[Senate Hearing 111-264]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-264
 
                     HEARING ON PENDING HEALTH AND 
                          BENEFITS LEGISLATION

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


                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 21, 2009

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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




                  U.S. GOVERNMENT PRINTING OFFICE
53-368                    WASHINGTON : 2009
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001



                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
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, Staff Director
                 Lupe Wissel, Republican Staff Director


                            C O N T E N T S

                              ----------                              

                            October 21, 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......................     3
Murray, Hon. Patty, U.S. Senator from Washington.................     3
Johanns, Hon. Mike, U.S. Senator from Nebraska...................     5
Begich, Hon. Mark, U.S. Senator from Alaska......................    34

                               WITNESSES

Reed, Hon. Jack, U.S. Senator from Rhode Island..................     5
    Prepared statement...........................................     6
Bayh, Hon. Evan, U.S. Senator from Indiana.......................     8
Cross, Gerald M., M.D., FAAFP, Acting Under Secretary for Health, 
  Veterans Health Administration, U.S. Department of Veterans 
  Affairs; accompanied by Brad G. Mayes, Director, Compensation 
  and Pension Service, Veterans Benefits Administration; Walter 
  A. Hall, Assistant General Counsel; and Richard J. Hipolit, 
  Assistant General Counsel......................................    10
    Prepared statement...........................................    13
    Response to request arising during the hearing by:
        Hon. Richard Burr........................................    27
        Hon. Mark Begich.........................................    36
    Response to post-hearing questions submitted by:
        Hon. Daniel K. Akaka.....................................    39
        Hon. Roger F. Wicker.....................................    45
Jackson, Robert, Assistant Director, National Legislative 
  Service, Veterans of Foreign Wars..............................    46
    Prepared statement...........................................    47
    Response to post-hearing questions submitted by Hon. Daniel 
      K. Akaka...................................................    53
DePlanque, Ian, Assistant Director for Claims 
  Service, The American Legion...................................    53
    Prepared statement...........................................    55
    Response to post-hearing questions submitted by Hon. Daniel 
      K. Akaka...................................................    61
    Response to request arising during 
      the hearing by Hon. Daniel K. Akaka........................    75
Driscoll, John, President and Chief Executive Officer, National 
  Coalition for Homeless Veterans................................    62
    Prepared statement...........................................    64
    Response to requests arising during 
      the hearing by Hon. Daniel K. Akaka........................ 76-78
McMichael, Rick, Doctor of Chiropractic, President, American 
  Chiropractic Association.......................................    67
    Prepared statement...........................................    69
    Response to request arising during 
      the hearing by Hon. Daniel K. Akaka........................    75
Fenn, William, Ph.D., P.A., Vice President, American Academy of 
  Physician Assistants...........................................    70
    Prepared statement...........................................    72

                                APPENDIX

Sanders, Hon. Bernard, U.S. Senator from Vermont; prepared 
  statement......................................................    81
Ilem, Joy J., Deputy National Legislative Director, Disabled 
  American Veterans; prepared statement..........................    82
McGah, John, Director, Give US Your Poor; letter.................    91
Berg, Steven R., Vice President for Programs and Policy, National 
  Alliance to End Homelessness; letter...........................    92
Paralyzed Veterans of America; prepared statement................    93
Veterans of Foreign Wars of the United States; letter............    98
Weidman, Richard, Executive Director, Policy and Government 
  Affairs, Vietnam Veterans of America; prepared statement.......    99


           HEARING ON PENDING HEALTH AND BENEFITS LEGISLATION

                              ----------                              


                      WEDNESDAY, OCTOBER 21, 2009

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:30 a.m., in 
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka, 
Chairman of the Committee, presiding.
    Present: Senators Akaka, Murray, Brown, Begich, Burr, and 
Johanns.

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

    Chairman Akaka. This hearing will come to order. Good 
morning and welcome to today's hearing. Our legislative agenda 
reflects the work and commitment of Members on both sides of 
the aisle, all of whom are looking for solutions in areas of 
veterans health and veterans benefits. I want to mention for 
everybody's information that we are glad to have Mr. Mayes 
here. I think this is the fourth hearing you are attending. 
That is great.
    Before we begin, I want to speak briefly about some of the 
progress this Committee has made since our legislative hearings 
in April. Earlier this year, I sponsored the Veterans Health 
Care Budget Reform and Transparency Act of 2009. This measure 
would provide timely and predictable funding for the veterans 
health care system. I am delighted to note that the President 
will sign this legislation into law tomorrow. I am grateful to 
all who worked on this, including the Committee's Ranking 
Member and the Veterans Service Organizations who made this one 
of their priorities.
    Other vital legislation reported out of this Committee is 
progressing to final passage, as well. The Veterans Benefits 
Enhancement Act of 2009 was unanimously approved by the Senate 
just 2 weeks ago and we are beginning to work with the House on 
the final benefits legislation. This bill would enhance a 
number of benefits for veterans and their families, including 
compensation, housing, employment, education, burial, and 
insurance benefits.
    Despite these successes, we as a Committee have not been 
able to achieve full support for two large health measures. The 
Veterans Health Care Authorization Act of 2009 has been held up 
by one Member of the Senate. This is very unfortunate, as it 
means vital changes to help women veterans and VA health 
workers are being delayed.
    Likewise, a single Member is holding up the Caregiver and 
Veterans Health Services Act of 2009. This important 
legislation provides long-overdue assistance to the caregivers 
of the most seriously injured veterans, including health care, 
counseling, support, and a living stipend. We are working on an 
agreement to bring the bill to the full Senate. Caring for 
wounded veterans is simply a cost of war and should be treated 
as such.
    So now let us turn to the agenda before us. I thank you all 
for joining us this morning and look forward to hearing from 
our witnesses. So let me call on our Ranking Member, Senator 
Burr, for his opening statement.
    Senator Burr?

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

    Senator Burr. Thank you, Mr. Chairman. Aloha.
    Chairman Akaka. Aloha.
    Senator Burr. Welcome to our witnesses.
    We do have an extensive legislative agenda before us today, 
so in the interest of time, I will be brief. I am going to 
focus on a bill I introduced with Senator Hagan, S. 1518, the 
Caring for Camp Lejeune Veterans Act of 2009.
    Two weeks ago, we held a hearing on the water contamination 
that existed for three decades at Camp Lejeune. We heard the 
personal stories of Michael Partain, who is the son of a Marine 
and was one of over 20 former Camp Lejeune residents diagnosed 
with a rare male breast cancer at an unusually young age. He 
was just 39 years old. To show how rare it is, the condition 
usually strikes fewer than 2,000 men each year in the United 
States and typically strikes those at an age of 55 or over.
    As I stated at the hearing, we have an obligation to figure 
out how much of these dangerous chemicals veterans and their 
families were exposed to and what impact these exposures might 
have had on their health. But while we wait for the science, we 
must deal with the fact that many continue to suffer from 
devastating conditions. We shouldn't ask sick veterans and 
family members to hold on while we wait for more studies. They 
have already waited two decades. We owe them much more than 
that.
    That is why I have introduced the Caring for Camp Lejeune 
Veterans Act, which would allow veterans stationed at Camp 
Lejeune while the water was contaminated to get the medical 
care from VA. It would also allow VA to treat their families 
for conditions associated with exposure to contaminated water. 
Providing health care to veterans and their families would be 
one step toward meeting, I think, our moral obligation to those 
who we put at risk.
    There are other bills on today's agenda I am anxious to 
hear testimony on. Two bills in particular propose additional 
assistance for homeless veterans, an important priority of 
mine. In fact, I have already drafted an amendment to the 
MILCON VA Appropriations Bill to increase funding for homeless 
programs by over $40 million. I would ask the Committee Members 
for their support on that amendment and I look forward to 
learning more about the bills before us today.
    I thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Burr.
    I would like to call for opening statements from Senator 
Brown, Senator Murray, and then I will introduce Senator Reed. 
So at this time, Senator Brown.

