator (case manager), the 
servicemember's physician, the servicemember, and the caregiver. All 
aspects of care for the medically retired servicemember and their 
caregiver shall be considered. These include a holistic examination of 
the medically retired servicemember, the caregiver, and the caregiver's 
family for, but not limited to, their needs and opportunities for 
health care, employment, transportation, and education. The priority 
for the relocation should be where the best quality of services is 
readily available for the medically retired servicemember and his/her 
caregiver.
    The consideration for a temporary partial shipment of caregiver's 
household goods may also be allowed, if deemed necessary by the case 
management team.
                             mental health
    Families' needs for a full spectrum of mental health services--from 
preventative care and stress reduction techniques, to individual or 
family counseling, to medical mental health services--will continue to 
grow. It is important to note if DOD has not been effective in the 
prevention and treatment of mental health issues, the residual will 
spill over into the VA health care system. The need for mental health 
services will remain high for some time even after military operations 
scale down and servicemembers and their families transition to veteran 
status. The VA must be ready. They must partner with DOD and State 
agencies in order to address mental health issues early on in the 
process and provide transitional mental health programs. They must 
maintain robust rehabilitation and reintegration programs for veterans 
and their families that will require VA's attention over the long-term. 
National Military Family Association recommends Congress require Vet 
Centers and the VA to develop a holistic approach to veteran care by 
including their families in providing mental health counseling and 
other programs.
    National Military Family Association is especially concerned with 
the scarcity of services available to the families as they leave the 
military following the end of their activation or enlistment. They may 
be eligible for a variety of health programs, such as TRICARE Reserve 
Select, TRICARE, or VA. Many will choose to locate in rural areas where 
there may be no mental health providers available. We ask you to 
address the distance issues families face in linking with mental health 
resources and obtaining appropriate care. Many isolated veterans and 
their families do not have the benefit of the safety net of services 
and programs provided by MTFs, VA facilities, Community-Based 
Outpatient Centers, and Vet Centers. Our Association recommends the use 
of alternative treatment methods, such as telemental health. Another 
solution is modifying licensing requirements in order to remove 
geographical practice barriers preventing mental health providers from 
participating in telemental health services outside of a VA facility.
    The VA must educate their health care and mental health 
professionals, along with veterans' families of the effects of mild 
Traumatic Brain Injury (TBI) in order to help accurately diagnose and 
treat the veteran's condition. Veterans' families are on the ``sharp 
end of the spear'' and are more likely to pick up on changes 
contributed to either condition and relay this information to VA 
providers. Our Association recommends spouses and parents of returning 
servicemembers and veterans need programs providing education on 
identifying mental health, substance abuse, suicide, and Traumatic 
Brain Injury.
    VA mental and health care providers must be able to deal with 
polytrauma--Post Traumatic Stress Disorder (PTSD) in combination with 
multiple physical injuries. National Military Family Association 
appreciates Congress establishing the National Center of Excellence and 
the Defense Center of Excellence. It is very important for DOD and VA 
to partner in researching TBI and PTSD. We believe the VA needs to 
educate their civilian health care providers on how to identify signs 
and symptoms of mild TBI and PTSD. As the VA incorporates Project Hero, 
they must educate civilian network mental health providers about our 
military culture.
              information technology (it) interoperability
    The DOD, VA, and State agencies, along with civilian providers, 
need to work together, creating a seamless transfer of medical record 
information regarding health care services received by our 
servicemembers, veterans, National Guard and Reserve members, retirees 
and their families and survivors. Interoperability, especially between 
DOD and VA, is crucial. A recent visit to the Naval Branch Medical 
Clinic Key West found servicemembers and their families utilizing a VA 
provider. This clinic is a joint facility. There are systems in place 
for sharing of data between the two agencies' electronic health 
servers, yet staff at the clinic were unable to access this option. 
Medical records were being hand carried and manually entered into the 
receiving health care server. As we move toward more joint facility 
operations, medical record information must be easily accessed and 
transferred between agency servers. This is especially important for 
our wounded, ill, and injured servicemembers who frequently transfer 
between the two agencies' health care systems and, eventually, from 
active duty status to veteran status. We encourage Congress to 
adequately fund VA and DOD IT interoperability.
                       senior oversight committee
    Our Association is appreciative of the provision in the NDAA FY09 
continuing the DOD/VA Senior Oversight Committee (SOC) for an 
additional year. We understand a permanent structure is in the process 
of being established and manned. We urge Congress to put a mechanism in 
place to continue to monitor DOD and VA's partnership initiatives for 
our wounded, ill, and injured servicemembers and their families, while 
this organization is being created.
    National Military Family Association proposes the top agenda items 
that would benefit veterans, wounded servicemembers, their families, 
and survivors are:

     Coordination and collaboration of health care and 
behavioral health care services between the VA, DOD, and State and 
governmental agencies in sharing of resources;
     Provision of sufficient, timely, and accurate funding for 
VA benefits and services;
     Train, certify, compensate, and provide benefits to 
include health care for the caregivers of our severely wounded 
servicemembers and veterans;
     Increased respite care for severely wounded veterans and 
their caregivers;
     Increased access to behavioral health services for 
survivors, caregivers of wounded servicemembers and veterans, and their 
families;
     Increased outreach to veterans, their families, and the 
communities they live in about available benefits and services, 
including education on the signs and symptoms of behavioral health 
conditions and available resources;
     Continue to quickly and efficiently address the needs of 
our wounded servicemembers, veterans, and their families regarding 
transition, IT sharing, and joint facility operations; and
     Inclusion of senior DOD and VA leaders, along with 
respective VSOs and MSOs regarding the discussion of a National health 
care agenda by Congress because of its potential impact on both health 
care systems and the veteran, servicemember, and their families.

    National Military Family Association would like to thank you again 
for the opportunity to present testimony for the record on the ``Family 
Caregiver Program Act of 2009'' for veterans and their caregivers. 
Military families support the Nation's military missions. The least 
their country can do is make sure servicemembers, veterans, and their 
families have consistent access to high quality health care in DOD and 
VA. Wounded servicemembers and veterans have wounded families. The 
caregiver must be supported by the VA by providing training, 
certification, and compensation for the care of their loved one. The 
system should provide coordination of care and DOD and VA to work 
together to create a seamless transition. We ask this Committee to 
assist in meeting that responsibility.
    We look forward to working with you to improve the quality-of-life 
for veterans and their families.
                                 ______
                                 
   Prepared Statement of the Nurses Organization of Veterans Affairs
    Mr. Chairman, Ranking Member Burr and other Members of the 
Committee: The Nurses Organization of Veterans Affairs (NOVA) is the 
professional organization of the approximately 40,000 registered nurses 
employed by the Department Affairs. NOVA is committed to providing high 
quality care to our Nation's veterans.
                                 s.362
    NOVA appreciates the opportunity to provide input into S.362, 
legislation that would allow VA health care professionals to bargain 
over the issue of Clinical Competency, Clinical Conduct, Title 38 
Compensation and Peer Review. NOVA is opposed to this legislation.
Summary:
    This bill would remove from the existing Title 38 collective 
bargaining statute the provisions that bar bargaining and grievances 
over issues relating to direct patient care, clinical competence, peer 
review, or Title 38 compensation. It would also repeal the statutory 
provision that authorizes the VA Secretary to determine whether a 
particular union proposal or grievance is subject to one of those 
subject matter exclusions.
    While proponents of the bill assert that it will ``restore'' 
collective bargaining rights for VA doctors, nurses, and other medical 
professionals, those employees have never had the right to bargain over 
the subjects excluded by the current statute. If this bill were to 
pass, VA would be required to bargain over patient care issues, 
clinical competence issues, peer review processes, and the 
discretionary aspects of Title 38 compensation (e.g. nurse locality pay 
and physicians' market pay and performance pay) to an extent that is 
unprecedented and would represent an unwarranted intrusion into the way 
that VHA manages its clinical practices and adjusts pay for physicians 
and nurses. Quality of care delivered to patients should not be subject 
to negotiation.
Background:
1. The existing statute.
    An existing provision of the Title 38 personnel statute, 38 U.S.C. 
Sec.  7422, was enacted in 1991 to authorize VA physicians, nurses, and 
other Title 38 medical professionals to engage in collective 
bargaining. Prior to 1991, VA physicians and nurses were not authorized 
to engage in collective bargaining because they were not covered by the 
Title 5 statute that authorizes bargaining for most Federal employees.
            a. What the existing statute says:
    Subsection (a) of section 7422 generally authorizes Title 38 
medical professionals to engage in bargaining under the Title 5 
collective bargaining rules that apply to other Federal employees.
    Subsection (b) of section 7422 excludes from Title 38 medical 
professionals' bargaining rights (and from any grievance procedure 
provided under a collective bargaining agreement) three specific 
subjects:

     professional conduct or competence (which subsection (c) 
of the statute defines to mean clinical competence or direct patient 
care);
     peer review (the process by which Professional Standards 
Boards and other peer review entities review medical professionals' 
clinical skills); and
     the establishment, determination, and adjustment of Title 
38 employee compensation (which in general means that VA doctors and 
nurses, like other Federal employees, can't bargain over their pay, but 
for slightly different reasons).

    Subsection (d) of section 7422 authorizes the VA Secretary to 
determine whether a particular bargaining proposal or union grievance 
is subject to one of the exclusions set forth in 38 U.S.C. Sec.  
7422(b). The VA Secretary has delegated that authority to the Under 
Secretary for Health.
    Subsection (e) of section 7422 says that only the U.S. Court of 
Appeals for the District of Columbia Circuit can hear certain types of 
cases relating to collective bargaining for Title 38 medical 
professionals.
            b. The legislative history of the existing statute:
    The current version of 38 U.S.C. Sec.  7422 was sponsored by 
Senator Alan Cranston (D-CA), the then-Chairman of the Senate Veterans' 
Affairs Committee. Senator Cranston and his colleagues worked for 
several years, over several sessions of Congress, to craft a compromise 
bill that would extend collective bargaining rights to VA doctors and 
nurses under terms that were acceptable to all stakeholders, including 
labor unions, physicians' and nurses' professional associations, 
Veterans' Service Organizations, and the Department. Senator Cranston's 
remarks to the Senate when he introduced the new law indicate that the 
statute was intended to strike a balance between inherently conflicting 
interests, i.e., between the interests of VA physicians and nurses to 
engage in collective bargaining, and of the Department and its veteran 
patients to ensure patient care is not compromised by the collective 
bargaining process.
2. Proposed bill.
    S.362 proposes to amend title 38, United States Code, ``to improve 
the collective bargaining rights and procedures for review of adverse 
actions of certain employees of the Department of Veterans Affairs.'' 
If enacted, this bill would:

     Repeal the collective bargaining exclusions for 
professional conduct or competence, peer review, and employee 
compensation that are currently set forth in 38 U.S.C. Sec.  7422(b);
     Repeal the provisions of 38 U.S.C. Sec.  7422(c) and (d) 
that define the 7422(b) exclusions and authorize the Secretary to 
determine whether a particular union proposal or grievance is excluded; 
and
     Modify certain provisions of 38 U.S.C. Sec. Sec.  7462 and 
7463 relating to Title 38 medical professionals' adverse action appeal 
rights.

    The effect of S.362 would be to require VA to bargain over issues 
of clinical competence, patient care, peer review, and employee 
compensation that are currently excluded from bargaining. Moreover, the 
bill would allow arbitrators, through rulings on grievances filed 
through the negotiated grievance procedure, to substitute their own 
judgment for the judgment of VA managers and clinicians on these 
issues. Examples of issues that are currently excluded from union 
bargaining and grievances, but would be subject to bargaining and the 
negotiated grievance procedure under the Filner legislation, include 
the following:

     Mandatory TB testing for employees
     Professional Standard's Board restricting a provider's 
clinical privileges due to competency issues.
     Work schedules for physicians and nurses, including 
alternative or compressed work schedules;
     The amount of market pay recommended for a particular 
physician by a Physician Compensation Panel or approved for that 
physician by a VAMC Director;
     The adjustment of locality pay for nurses at a particular 
VAMC or within a particular work unit;
     The selection of a particular RN or physician for a 
specialized work assignment for clinical competence reasons;
     A Professional Standards Board's assessment of a 
provider's clinical competence;
     A Physical Standards Board's assessment of a provider's 
mental or physical fitness for duty; and
     The decision of a VAMC Director to require staff 
psychiatrists to rotate weekend call duty, rather than relying on the 
Medical Officer of the Day to assess patients' emergent mental health 
needs.