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

    Senator Brown. Thank you, Mr. Chairman. Aloha. I want to 
thank the Chairman for his leadership on the wide range of 
legislation we are discussing today. The variety of today's 
discussion spans issues from homelessness to chiropractic care.
    I welcome our colleague, Senator Reed from Rhode Island, to 
talk about his Zero Tolerance for Homeless Veterans Act of 
2009. I thank Senator Murray for her work on S. 1204, the 
Chiropractic Care Available to All Veterans Act, which is one 
of the bills we will be discussing today. Her work on our 
Nation's health reform in this Committee and on the HELP 
Committee has been so valuable.
    Veterans coming home have serious muscular-skeletal 
problems. Chiropractors can help, but only if we increase 
access to care. Many of our Vietnam-era veterans have suffered 
from these same problems for decades. We should not be shutting 
the door on one type of care. The backlogs, the wait lists, the 
need for chiropractic care at the VA is clear. I can see it in 
my State in the uneven availability of care. We see this with 
the number of outside referrals at VA medical centers all over 
the country, like I said, in my State in Chillicothe, Columbus, 
and Cleveland.
    I look forward to working on the legislation we are 
discussing. I appreciate today's witnesses being here and want 
to welcome Dr. Rick McMichael, who is President of the American 
Chiropractic Association. We talked yesterday about this 
legislation. He is from Canton, Ohio.
    Mr. Chairman, I regret I cannot stay very long today 
because we have confirmation proceedings in the HELP Committee 
in a few minutes, but I thank the Chairman for moving forward.
    Chairman Akaka. Thank you very much, Senator Brown.
    Senator Murray?

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

    Senator Murray. Thank you very much, Chairman Akaka and 
Senator Burr, for holding today's hearing on the legislation 
before us to help improve veterans health care and benefits. I 
also want to thank all of our witnesses for joining us today. I 
look forward to hearing your comments on the legislation we are 
considering.
    Mr. Chairman, I have introduced three bills that are being 
discussed today. Each of those bills deals with a different 
area of veterans care, but they all share a common thread. Each 
of them will give the VA better tools to provide our veterans 
with the care and benefits that they have earned through their 
selfless service to our Nation.
    One of my bills would expand grant programs for homeless 
women veterans and homeless veterans with children. Another 
would increase benefits for former POWs. And a third, as 
Senator Brown alluded to, would improve chiropractic care at VA 
hospitals.
    Mr. Chairman, I just want to take a few minutes to talk 
about these bills and why it is so important that we pass them.
    The first bill is designed to help homeless veterans. In 
particular, it will address the problems faced by homeless 
women veterans and homeless veterans with children--two very 
vulnerable groups that are growing by the day. We are seeing 
more and more homeless veterans with children coming to the VA 
and to Veterans Service Organizations looking for help. Women 
now make up about 5 percent of our homeless veterans, which is 
up from 3 percent just a decade ago. And about 10 percent of 
these homeless are Iraq and Afghanistan veterans. In fact, 
female veterans are between two and four times as likely to be 
homeless as their civilian counterparts, plus they have unique 
needs and require special services.
    That is why I introduced the Homeless Women Veterans and 
Homeless Veterans with Children Act with Senator Jack Reed and 
Senator Tim Johnson. This legislation will take three steps 
toward tackling the problem. It will make more front-line 
homeless service providers eligible to receive special needs 
grants. It will expand the special needs grants to cover 
homeless male veterans with children, as well as dependents of 
homeless veterans themselves. And it will extend the Department 
of Labor's Homeless Veterans Reintegration Program to provide 
workforce training, job counseling, child care services, and 
placement services to homeless women veterans and homeless 
veterans with children.
    Mr. Chairman, I think it is our duty to give every veteran 
the resources he or she needs to keep themselves and their 
families off the streets and in safe and stable housing. My 
bill would help provide an open door and a helping hand to 
homeless women and their families who have made a lot of great 
sacrifices and deserve more than just a thank you from a 
grateful Nation. I hope my colleagues will support it.
    I also introduced the Prisoner of War Benefits Act of 2009. 
This bill will provide former POWs with expanded health care 
benefits for conditions like Type 2 diabetes. It would also 
eliminate the minimum time held requirement in order to qualify 
for those benefits. Currently, former POWs have to be detained 
for at least 30 days to qualify for the presumption of service 
connection for some diseases. I think a veteran who endured 29 
days of captivity should be entitled to the same benefits as 
one who was a prisoner for one more day. And no veteran should 
have to fight to cut through bureaucratic red tape to receive 
the benefits they earned and deserve. To me, this is just 
common sense and fair play, and for those reasons, I hope that 
we can all support this legislation.
    And finally, as Senator Brown mentioned, we have before us 
the Chiropractic Care Available to All Veterans Act. I 
introduced this bill with Senator Sam Brownback and a number of 
others to expand chiropractic care at VA facilities in my home 
State and across the country. Of the more than 150 VA medical 
centers, less than one-third of them today offer chiropractic 
care and services. So our bill will address that shortfall by 
mandating chiropractic care and services at all of our VA 
medical centers. Again, I hope my colleagues will support that 
legislation, as well.
    So, thank you very much, Mr. Chairman. I look forward to 
the hearing.
    Chairman Akaka. Thank you very much, Senator Murray.
    Before I call on Senator Jack Reed, let me ask for an 
opening statement from Senator Johanns.

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

    Senator Johanns. Thank you very much, Mr. Chairman. I 
appreciate the opportunity to be here today.
    Many good things have happened in the short time that I 
have been on this Committee, and, of course, many good things 
predated my arrival. I would like to focus, if I could, on one 
thing that I think we are going to be talking about today, 
S. 1427, which I introduced with Senator Wyden and I hope there 
will be broad support on.
    Basically, what this bill would do would be to direct the 
VA to rate the different services of its medical centers with a 
straightforward, very easy to understand A to F grade and make 
those ratings public and simple to compare. The information 
would allow veterans to assess how the VA hospital in their 
region stacks up against other VA facilities. My hope is that 
by rating them, it will lead to improvements in areas that 
would otherwise be regarded as deficient. Now, I do know if 
there are some comparative data already provided by the VA. I 
am appreciative of that. VA is also working on grading its 
hospitals internally, as is noted in the testimony today by one 
of the witnesses.
    As you also say, VA is focused this year on health care 
transparency. I really applaud that effort. I think that we can 
work together on this to achieve a goal where veterans can 
simply look up how health care stacks up. You shouldn't have to 
be a medical care specialist to be able to do that. And some of 
these veterans, especially the elderly or the seriously 
disabled, might have difficulty pursuing the data as it stands 
now. So I am hoping we can take a step toward increased 
transparency.
    Let me, if I might, just wrap up my comments today by once 
again expressing my appreciation to the Chairman and to the 
Ranking Member for allowing me to have a hearing at the Omaha 
facility this summer. To all those who participated in it, I 
thought it was a great hearing. It certainly underscored the 
need we have in terms of that facility and trying to bring it 
up to date. So, Mr. Chairman, I thank you for that. I hope we 
established a very good record to move forward on that issue.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Johanns.
    I am delighted to welcome my friend, Jack Reed from Rhode 
Island, here to join us, and ask Jack for his opening 
statement.

                 STATEMENT OF HON. JACK REED, 
                 U.S. SENATOR FROM RHODE ISLAND

    Senator Reed. Well, thank you very much, Mr. Chairman. 
Aloha.
    Chairman Akaka. Aloha.
    Senator Reed. If I knew the Hawaiian word for thank you, I 
would say that, too. I appreciate your hospitalities, Senator 
Burr and all my colleagues.
    I want to spend a moment talking about S. 1547, the Zero 
Tolerance for Veterans Homelessness Act. I am very pleased that 
Senator Murray is an original cosponsor, along with Senator 
Bond and Senator Tim Johnson, and we have been joined by 
Senators Kerry, Durbin, Begich, Mikulski, Burris, Leahy, 
Whitehouse, Baucus, and Udall.
    This legislation would address one of the most, I think, 
difficult problems that we recognize in the country when it 
comes to veterans. I was with the Chairman of Joint Chiefs of 
Staff, Admiral Mike Mullen, and one would expect in a 
conversation with him, it would all be about new systems and 
budgets, et cetera. His point to me was he was in San Diego 
meeting with homeless veterans--homeless veterans of Iraq and 
Afghanistan. These were individuals in their 20s and 30s who 
couldn't find work, couldn't find housing, et cetera. That is a 
shame, to be blunt. We have to do more.
    This bill proposes to do more. It will essentially try to 
support at-risk veterans by providing short-term rental 
assistance and housing relocation services. It also will 
support existing programs, like the HUD-VASH program, which 
provides vouchers for veterans who can rent in areas which 
require that type of assistance. Presently, there are 20,000 of 
these vouchers. This bill would increase those by 10,000 each 
year up to a total of 60,000, so we could be reasonably assured 
that we wouldn't be seeing young veterans, or any age veteran, 
without access to housing. It would also make it easier for 
nonprofits to apply for grants from the VA to go ahead and 
participate in developing housing for veterans.
    There are other features of the legislation, and I would 
like to submit for the record my statement, together with 
letters of support from the National Alliance to End 
Homelessness and the Veterans of Foreign Wars.
    And again, Mr. Chairman, thank you very, very much.
    [The prepared statement of Senator Reed follows:]
  Prepared Statement of Hon. Jack Reed, U.S. Senator from Rhode Island
    Mr. Chairman, Senator Burr, and distinguished Members of this 
Committee, thank you for the opportunity to speak today regarding 
legislation I have introduced to help homeless veterans--S. 1547, the 
Zero Tolerance for Veterans Homelessness Act. This comprehensive bill 
enhances and expands the assistance provided by the Department of 
Veterans Affairs and the Department of Housing and Urban Development to 
homeless veterans and veterans at risk of becoming homeless.
    It is one of our Nation's great tragedies that on any given night, 
an estimated 131,000 veterans are homeless. The VA estimates that more 
than 200,000 veterans experience homelessness each year and that nearly 
1/5 of all homeless people in the United States are veterans. These 
numbers are expected to climb as our servicemembers fighting in Iraq 
and Afghanistan return home to face tough economic conditions.
    Unfortunately, we know that veterans are often at a greater risk of 
becoming homeless. Some return from deployments to discover that the 
skills they have honed in the military are difficult to transfer to 
jobs in the private sector. Others struggle with physical or mental 
wounds of war. Still others return to communities that lack safe, 
affordable housing.
    Our veterans have made great sacrifices to serve our country, and 
we have an obligation to honor our commitment to them. Many programs 
through HUD and the VA are already helping homeless veterans with 
transitional housing, health care and rehabilitation services, and 
employment assistance. This legislation recognizes these efforts by 
building on the existing structures to provide a more comprehensive and 
coordinated approach.
    First, this bill would create a new Homelessness Prevention program 
that would enable the VA to keep at-risk veterans in stable housing and 
offer increased assistance to veterans who have fallen into 
homelessness. Specifically, the VA could provide short-term rental 
assistance, housing relocation and stabilization services, services to 
resolve personal credit issues, payments for security deposits or 
utility costs, and assistance for moving costs. These up-front expenses 
can be the major obstacle that puts low-income or unemployed veterans 
at risk of becoming homeless. These homelessness prevention and rapid 
re-housing techniques have been successfully used in numerous 
communities to significantly reduce family homelessness, and this bill 
would provide the VA with resources to put these strategies into 
practice.
    Second, this bill would expand the HUD-Veterans Affairs Supportive 
Housing program, also known as the HUD-VASH program. This collaborative 
program provides homeless veterans with vouchers to rent apartments in 
the private rental market, as well as case management and clinical 
services at local VA medical centers. In this way, veterans receive the 
supportive housing they deserve and have earned.
    The HUD-VASH program has grown in recent years, with 20,000 
vouchers funded over the last two years. However, more homeless 
veterans should benefit from this important resource. As such, the Zero 
Tolerance for Veterans Homelessness bill authorizes up to 10,000 
additional vouchers each year to reach a maximum of 60,000 vouchers by 
2013.
    Third, this legislation would make it easier for non-profits to 
apply for capital grants through the VA's grants and per diem program 
to build transitional housing and other facilities for veterans. This 
would streamline the process for non-profit organizations to use 
financing from other sources to break ground on new housing 
construction. This is particularly important in the current economy, 
when non-profits are stretched and have to be more creative than ever 
to fund new capital projects.
    Among its other provisions, the Zero Tolerance for Veterans 
Homelessness Act would:

     create a Special Assistant for Veterans Affairs position 
within HUD to serve as a liaison between HUD and the VA to coordinate 
their services;
     establish a new data collection system for the VA to track 
the number of homeless veterans and the types of assistance they 
receive; and
     require the Secretary of Veterans Affairs to develop a 
comprehensive plan with recommendations on how to end homelessness 
among veterans.

    I am proud to have introduced this bill with my colleagues, 
Senators Bond, Murray, and Johnson. Since this bill was introduced, 
nine additional Senators have joined as cosponsors, including Senators 
Kerry, Durbin, Begich, Mikulski, Burris, Leahy, Whitehouse, Baucus, and 
Tom Udall.
    The bill is supported by many homelessness and veterans advocacy 
groups, including the National Coalition for Homeless Veterans, the 
National Alliance to End Homelessness, the VFW, the Local Initiatives 
Support Coalition, and Give Us Your Poor. I ask that letters of support 
from these organizations be entered into the record.
    Our legislation also complements Senator Murray's bill, S. 1237, 
which I am cosponsoring, that will enable programs at the VA and the 
Department of Labor to better serve homeless women veterans and 
homeless veterans with children.
    Only by working together, across the Federal Government and in 
partnership with non-profits and local housing authorities, will we be 
able to comprehensively help homeless veterans and reach those in 
danger of becoming homeless. We owe it to our veterans to ensure that 
they and their families have safe, affordable places to live and to 
provide the services and benefits they have earned. The Nation's brave 
veterans deserve nothing less.

    I look forward to continue working with the Committee on this 
important legislation. Thank you for the opportunity to testify and for 
your leadership on behalf of our veterans.

    Chairman Akaka. Thank you very much, Senator Reed, for your 
statement. I am glad to hear of your support on some of our 
pending bills.
    And now, I would like to introduce Senator Bayh. It is good 
to have you here with us this morning and we look forward to 
your statement.