    Consider that without the Title 38 collective bargaining 
exclusions, the Department would be unable to respond expeditiously to 
changes in veterans' health care needs. For example, as the need for 
expanded mental health services for returning OEF/OIF veterans became 
clear, the Department was able to quickly set up a dedicated Suicide 
Prevention hotline and to assign qualified medical professionals to 
staff the hotline on a 24/7 basis. In the first 60 days of the Suicide 
Prevention hotline's existence, hundreds of veterans in critical need 
of mental health counseling called the hotline and received the care 
they needed. Absent the Title 38 collective bargaining exclusion for 
issues of direct patient care, the Department would have been required 
to bargain over the procedures by which employees would be assigned to 
the hotline before it could be implemented, resulting in unacceptable 
delays and potentially many lost lives.
    Finally, the Unions would have you think that the existing statute 
weakens the VA's ability to recruit and retain an adequate work force. 
To the contrary, one of the draws for the VA in being able to recruit 
high quality clinical staff is the high level of ``clinical 
competence'' of its existing workforce. Allowing the Unions status to 
address competency issues will only erode the high level of clinical 
competence that exists. The VA's current branding for recruitment is 
``The Best Care/The Best Careers.'' Nurses are drawn to the VA because 
of the quality of care VA nurses provide to the Veterans. VA Nurses are 
proud of their reputation of providing the best care.

          The Secretary has not abused his discretionary authority in 
        using 38 U.S.C. 7422 to exclude issues relating to direct 
        patient care, clinical competence, peer review, or Title 38 
        compensation. Of the issues that were decided by the Secretary 
        in 2008, approximately 41 percent were held to be partially or 
        fully negotiable.
          As is noted above, the current Title 38 statute was a 
        carefully crafted compromise bill that empowers VA doctors and 
        nurses to engage in collective bargaining while protecting from 
        compromise VA clinicians' patient care determinations and 
        related peer review and compensation adjustment processes. 
        S.362 would upset that careful balance in a way that is 
        unwarranted, unprecedented, and unwise at a time where 
        responding quickly to the needs of our Veterans is imperative.

    In conclusion, repeal of Title 38 Collective Bargaining exclusions 
would cripple VA's patient care mission by:

     Delaying critical changes in health care delivery and 
substituting the decisions of labor negotiators/arbitrators for 
clinician's professional judgment;
     Allowing the unions to decide whether or not it is 
appropriate if patient care needs dictate than an RN stay beyond their 
scheduled tour;
     Substituting staff preferences for tours of duty in lieu 
of patient care needs;
     Delay the detail of staff from one area of need to another 
until negotiations are completed; and
     All other issues pertaining to the clinical needs of our 
Veterans.

    NOVA understands that provisions in S.362 have been adopted by the 
Department of Defense (DOD); however we feel strongly that this policy 
cannot adequately be compared to the VA health care system. The unions 
have used the argument that Collective Bargaining within Walter Reed on 
issues of Clinical Competency, Clinical Conduct, Title 38 Compensation 
and Peer Review has not compromised patient care and should, therefore, 
also be adopted by VA. This is not a true comparison. DOD employs 
considerably fewer bargaining unit MDs and nurses than the VA does. DOD 
has approximately 500 bargaining unit physicians and 4,600 bargaining 
unit nurses while VA has 10,000 bargaining unit physicians and 50,000 
bargaining unit nurses. If absolutely necessary, NOVA would agree to 
the reestablishment of Mandatory Labor/Management Councils at each VA 
Facility and alternative legislative language as proposed by VA. NOVA 
is dedicated to the safe, quality care of America's heroes and thanks 
the Committee for considering NOVA's position on S.362.
                                 ______
                                 