     STATEMENT OF HON. EVAN BAYH, U.S. SENATOR FROM INDIANA

    Senator Bayh. Thank you, Mr. Chairman. I appreciate your 
hospitality and your leadership on these critically important 
issues. I want to thank you for your invitation to testify 
today and for all that you are doing to ensure that the VA has 
the tools and authority it needs to help our brave men and 
women returning from Iraq and Afghanistan nursing the wounds of 
war.
    I am here today to testify about a tragedy that took place 
in 2003 on the outskirts of Basra in Iraq. I am here on behalf 
of LTC James Gentry and the brave men and women who served 
under his command in the First Battalion, 152nd Infantry of the 
Indiana National Guard. I spoke with LTC Gentry by phone just 
last week. Unfortunately, he is at home with his wife, Luanne, 
waging a valiant fight against terminal cancer.
    The Lieutenant Colonel was a healthy man when he left for 
Iraq. Today, he is fighting for his life. Tragically, many of 
his men are facing their own bleak prognosis as a result of 
their exposure to sodium dichromate--one of the most lethal 
carcinogens in existence. The chemical is used as an anti-
corrosive for pipes. It was strewn all over the water treatment 
facility guarded by the 152nd Infantry. More than 600 soldiers 
from Indiana, Oregon, West Virginia, and South Carolina were 
exposed. One Indiana Guardsman has already died from lung 
disease and the Army has classified it as a service-related 
death. Dozens of others have come forward with a range of 
serious respiratory symptoms.
    The DOD Inspector General just launched an investigation 
into the breakdowns and gaps in our system that allowed this 
tragic exposure to happen. Neither the Army nor the private 
contractor, KBR, performed an environmental risk assessment of 
the site, so our soldiers were literally breathing in this 
chemical and swallowing it for months. Our country's reliance 
on military contractors and their responsibility to their 
bottom line versus our soldiers' safety is the topic for 
another day and for another hearing.
    Mr. Chairman, today I would like to tell this Committee 
about S. 1779. It is legislation that I have written to ensure 
that we provide full and timely medical care to soldiers 
exposed to hazardous chemicals during wartime military service, 
like those on the outskirts of Basra. The Health Care for 
Veterans Exposed to Chemical Hazards Act of 2009 is bipartisan 
legislation that has already been cosponsored by Senators 
Lugar, Dorgan, Rockefeller, Byrd, Wyden, and Merkley. With a 
CBO score of just $10 million, it is a bill with a modest cost 
but a critical objective: to ensure that we do right by 
America's soldiers exposed to toxic chemicals while defending 
our country.
    This bill is modeled after similar legislation that 
Congress approved in 1978 following the Agent Orange exposure 
in the Vietnam conflict. That bill ensured lifelong VA care for 
soldiers unwittingly exposed to the cancer-causing herbicide in 
the jungles of Vietnam. Some have called toxic industrial 
hazards ``the Agent Orange of the wars in Iraq and 
Afghanistan.''
    My legislation would make soldiers eligible for medical 
examinations, laboratory tests, hospital care, and nursing 
services. It would ensure that soldiers receive priority health 
care at VA facilities. It would recognize a veteran's own 
report of exposure and inclusion on a Department of Defense 
registry as sufficient proof to receive medical care, barring 
evidence to the contrary.
    My legislation will help to ensure that we provide the best 
possible care for American soldiers exposed to environmental 
hazards during the reconstruction of Iraq and Afghanistan. At a 
bare minimum, Mr. Chairman, my bill will ensure compassionate 
care so families are spared the added grief of going from 
doctor to doctor in their loved ones' final days, searching for 
an accurate diagnosis.
    The 1978 Agent Orange Registry only covered one chemical 
compound, but our bill is broader. It covers all members of the 
Armed Forces who have been exposed to any environmental 
chemical hazard, not just sodium dichromate. It recognizes a 
new set of risks that soldiers face today throughout the world.
    Senate testimony last year identified at least seven 
serious instances of potential contamination involving 
different industrial hazards: sulfur fires; ionizing radiation; 
sarin gas; and depleted uranium, to name just a few. S. 1779 
ensures that veterans who were exposed to these chemicals will 
be eligible for hospital care, medical services, and nursing 
home care. It allows the Secretary of Defense to identify the 
hazards of greatest concern that warrant special attention from 
the VA.
    Our bill switches the burden of proof from the soldier to 
the government, where in such cases it rightfully belongs. 
Soldiers exposed to toxic chemicals will receive care 
presumptively, unless the VA can show their illness is not 
related to their service.
    Exposure to toxic chemicals is a threat no servicemember 
should have to face. It is our moral obligation to offer access 
to prompt, quality care. We should cut the red tape for these 
heroes.
    Mr. Chairman, I promised LTC Gentry that I would fight for 
his men here in Congress. I promised him I would use my 
position to get them the care they deserve and to make sure we 
protect our soldiers from preventable risks like these in the 
future. This tragedy will be compounded if we do not take the 
steps to provide the best medical care our country has to 
offer.
    I want to thank you for this opportunity to offer testimony 
today. I urge this Committee to adopt S. 1779 to honor the 
sacrifice of LTC Gentry and all of our brave men and women 
doing the hard, dangerous work to keep America safe. It is the 
least we can do for them.
    Chairman Akaka. Thank you very much, Senator Bayh. Thank 
you for your statement and your legislation on exposures. Thank 
you.
    Senator Bayh. Thank you, Mr. Chairman.
    Chairman Akaka. And now, I would like to welcome our 
principal witnesses. I want to welcome from VA Dr. Gerald M. 
Cross--it is good to have you back--who is the Acting Under 
Secretary for Health. Dr. Cross is accompanied today by Brad 
Mayes, the Director of the Compensation and Pension Service; 
Walter Hall, Assistant General Counsel; and Richard Hipolit, 
Assistant General 
Counsel.
    I thank you all for being here this morning. VA's full 
testimony will, of course, appear in the record. So, Dr. Cross, 
will you please begin with your statement.

    STATEMENT OF GERALD M. CROSS, M.D., FAAFP, ACTING UNDER 
  SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. 
  DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY BRAD MAYES, 
 DIRECTOR, COMPENSATION AND PENSION SERVICE, VETERANS BENEFITS 
  ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; WALTER 
 HALL, ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS 
 AFFAIRS; AND RICHARD HIPOLIT, ASSISTANT GENERAL COUNSEL, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Dr. Cross. Good morning, Mr. Chairman and Members of the 
Committee. I want to thank you for the opportunity to testify 
on a number of important pieces of legislation. I will be 
addressing legislation affecting health care, while my 
colleague, Mr. Mayes, will discuss benefits legislation.
    I will focus on five bills that we believe touch upon 
particularly important issues for VA and the Committee, and 
these include 
a bill on homeless veterans, the Veterans Health Care 
Improvement Act of 2009, the Quality Report Card Act, the 
Caring for Camp Lejeune Veterans Act, and the reporting chain 
for physician 
assistants.
    VA supports S. 1237, the Homeless Women Veterans and 
Homeless Veterans with Children Act of 2009, which would expand 
eligibility for entities to receive grant and per diem payments 
and would make available benefits to all homeless veterans with 
minor dependents. It would also authorize grant recipients to 
provide services directly to dependents of homeless veterans. 
VA supports all of these changes and recognizes them as 
important to complement VA's current efforts.
    The Secretary and the President have announced an ambitious 
goal to end veteran homelessness within 5 years. We will assist 

all eligible veterans willing to accept our services. We will 
help them acquire safe housing, obtain needed medical and 
mental health treatment, and receive educational and employment 
assistance. We can't achieve this goal on our own. We will need 
the collaboration of Federal and State and community partners 
and, of course, Congress.
    VA does not support S. 1302, the Veterans Care Improvement 
Act of 2009. VA is devoting significant efforts toward quality 
control and effective incentives that Community-Based 
Outpatient Clinics contracting, and that is a complex, multi-
faceted endeavor. There is a great deal of emerging research in 
the medical field on pay-for-performance, and it is clear that 
programs must be carefully thought out to avoid unintended 
consequences. Prescribing a fixed set of tools would impair 
VA's flexibility. Moreover, the legislation would not provide 
any additional statutory authority to establish a CBOC 
performance-based quality care incentive contract beyond what 
is currently already available.
    We agree with the intent of S. 1427, the Department of 
Veterans Affairs Hospital Quality Report Card Act of 2009. We 
agree with it quite strongly in terms of the intent. But we do 
not think the bill is actually necessary. Veterans in need of 
health care should know that they have access to the best 
services possible, which is why we have identified health care 
transparency as one of our major strategic initiatives. We will 
publish more data about our facilities online than ever before, 
and we are working with the Centers of Medicare and Medicaid 
Services to support comparisons between VA and non-VA 
facilities. We believe that these efforts will fully achieve 
the objectives of the proposed legislation. We also have some 
technical concerns about the bill, as written.
    VA also supports the intent of S. 1518, the Caring for Camp 
Lejeune Veterans Act of 2009, which would provide for treatment 
of veterans and their dependents who were exposed to 
contaminants at Camp Lejeune. We are very concerned about the 
health problems experienced by veterans who served at Camp 
Lejeune. However, we believe that S. 1518, as written, is too 
broad.
    As a result of a recent National Research Council report, 
VA has convened a special work group. This work group will 
address the findings of the report and make recommendations to 
the Secretary about the need for any additional service 
connections.
    VA currently provides veterans with information about this 
issue and offers referrals to the Navy's registry. My Office of 
Public Health and Environmental Hazards has already been 
contacted by the U.S. Marine Corps regarding VA's access to the 
registry. Affected veterans may already apply for health care 
enrollment and disability compensation based upon direct 
service connection. We recommend that any further priority for 
this group of veterans be established only in accordance with 
scientific evidence. Further, we strongly recommend that any 
care and treatment provided to eligible family members be 
coordinated with DOD and provided by DOD.
    Finally, S. 1155 would require the establishment of the 
position of Physician Assistant Director and require this 
Director to report directly to the Under Secretary of Health. 
We value our Physician Assistants tremendously, as we do all of 
our professional groups who provide care to veterans. There 
already exists an equivalent position within VHA. It is called 
the Physician Assistant Advisor. We have already made several 
enhancements to the Physician Assistant Advisor's position, 
including making it a full-time position. It will also become a 
Washington, DC-based office at the end of the incumbent's 
tenure.
    We believe that these measures give the Physician Assistant 
Advisor the status necessary to carry out all of the 
responsibilities needed. The proposed legislation would go a 
step further by elevating the reporting relationship of the 
Physician Assistant Advisor above nurse practitioners, 
surgeons, physical therapists, mental health staff, and other 
professional groups in VHA. For this reason, we oppose that 
bill.
    Mr. Mayes is now available to discuss legislation affecting 
VBA, and after his remarks, sir, we will be pleased to answer 
any of your questions.
    Mr. Mayes. Mr. Chairman and Members of the Committee, thank 
you for allowing me the opportunity to appear before you here 
today. In the interest of time, I will limit my oral statement 
to four bills of importance to the Veterans Benefits 
Administration. However, our full views have been submitted for 
the record.
    VA does not support S. 977, the Prisoner of War Benefits 
Act of 2009, with the exception of the provision that would 
remove the requirement that VA determine that a former prisoner 
of war has PTSD in order to extend the presumption of service 
connection for osteoporosis. We previously changed the 
regulation eliminating that predicate requirement for a 
diagnosis of PTSD. That rule was published in the Federal 
Register on August 28, 2009.
    VA does not support extending the presumption of service 
connection for Type 2 diabetes because we are not aware of 
scientific evidence demonstrating that such a presumption is 
warranted. And we cannot support the elimination of the 30-day 
minimum internment period for disabilities resulting from 
nutritional deficiencies because these disabilities, by 
definition, are the result of deprivation or improper diet over 
a sustained period of time.
    VA does not support an increase in the monthly dependency 
and indemnity compensation payment rate as proposed in S. 1118. 
In October 2007, the Veterans Disability Benefits Commission 
assessed the appropriateness of the level of dependency and 
indemnity compensation (DIC) payments and found the current 
level of DIC pay to a surviving spouse is comparable to or 
higher than the earnings of a widow or widower in the general 
population. In addition, 89 percent of the surviving spouses 
responding to a survey were satisfied with their DIC payments.
    A May 2001 VA program evaluation of benefits for survivors 
indicated findings similar to those of the Veterans Disability 
Benefits Commission, specifically, that DIC is a competitive 
survivor benefit compared to employer-provided benefits for 
survivors of non-veterans. The report pointed out that DIC 
provides a benefit that is approximately twice as large as 
benefits for survivors of private-sector employees, State 
employees, and Federal employees covered by the Civil Service 
Retirement System.
    However, VA would not be opposed to lowering the age from 
57 to 55 at which a surviving spouse can remarry and retain 
eligibility for several VA benefits, including DIC paid under 
Section 1311, Chapter 35 educational assistance, and housing 
loans made under Chapter 37 of the title, provided Congress 
finds the offsets for the costs of these changes. By lowering 
the age, this change would make Title 38 provisions similar to 
those found in Title 10. Changing similar provisions in Title 
38, we believe, is not only equitable, but would also simplify 
the administration of benefits under both titles.
    Regarding S. 1444, the Combat PTSD Act, VA is concerned 
that the language of the bill is too broad, encompasses more 
than just PTSD claims, and may unduly complicate the 
adjudication process. While we cannot support the bill as 
proposed, we have taken a number of steps that we believe are 
consistent with the bill's intent to relax the evidentiary 
standard for veterans to prove their PTSD claim.
    On August 24 of this year, VA proposed a rule that would 
liberalize the evidentiary standard for establishing the 
required in-service stressor for entitlement to service 
connection benefits for Post Traumatic Stress Disorder. The 
amendment to VA's adjudication regulations governing service 
connection for PTSD would eliminate the requirement for 
corroborating evidence that the claimed in-service stressor 
occurred if the stressor claimed by a veteran is related to the 
veteran's fear of hostile military or terrorist activity and a 
VA psychiatrist or psychologist confirms that the claimed 
stressor is adequate to support a diagnosis of PTSD, provided 
that the claimed stressor is consistent with the places, types, 
and circumstances of the veteran's service, and that the 
veteran's symptoms are related to the claimed stressor.
    Finally, VA supports the objective of S. 1752, which would 
add Parkinson's disease manifested to the degree of 10 percent 
or more to the list of diseases presumed service-connected for 
a veteran who served in Vietnam. Based on an independent study 
by the Institute of Medicine, the Secretary announced on 
October 13, 2009, that VA would add Parkinson's disease to the 
list of presumptive diseases associated with herbicide 
exposure. Therefore, we believe the legislation is unnecessary.
    This concludes my testimony and we would be pleased to 
answer any questions you or any of the Members of the Committee 
may have. Thank you.
    [The prepared statement of Dr. Cross follows:]
    Prepared Statement of Gerald M. Cross, MD, FAAFP, Acting Under 
 Secretary for Health, Veterans Health Administration, U.S. Department 
                          of Veterans Affairs
    Good Morning Mr. Chairman and Members of the Committee: Thank you 
for inviting me here today to present views on several bills that would 
affect Department of Veterans Affairs (VA) benefits and services. 
Joining me today are Mr. Brad Mayes, Director of the Compensation and 
Pension Service, Mr. Richard Hipolit, Assistant General Counsel, and 
Mr. Walter Hall, Assistant General Counsel. Unfortunately, we do not 
have views and estimates on several bills including S. 1109, S. 1467, 
S. 1556, S. 1753, and a draft bill regarding exposure to chemical 
hazards referred to in the list of bills provided in the Committee's 
witness letter of October 8. We will forward those as soon as they are 
available. We appreciate the opportunity to address these bills that 
would affect the Department's health care and benefits programs.
            s. 977 ``prisoner of war benefits act of 2009''
    S. 977 would eliminate two current requirements for presuming 
service connection of certain diseases in a former prisoner of war 
(POW): (1) the requirement that a Veteran be detained or interned as a 
POW for at least 30 days; and (2) the requirement that VA determine 
that a former POW has Post Traumatic Stress Disorder (PTSD) for service 
connection of osteoporosis to be presumed. It would also add type II 
diabetes to the list of presumptive diseases. The bill would authorize 
the Secretary to add through rulemaking to the list of diseases that 
may be presumed service-connected in a former POW, by reason of having 
a positive association with the experience of being a POW, and would 
establish procedures, including taking into account the recommendations 
of the Advisory Committee on Former Prisoners of War, on how those 
diseases should be added. Finally, if a disease is removed from the 
presumptive list and a Veteran was awarded compensation for that 
disease or a Veteran's survivor was awarded dependency and indemnity 