  Prepared Statement of David J. Holway, National President, National 
       Association of Government Employees, SEIU/NAGE Local 5000
    On behalf of the National Association of Government Employees 
(SEIU/NAGE), and the more than 100,000 workers we represent, including 
20,000 at the Department of Veterans Affairs (VA), I would like to 
thank you for the opportunity to submit written testimony regarding 
pending health care legislation.
    SEIU/NAGE strongly supports S. 362. This bill would restore a 
meaningful scope of bargaining for Title 38 health care providers at 
the VA, a critical necessity to boost morale and strengthen recruitment 
and retention at the agency. Giving health care providers a meaningful 
voice in their workplace will lead to better care for the American 
veteran.
    In 1991, Congress amended Title 38 to provide VA medical 
professionals with collective bargaining rights, which include the 
rights to use the negotiated grievance procedure and arbitration. Under 
Sec. 7422 of Title 38 (``7422''), covered employees can negotiate, file 
grievances and arbitrate disputes over working conditions, except for 
matters concerning or arising out of professional conduct or 
competence, peer review, or compensation. Increasingly, VA management 
is interpreting these exceptions very broadly, and refusing to bargain 
over virtually every significant workplace issue impacting medical 
professionals. The broad interpretation 7422 is leading to significant 
dissatisfaction among rank-and-file VA health care providers.
    We have heard from our local members across the country, who have 
urged our union to make passage of S. 362 our top legislative priority 
for legislation impacting the VA workforce in the 111th Congress. Their 
concern is that too many highly qualified, outstanding health care 
professionals have left the VA for other employment because they were 
unsuccessful in getting someone of authority at the agency to listen to 
or address legitimate concerns because the issue fell under the ever-
growing umbrella of 7422.
    The agency has increasingly been unwilling to address those issues 
that are most important to Title 38 employees, including time 
schedules, shift rotations, evaluations, fair and equal opportunity to 
be considered for a different position within the facility, and fair 
treatment among colleagues. Rather than suffer under a system where 
they have no mechanism to provide input or air grievances, 
disenfranchised VA employees simply move on to other employment. It has 
gone on too long, and it has to stop.
    VA medical professionals have extremely limited collective 
bargaining rights in the first place, and the broad interpretation of 
7422 is narrowing the scope of bargaining to the point that it is 
practically meaningless. As a result, RNs, doctors, and other impacted 
employees at the VA are experiencing increased job stress, low morale 
and burnout. This in turn exacerbates the VA's well-documented 
recruitment and retention problems. Chronic short-staffing has been 
shown to adversely impact quality of care, patient safety, and 
workplace safety, leading to costly stopgap measures such as the 
overuse of contract nurses and doctors.
    I want to share a good example of the kind of management abuse that 
occurs at the VA when management has the unfettered discretion to 
attain a 7422 ruling, and therefore, take a seemingly bargainable issue 
off the table. We witnessed a case where a staff RN position was posted 
for nurse on an acute medical/surgical unit. Four RNs applied for the 
position, one of which had far more experience and competence by any 
reasonable measure than the other three. This was meaningful because 
the local collective bargaining agreement provided that when two or 
more equally competent nurses request to fill an open position, 
preference will be given to the most senior competent nurse. When the 
more senior competent nurse was passed up for the position in favor of 
a nurse with substantially less experience, the union filed a grievance 
on behalf of the more senior nurse. In the first step of the grievance, 
which involved the unit manager, no settlement could be reached. In the 
second step of the grievance, which involved the acting nurse 
executive, the unit manager's decision to hire the less experienced 
nurse was upheld. In the third step of the grievance, which involved 
the medical center director, our nurse's case was heard, but management 
chose to use their allotted time to respond after hearing our case. But 
management never ended up responding. Instead, at this late stage of 
the grievance process, the director notified the union that the 
grievance was a 7422 issue and was therefore not grievable. The union 
reminded the director that he did not have the authority to make that 
decision. The director then made a request for a 7422 ruling from the 
Under Secretary who did, in fact, render the grievance as a 7422 issue 
and therefore not grievable. This was extremely demoralizing to this 
nurse, who had spend years caring for the American veteran and 
rightfully deserved the position that was applied for.
    We see cases like this, and worse, every day at the VA. Our health 
care providers know that there is no use in even questioning 
management's decisions when they can always fall back on 7422 as a way 
to trump the efforts of the union to give Title 38 VA workers a fair 
shake. It is especially egregious that management can claim 7422 very 
late in the grievance process. Our local union representatives report 
management threatening to seek a 7422 decision over practically any 
issue they do not want to bargain over, and the disturbing thing about 
that is, in most cases, those managers will be granted their 7422 claim 
if it is requested.
    Additionally, we have seen cases where RNs have been denied union 
representation during fact-finding for a potential disciplinary action; 
the agency claimed this was a competence issue. We have been prevented 
from bargaining over nurse-patient ratios, which has resulted in 
geriatric nurses having as many as 30 patients in their care because of 
poor staffing. We have seen nurses sent on mandatory temporary 
reassignments that required them to take a shuttle bus from one 
facility to another that was approximately 60 miles away. We have seen 
management spontaneously cancel annual leave requests that were granted 
months in advance, because of chronic understaffing. This causes nurses 
to scrap vacation plans that may have been several months in the 
making.
    Health care providers at the VA are very frustrated with the kind 
of management style that has been demonstrated in many VA facilities in 
recent years, and they end up leaving because they do not have to take 
it. Most nurses and other health care providers can find equal or even 
higher paying jobs in private sector medical facilities in the same 
city or town where they are currently living; places where they can 
have a meaningful voice in their workplace. This is a major reason why 
maintaining staffing has been such a major concern at the VA. VA 
workers are not willing to tolerate being disrespected by the agency 
when they can go down the street to a private facility, where they can 
probably make more money while getting treated with dignity.
    Passing S. 362 would help to address many of these concerns. This 
bill would restore a meaningful scope of bargaining for Title 38 VA 
professionals by eliminating the ``7422 exceptions'' (conduct, 
competence, compensation, and peer review) under the law.
    Eliminating these exceptions will provide health care providers 
with the same rights as other VA providers, including psychologists, 
LPNs, and pharmacists, as well as other Federal employees. Title 5 
health care providers at the VA have full collective bargaining rights. 
Even nurses and doctors at Army Medical Centers such as Walter Reed, 
who perform the same exact function as nurses and doctors at the VA, 
have full collective bargaining rights. Most private sector health care 
providers have a meaningful voice in their workplace as well. Nowhere 
have we seen cases where collective bargaining has had a negative 
impact on patient care. There is no reason for Title 38 VA workers to 
have these critical rights taken away.
    Restoring meaningful bargaining rights will greatly increase morale 
at the VA. It will also serve to address recruitment and retention 
issues at the VA, which are critical at this time, given the veterans 
returning home from conflicts abroad. All this will lead to better care 
for our Nation's veterans.
    SEIU/NAGE greatly appreciates the Committee's decision to hold a 
hearing on pending health-related legislation. I thank the Committee 
for the opportunity to provide testimony.
                                 ______
                                 