compensation for the Veteran's death resulting from that disease before 
the removal effective date, the bill would protect entitlement to 
benefits for that disease.
    VA does not support this bill. The presumption for some conditions 
currently requires a minimum internment period for good reason. Some 
presumptive conditions, such as avitaminosis, malnutrition, and other 
nutritional deficiencies, require a minimum period of deprivation to 
develop. The 30-day minimum internment period reflects the need for a 
period during which a person would be deprived of a proper diet. As a 
result, VA relied upon the 30-day timeframe established by Congress 
when it added osteoporosis to the regulatory list of presumptive 
diseases. VA already recognized that the presumption of service 
connection for osteoporosis for former POWs should not be limited to 
former POWs who have PTSD. Based on studies suggesting a link between 
osteoporosis and internment or detention as a POW for a period 
sufficient to result in nutritional deficiency, we amended our 
regulations to provide a presumption of service connection for 
osteoporosis independent of any determination regarding PTSD. VA cannot 
support the addition of type II diabetes to the list of presumptive 
diseases because we are not aware of scientific evidence demonstrating 
that such a presumption is warranted.
    VA agrees that it should amend applicable regulations when sound 
medical and scientific evidence shows a positive association between 
the experience of being a former POW and the occurrence of a disease. 
VA already relies upon recommendations from its advisory committees, 
such as the Advisory Committee on Former Prisoners of War, to carefully 
study and recommend appropriate regulatory amendments, including 
additional POW presumptive conditions and has added by regulation new 
presumptions recommended by the Advisory Committee on Former Prisoners 
of War. However, because VA already has in 38 U.S.C. 501 sufficient 
statutory authority to prescribe necessary or appropriate regulations, 
additional statutory authority to authorize such rulemaking is 
unnecessary. Moreover, because VA already consults the Advisory 
Committee, requiring it to do so is unnecessary. VA intends to continue 
to review for possible regulatory amendment any recommendations from 
the Advisory Committee, as well as from other sources. Congress created 
the Advisory Committee to assess the needs of POWs with respect to 
compensation, health care, and rehabilitation. We welcome the 
opportunity to meet with the Advisory Committee at any time.
    However, VA opposes mandatory timeframes within which to promulgate 
regulations in response to an Advisory Committee recommendation and any 
requirement to publish a notice of a decision that a presumption is not 
warranted for a disease. Under 38 U.S.C. 541, every two years the 
Advisory Committee is to submit a report to the Secretary on the 
programs and activities of VA that pertain to former POWs. Within 60 
days of receipt of this report, VA is required to submit a copy to 
Congress along with appropriate comments. The Advisory Committee may 
submit any other reports or recommendations that it considers 
appropriate. These statutory provisions are clear that the Advisory 
Committee is to assist VA in making reports and recommendations 
regarding the needs of former POWs. The Advisory Committee is not and 
should not be a substitute for VA's regulatory efforts.
    VA is unable to provide costs on this bill at this time because 
sufficient data are not yet available. With the Chairman's permission, 
we will provide a cost estimate in writing for inclusion in the record.
 s. 1118 ``increase in the amount of monthly dependency and indemnity 
                  compensation to surviving spouses''
    Section 1 of S. 1118 would increase the monthly amount of 
dependency and indemnity compensation (DIC) payable to a Veteran's 
surviving spouse. Instead of the current base amount, VA would pay 55 
percent of the rate of monthly compensation in effect under 38 U.S.C. 
1114(j), the rate of disability compensation for disability rated 
totally disabling. In the case of an individual who is eligible for DIC 
under section 1311 and for benefits under another provision of law by 
reason of the individual's status as a Veteran's surviving spouse, 
section 1 would also prohibit the reduction or offset in benefits under 
the other provision of law by reason of eligibility for DIC under 
section 1311. These changes would apply to DIC paid under 38 U.S.C. ch. 
13 for months beginning after 180 days after the date of enactment.\1\
---------------------------------------------------------------------------
    \1\ The bill language refers to "compensation" paid under chapter 
13. We interpret the provision to apply to payments of DIC under 
chapter 13.
---------------------------------------------------------------------------
    VA does not support section 1 of this bill because the current 
rates of DIC are appropriate. In October 2007, the Veterans' Disability 
Benefits Commission assessed the appropriateness of the level of DIC 
payments and found the current level of DIC paid to a surviving spouse 
is comparable to, or higher than, the earnings of a widow or widower in 
the general population. In addition, 89 percent of surviving spouses 
responding to a survey were satisfied with their DIC payments.\2\ A May 
2001 VA Program Evaluation of Benefits for Survivors indicated findings 
similar to those of the Veterans' Disability Benefits Commission--that 
DIC is a competitive survivor benefit compared to employer-provided 
benefits for survivors of non-Veterans. The report pointed out that DIC 
provides a benefit that is approximately twice as large as benefits for 
survivors of private sector employees, state employees, and Federal 
employees covered by the Civil Service Retirement System, and that VA 
provides a significantly broader array of non-income benefits for 
survivors of disabled 
Veterans.
---------------------------------------------------------------------------
    \2\ Veterans' Disability Benefits Commission, "Honoring The Call To 
Duty: Veterans' Disability Benefits in the 21st Century, October 2007, 
page 393.
---------------------------------------------------------------------------
    DIC payments, unlike most other Federal benefits, are tax-free. 
Surviving spouses who are entitled to DIC are entitled to other non-
income Federal benefits, such as care under the Civilian Health and 
Medical Program, Dependents' Educational Assistance, burial expense 
reimbursement, and Servicemembers' or Veterans' Group Life Insurance. 
These additional benefits significantly increase the value of a 
surviving spouse's ``benefit package'' and help a surviving spouse to 
adjust during the critical transition period after a Veteran's death.
    The language of the provision that would eliminate the offset 
between DIC and other benefits for a Veteran's surviving spouse is 
broad enough to include annuities under the Survivor Benefit Plan (SBP) 
and other Federal benefits, such as payments under the Radiation 
Exposure Compensation Act of 1990, the Federal Tort Claims Act, and the 
Federal Employees Compensation Act based on ``death due to service in 
the Armed Forces.'' Current law generally prohibits payment of any 
other Federal benefit to a surviving spouse who is receiving DIC 
payments.
    If the scope of the offset elimination is intended only for DIC and 
SBP payments, then VA defers to the Department of Defense (DOD) because 
DOD would incur the costs associated with enactment of the bill. VA 
pays the full amount of DIC regardless of whether a surviving spouse is 
entitled to SBP benefits. A provision of title 10, United States Code, 
which governs DOD programs, requires that SBP payments be offset.
    If the offset elimination is intended to cover Federal benefits in 
general, not only SBP, there would again be no financial implications 
for VA. However, this provision could result in some circumstances in 
duplication of benefits for the same condition or event. If, for 
example, a surviving spouse receives DIC based on the Veteran's death, 
which was attributed to his service-connected bladder cancer due to 
radiation exposure, then the surviving spouse would also receive a lump 
sum payment for the same disability from the Department of Justice 
under the Radiation Exposure Compensation Act of 1990. In this 
hypothetical instance and others like it, the surviving spouse would 
receive duplicate payments for the same disability.
    VA estimates the costs associated with section 1 of this bill would 
be $1.1 billion in the first year following enactment and $14.3 billion 
over ten years.
    Current law authorizes the payment of DIC to the surviving spouse 
and children of a deceased Veteran who was entitled to receive 
compensation at the time death for a service-connected disability that 
was rated totally disabling for a minimum period of 10 years 
immediately preceding death. Section 2 of S. 1118 would reduce the 
amount of time required from 10 years to 5 years and would provide 
graduated rates of DIC depending on how long the disability was rated 
totally disabling. For example, if the disability was continuously 
rated totally disabling for at least five years but less than six 
years, DIC would be paid at the rate of 50 percent of the DIC otherwise 
payable. If the disability was continuously rated totally disabling for 
at least six years but less than seven years, DIC would be paid at the 
rate of 60 percent of the DIC otherwise payable.
    VA needs additional time to evaluate section 2. We will forward 
views on this provision as soon as they are available.
    Section 3 of S. 1118 would lower from 57 to 55 the age at which a 
surviving spouse can remarry and retain eligibility for several VA 
benefits, including DIC paid under section 1311, educational assistance 
paid under 38 U.S.C. ch. 35, and housing loans made under 38 U.S.C. ch. 
37. The change would be effective on the later of the first day of the 
first month that begins after the date of enactment and the first day 
of the fiscal year that begins in the calendar year of enactment. 
Section 3 would prohibit the payment of any benefit for any period 
before the effective date. An individual who, but for having remarried, 
would be eligible for a VA benefit by reason of these amendments but 
who remarried before enactment and after attaining age 55, would be 
eligible for benefits under the amendment made by section 3, but only 
if the individual applies to VA not later than one year after 
enactment.
    VA does not oppose enactment of this provision provided Congress 
finds savings to offset increased costs from its enactment. By lowering 
the age, this bill would make title 38 provisions similar to those 
already existing in title 10. Changing similar provisions in title 38 
is not only equitable but would also simplify the administration of 
benefits under both titles.
    VA is unable to provide a cost estimate for this provision at this 
time because sufficient data are not available. With the Chairman's 
permission, we will provide VA's estimate in writing at a later date.
  s. 1155 ``establishing position of director of physician assistant 
                               services''
    S. 1155 would eliminate the Physician Assistant (PA) Advisor 
position established by Public Law 106-419, the Veterans Benefits and 
Health Care Improvement Act of 2000, and establish a Director of 
Physician Assistant (PA) Services within the Office of the Under 
Secretary for Health. VA does not support this bill.
    The functions of the proposed Director of PA Services are already 
being performed by the PA Advisor. Moreover, the PA Advisor position 
was converted to full-time on April 14, 2008, and it will be based in 
VA Central Office at the expiration of the current incumbent's term in 
April 2010.
    In addition, VA does not support the proposed organizational 
realignment of the Director of PA Services to the Office of the Under 
Secretary for Health. The position's current alignment within the 
Office of Patient Care Services is consistent with most other clinical 
program leadership positions and provides the PA Advisor access to the 
Under Secretary for Health for any issues that cannot be resolved 
within the current structure. The cost of implementing this bill is 
insignificant.
  s. 1204 ``chiropractic care available to all veterans act of 2009''
    S. 1204 would require VA to increase to not fewer than 75 the 
number of VA facilities directly providing chiropractic care through VA 
medical centers and clinics by December 31, 2009. In addition, S. 1204 
would require that chiropractic care be provided at all VA medical 
centers by December 31, 2011.
    VA opposes S. 1204. While musculoskeletal conditions are common in 
VA patients, and are increasingly prevalent among Operation Enduring 
Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans, there is 
currently a facility with an in-house chiropractic care program in each 
of our geographic service areas. Specifically, VA has 28.5 
chiropractors providing on-station care and services at 36 facilities. 
VA does not oppose eventually increasing the number of VA sites 
providing chiropractic care; however, the projected demand for 
chiropractic care is insufficient to justify mandating it at all VA 
medical centers by the end of 2011. Moreover, the requirement to 
increase the number of facilities in which VA provides chiropractic 
care from 36 facilities to 75 facilities by the end of the calendar 
year is unrealistic and unnecessary. Currently, 98 percent of VA 
patients are able to receive chiropractic care within thirty days of 
their desired date.
    VA estimates that S. 1204 would cost $5.3 million in fiscal year 
(FY) 2010, $5.5 million in FY 2011, $29.8 million over 5 years, and 
$63.6 million over 10 years.
     s. 1237 ``homeless women veterans and homeless veterans with 
                         children act of 2009''
    S. 1237 would expand those eligible to receive grants under 38 
U.S.C. 2061 beyond grant and per diem providers to include those 
entities eligible to receive grant and per diem payments. It would also 
provide that both male and female homeless Veterans who are responsible 
for the care of minor dependents may qualify as Veterans with special 
needs. In addition, S. 1237 would authorize the use of funds for the 
provision of direct services to the dependents of homeless Veterans. 
Section 3 of S. 1237 would require the Secretary of Labor to award 
grants to eligible programs and facilities to provide services to 
reintegrate homeless women Veterans and homeless Veterans with children 
into the workforce. Grant recipients would provide job training, 
counseling, job placement services and child care. The law would be 
implemented by the Assistant Secretary for Veterans' Employment and 
Training, who would report through the Secretary of Labor on this 
program biennially. An additional $10 million, in excess of other 
appropriated funds, would be made available for fiscal years 2010 and 
2014.
    VA supports section 2 as it would allow any eligible entity 
providing services to special needs populations to apply for special 
needs grants by eliminating the requirement that recipients also be a 
grant and per diem recipient. VA also supports making the provision 
recognizing homeless Veterans with dependent children as a special 
needs population gender neutral because it would allow VA to directly 
provide equal services to all homeless Veterans with dependents.
    VA estimates the cost of this section would be $8.9 million in FY 
2010, $15.1 million in FY 2011, $91 million over 5 years, and $239.6 
million over 10 years.
    The Secretary of Labor is responsible for awarding grants under 
Section 3 of the bill. VA defers to the Department of Labor concerning 
this portion of the legislation.
        s. 1302 ``veterans health care improvement act of 2009''
    S. 1302 would require VA to submit to Congress within one year a 
plan to introduce pay-for-performance measures into community-based 
outpatient clinic (CBOC) contracts. This plan would require VA to 
include measures to ensure contracts utilize pay-for-performance 
mechanisms including incentives for providing high-quality health care, 
patient satisfaction, and data collection on the outcomes of services 
provided by CBOCs. The plan would also require VA to impose penalties 
for substandard care, and to eliminate abuses by CBOCs that use 
capitated-basis compensation. Moreover, VA's plan would need to include 
mechanisms to ensure Veterans are not denied care and do not face undue 
delays. VA would be required to implement this plan within 60 days of 
submitting it to Congress, though in implementing the plan the 
Secretary may initially carry out of one or more pilot programs to 
assess its feasibility and advisability. VA would be required to report 
to Congress every 6 months providing recommendations on the feasibility 
and advisability of utilizing pay-for-performance compensation in 
providing health care services through means other than CBOCs.
    VA does not support S. 1302. VA is devoting significant effort into 
quality control and effective incentives in its CBOC contracting now, 
and that is a complex multi-faceted endeavor. There is a great deal of 
emerging research in the medical field on pay-for-performance, and it 
is clear that programs must be carefully thought out to avoid 
unintended consequences. Prescribing a fixed set of tools would impair 
VA flexibility. Additionally the legislation would not provide any 
additional statutory authority to establish a CBOC performance-based 
patient quality care incentive contract than what is currently provided 
in the Federal Acquisition Regulations.
    VA estimates there would be no additional costs associated with 
this legislation as it only requires VA to develop a different type of 
contract during the normal acquisition process.
    s. 1394 ``veterans entitlement to services (vets) act of 2009''
    S. 1394, the ``Veterans Entitlement to Service Act of 2009,'' would 
require the Secretary to acknowledge the receipt of any claim for 
medical services, disability compensation, or pension or other 
communication relating to those services or benefits within 30 days of 
receipt. The acknowledgment would have to specify the date of receipt 
and would be permitted to be communicated ``via written or electronic 
means'' including email.
    VA does not support S. 1394. By requiring additional paperwork and 
administrative workload that would not materially advance the merits of 
a claim, the bill would be detrimental to VA's efforts to streamline 
and expedite claims processing. Moreover, the benefits of such a 
requirement are unclear; VA already contacts individuals who submit 
claims generally within 30 days. Individuals who submit claims 
electronically receive immediate acknowledgement. VA continues to 
communicate with claimants throughout the claims process.
    In addition, the term, ``or other communication'' is too broad and 
could be interpreted to require VA to formally respond to an indefinite 
number of telephonic, written, or electronic contacts by Veterans to VA 
call centers, health care facilities, Regional Offices, Vet Centers and 
other locations. It is VA policy to respond as quickly as possible to 
any Veteran's request or inquiry but the legislation is too 
prescriptive in this regard. VA receives roughly 21 million telephone 
calls each year at the main Veterans Benefits Administration (VBA) call 
center; the Veterans Health Administration's (VHA) Pharmacy Customer 
Call Center is expected to receive in excess of 8 million calls per 
year, and VA estimates VHA, VISN, and medical center call centers 
receive in excess of 20 million calls per year.
    Enactment of S. 1394 would not result in any mandatory costs. VA 
cannot estimate the cost for the proposed legislation as there is no 
central accounting system for the number of contacts made by Veterans 
to VA.
           s. 1427 ``department of veterans affairs hospital 
                   quality report card act of 2009''
    S. 1427 would add section 1706A to title 38 and require VA, within 
18 months of enactment, to establish and implement a Hospital Quality 
Report Card Initiative. This initiative would require the Secretary to 
publish a report at least twice a year on Department medical centers 
containing information on effectiveness, safety, timeliness, 
efficiency, patient-centeredness, patient satisfaction, health 
professional satisfaction, and equity of care for various populations 
(female, geriatric, disabled, rural, homeless, mentally ill, racial and 
ethnic minorities). VA would be required to grade facilities in these 
areas on a scale from A+ to F. VA would also be required to provide 
information, to the maximum extent practicable, on: staffing levels of 
nurses and other health professionals; rates of nosocomial infections; 
volumes of different procedures performed; hospital sanctions and 
violations; quality of care to various populations; availability of 
emergency rooms, intensive care units (ICUs), maternity and specialty 
services; quality of care in inpatient, outpatient, emergency, 
maternity and ICU; ongoing patient safety initiatives; use of health 
information technology; and other matters. S. 1427 would allow the 
Secretary to provide information in addition to or in lieu of the 
specific requirements identified in the bill by informing the Senate 
and House Committees on Veterans' Affairs at least 15 days before the 
report is to be published. S. 1427 would also allow Secretary to adjust 
quality measures based upon risk, but it would require VA to establish 
procedures for making unadjusted data available to the public in a 
manner deemed appropriate by VA and to disclose its analysis 
methodology. These reports would need to be written for non-medical 
professionals and available electronically and in hard copy upon 
request at each medical center. The legislation is intended to ensure 
information VA provides is of a type and in a form that is conducive to 
comparisons with other local or regional hospitals. At least once a 
year, VA would be required to annually compare quality measures across 
years to identify and report any false or artificial improvements in 
quality measurements. In addition, VA would be required to develop and 