   Prepared Statement by Luanne Long, RN, President, Hawai'i Nurses 
              Association, United American Nurses, AFL-CIO
    I would like to thank Chairman Akaka, Ranking Republican Member, 
and Members of the Committee for the opportunity to provide testimony 
for the hearing on S.362, legislation that will restore collective 
bargaining rights to registered nurses working in the Department of 
Veterans Affairs. My name is Luanne Long and I have been a registered 
nurse for over 21 years. I'm also the President of the Hawai'i Nurses 
Association and an 18 year Army veteran.
    I'm testifying today as a member of the United American Nurses AFL-
CIO, a union representing registered nurses--6,000 of whom are VA 
nurses. I will give my testimony from the perspective of a nurse labor 
leader, as well as a veteran who has used the VA health care system.
    There exists a health care crisis in our country regarding the 
shortage of registered nurses. A 2002 report by the Health Resources 
and Services Administration states that, by 2020 hospitals will be 
short 808,416 RNs. In a 2002 survey by the United American Nurses, 
three out of every ten nurses said it was unlikely they would be a 
hospital staff nurse in 5 years. The VA health care system has by no 
means been immune to the shortage.
    As nurses leave the VA system, new nurses are not joining the VA at 
comparable rates, and patient load is increasing. In its own report, 
``A Call to Action,'' the VA states that it must replace up to 5.3 
percent of its RN workforce per year to keep up with RNs retiring. By 
all accounts, that is not happening. In its web site documentation of 
system-wide capacities, VA statistics show that between 1996 and 2002 
the number of full-time-equivalent RNs went down by 8.4 percent. During 
that same time period, the number of ``unique patients'' treated at the 
VA went up by 55 percent.
    Congress amended Title 38 to provide medical professionals who work 
at VA facilities with collective bargaining rights, which include the 
rights to use the negotiated grievance procedure and arbitration. Under 
38 U.S.C., section 7422, covered employees can negotiate, file 
grievances and arbitrate disputes over working conditions except ``any 
matter or question concerning or arising out of:''

     professional conduct or competence (defined as direct 
patient care or clinical competence;
     peer review; or
     the establishment, determination, or adjustment of 
employee compensation.

    Increasingly, VA management has interpreted these exceptions very 
broadly, and has refused to bargain over significant workplace issues 
affecting medical professionals. Recent court decisions are upholding 
the VA's broad reading of Section 7422, even when management raises it 
after completion of the arbitration process.
    Congress recognized the benefits of collective bargaining rights in 
the VA and the merit of nurses' input into workplace and quality of 
care issues. As a result, Congress passed a law in 1991 to strengthen 
collective bargaining rights for nurses working at the VA. The VA has 
also acknowledged the critical role that nurses have in improving 
quality of care. According to the VA Office of Nursing, ``VA nurses 
have been widely recognized for their instrumental work in initiating, 
developing, implementing, and monitoring the practices and policies 
that made VHA one of the world's foremost authorities in patient safety 
and quality outcomes evidenced by performance measures--an exceptional 
achievement by any assessment.'' (DVA Web site, April 30, 2007) An 
excellent example of this can be seen in the development of VA's health 
information technology system. Nurses and other health care providers 
worked with VA management on the design and implementation of VA's 
health IT system. The VA's health IT system is now well-recognized as 
one of the most effective and efficient systems in the world, a shining 
example for other health care systems.
    Unfortunately, VA nurses are experiencing an ever-shrinking role in 
workplace issues, quality assurance, and patient safety. Too often, the 
Human Resources staff is making health care decisions instead of 
nurses. The VA's current 7422 policy goes directly against good 
medicine and Congressional intent. Congress needs to amend section 7422 
of Title 38 to ensure that the VA complies with Congressional intent 
and that registered nurses are able to care for veterans with dignity, 
respect and the basic bargaining rights they were intended to have.
    As an RN, I am proud to be a member and leader of the Hawai'i 
Nurses Association--the union representing nurses where I work. Because 
I have the protections of my union behind me, I am able to forcefully 
and effectively advocate for my patients every day, using the tools 
afforded me by my union, such as a grievance and arbitration procedure, 
to improve working conditions for nurses and quality for patients. 
Congress intended that VA nurses likewise have the benefits of union 
representation in all matters except those dealing with compensation, 
direct patient care, and clinical competence, but VA management has 
stepped in to change Congress' intent, depriving VA nurses of the full 
benefits of union representation to which they are entitled.
    As a veteran whose sizable extended family uses the VA health care 
system, I fully support legislation that would restore the collective 
bargaining right of registered nurses. I am concerned about the nurse 
shortage in the VA health care system. This shortage has been 
exacerbated by the VA's recent effort to restrict RNs' collective 
bargaining rights through the use of section 7422 of Title 38. Nurses 
are becoming frustrated by the fact they have less rights than the LPNs 
and Certified Nursing Assistants that work in same units, just because 
these health care providers work under Title 5. As a result, registered 
nurses are leaving the VA to work at private sector hospitals right 
down the street, where they have full collective bargaining rights.
    As a veteran, I'm also concerned that VA RNs are not fully 
protected by their collective bargaining rights. RNs should be able to 
use the grievance process to challenge management when well established 
policies are being broken. For example, if a nurse is asked to complete 
assignments that regularly violate the VA's safe patient handling 
policy, the RN should be able to file a grievance. This would make it 
safer the nurse as well as veteran patients. Unfortunately, VA's use of 
section 7422 unfairly prohibits the grievance of most any issue.
    To address the problems with section 7422 of Title 38, Senate 
Rockefeller has introduced S.362, a bill that would improve collective 
bargaining rights of registered nurses in the Department of Veterans 
Affairs. Congress needs to pass S.362 to increase RN recruitment and 
retention, as well as protect RN's and veteran patients they take care 
of. The UAN and HNA strongly urge Members of the Committee to support 
and work for the passage of this important legislation.

    Thank you again for opportunity to provide testimony regarding this 
important issue.
      

                                  
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