implement effective safeguards to protect against unauthorized use or 
disclosure of medical center data and to ensure that no identifiable 
patient data is released to the public.
    VA does not oppose increasing transparency of quality measures for 
its facilities and agrees with the general premise of this legislation; 
however, the agency does not support S. 1427 as written because some of 
the requirements may not be possible or would require VA to develop its 
own data categories that could not be compared or benchmarked to other 
leading health care organizations.
    VA has identified health care transparency as one of its major 
Strategic Transformation Initiatives this fiscal year and is working 
with the Centers for Medicare & Medicaid Services (CMS) to post VA 
comparable data on their ``Hospital Compare'' Web site 
(www.hospitalcompare.hhs.gov). CMS requires three data streams, each of 
which has different reporting periods based on assuring data validity. 
They post process data quarterly but outcome and patient satisfaction 
data annually. VA consequently believes that it is impractical to 
report data twice a year as the data may be invalid. VA is similarly 
exploring other public reporting programs, such as the Medicare 
Prescription Drug Plan Finder, Medicare Options Compare, CMS' Nursing 
Home Compare, Commonwealth Fund's WhyNotTheBest, and others.
    Additionally, VA is developing composite metrics meaningful to both 
consumers and stakeholders. While seemingly simple, an incremental 
letter grade scale may not be the best way to communicate the quality 
of a particular hospital to consumers. For example, CMS uses a five 
star rating system for Nursing Home Compare. VA will be conducting 
focus groups with Veterans to determine how they would like to be 
provided quality information about medical facilities. VA has proposed 
an initiative to develop an internal VA Hospital Report Card prototype 
for internal measurements and comparison at all organizational levels. 
The data elements are similar but not exactly the same as the elements 
identified in this legislation. VA proposes to include: structure and 
volume; workforce productivity; population and disease burden; care 
delivery utilization; quality, efficiency and outcomes; and trends and 
benchmarks. This approach offers VA the flexibility to provide 
meaningful measures that may be benchmarked with other hospitals and 
develop new measures through consensus-based processes involving all 
stakeholders. Measures should focus on areas with the greatest 
potential for making care safe, effective, timely, efficient or 
equitable, and patient-centered. Primarily, these data will be used to 
identify areas where VA can improve the most.
    VA estimates S. 1427 would cost $2 million in FY 2010, $2.1 million 
in FY 2011, $10.8 million over 5 years, and $24.0 million over 10 
years.
      s. 1429 ``servicemembers mental health care commission act''
    S. 1429 would establish a 12 member commission, jointly appointed 
by VA and DOD, responsible for overseeing the monitoring and treatment 
of Veterans and servicemembers with Post Traumatic Stress Disorder 
(PTSD), Traumatic Brain Injury (TBI), and other mental health disorders 
caused by service in the Armed Forces. The Commission would consist of 
at least one of each of the following: active duty servicemembers, 
Veterans retired from armed services, VA employees, DOD employees, 
recognized medical or scientific authorities in related fields, non-
physician mental health professionals, and Veterans who have undergone 
treatment for PTSD, TBI or other mental health disorders. VA and DOD 
would be required to consult with Veterans Service Organizations (VSO), 
members of the Armed Forces, and family members of Veterans and 
servicemembers when identifying members of the Commission. The 
Commission would conduct a thorough study of all matters relating to 
the long-term adverse consequences of these conditions. This would 
include analyzing information gathered from post-deployment interviews, 
effective treatments, effects on military careers for those seeking 
care, and continuity and effectiveness of care provided individuals 
during transition from DOD to VA. The Commission would make 
recommendations to mitigate any adverse consequences identified in the 
study and reduce the cultural and professional stigmas associated with 
treatment. The Commission would, not later than September 30 of each 
year, submit a report to Congress on their findings, conclusions, and 
recommendations of the Commission. The Commission would be authorized 
to conduct site visits, secure information from any Federal department 
or agency, and solicit testimony from servicemembers, Veterans, 
caregivers and other sources. The Commission would be terminated at the 
joint discretion of the Secretaries of DOD and VA.
    VA does not support S. 1429 because it is unnecessary. The 
Commission would review and advise on PTSD in current and former 
servicemembers who developed this condition as a result of service, 
regardless of era, but would not have oversight responsibilities for 
the care of Veterans with mental health conditions that were not 
determined to be service-connected. VA's mental health program provides 
care for enrolled Veterans with mental health conditions regardless of 
the origin of their conditions. Consequently, this Commission would be 
overseeing part of VA's mental health program, but not the entirety. 
The charge to address care in both Departments, and to address VA care 
across the lifespan, but only for those with service-connected 
conditions, is likely to limit its impact in either setting.
    Additionally, the Federal Advisory Committee on Prosthetics and 
Rehabilitation already addresses care for Veterans with TBI. Care for 
Veterans with mental health conditions is being address by two 
congressionally authorized committees: the Special Committee on Serious 
Mental Illness, and the Special Committee on PTSD. Membership for both 
committees is determined by the Under Secretary for Health, and each 
submits an annual report to Congress. The Commission proposed by this 
legislation would duplicate these existing and effective mechanisms for 
oversight.
    VA estimates the bill would cost $1 million in FY 2010, $1 million 
in FY 2011, $5 million over 5 years, and $10 million over 10 years.
                      s. 1444 ``combat ptsd act''
    S. 1444 would clarify the meaning of the term ``combat with the 
enemy'' in 38 U.S.C. 1154(b) for the purpose of determining service 
connection. For Veterans who engaged in ``combat with the enemy,'' 
section 1154(b) provides a relaxed evidentiary standard for proving 
service connection. Under this legislation, the term ``combat with the 
enemy'' would include active duty in a theater of combat operations (as 
determined by VA in consultation with DOD) during a period of war and 
active duty in combat against a hostile force during a period of 
hostilities. The clarification would apply to any disability 
compensation claim pending on or after the date of enactment.
    VA opposes this bill. While we understand and support the intent to 
give every benefit of the doubt to combat Veterans, S. 1444 is too 
broad, encompasses more than just PTSD claims, and may unduly 
complicate the adjudication process.
    Section 1154(b) provides a relaxed evidentiary standard that 
facilitates a combat Veteran's establishment of service connection for 
disease or injury alleged to have been incurred in or aggravated by 
certain active service. Specifically, section 1154(b) provides that, in 
the case of any Veteran who engaged in combat with the enemy in active 
service during a period of war, campaign, or expedition, VA shall 
accept as sufficient proof of service connection of any claimed disease 
or injury satisfactory lay or other evidence of service incurrence or 
aggravation, if consistent with the circumstances, conditions, or 
hardships of such service, notwithstanding the absence of an official 
record of such incurrence or aggravation. In short, section 1154(b) 
allows a combat Veteran to establish the incurrence or aggravation of a 
disease or injury in combat service by lay evidence alone. However, to 
be afforded this relaxed evidentiary standard, the Veteran must have 
``engaged in combat with the enemy.'' Furthermore, the relaxed 
evidentiary standard does not apply to the predicate fact of engagement 
in combat with the enemy.
    Historically, evidence of combat engagement with the enemy required 
evidence of personal participation in events constituting an actual 
fight or encounter with a military foe or hostile unit or 
instrumentality. Presence in a combat zone or participation in a 
campaign alone did not constitute engagement in combat with the enemy 
for purposes of the relaxed evidentiary standard.
    The reason for relaxing the evidentiary requirements for combat 
Veterans was that official documentation of the incurrence or 
aggravation of disease or injury was unlikely during the heat of 
combat. Combat Veterans should not be disadvantaged by the 
circumstances of combat service in proving their benefit claims. Under 
the relaxed requirements, satisfactory lay or other evidence, if 
consistent with the circumstances, conditions, or hardships of the 
Veteran's service, is sufficient to establish that a disease or injury 
was incurred in or aggravated by combat service.
    S. 1444 would extend the relaxed evidentiary standard to certain 
Veterans who did not engage in combat with the enemy during a period of 
war. It would require that a Veteran who served on active duty in a 
theater of combat operations during a period of war or in combat 
against a hostile force during a period of hostilities be treated as 
having ``engaged in combat with the enemy'' for purposes of 
establishing service connection for disease or injury alleged to have 
been incurred in or aggravated by such service. S. 1444 would also 
require that VA, in consultation with DOD, determine what constitutes a 
theater of combat operations. DOD defines theater of operations broadly 
to encompass geographic operational areas of significant size defined 
for the conduct or support of specific military operations. An area 
designated as a theater of combat operations in consultation with DOD 
would encompass all Veterans who served on active duty in that theater 
during a period of war, whether or not they were actually involved in 
combat.
    Service in a theater of combat operations does not necessarily 
equate to engaging in combat with the enemy and does not in many cases 
present the same difficulties encountered by combat Veterans when later 
pursuing compensation claims. So, although we share the goals of this 
bill to improve the processing of compensation claims, we are concerned 
that it would extend the relaxed evidentiary standard to Veterans who 
served in a theater of combat operations regardless of whether their 
service involved combat or was even near actual combat and regardless 
of whether the circumstances of their service were of the kind that 
would inhibit official documentation of incurrence or aggravation of 
injury or disease.
    We also are uncertain of the scope of S. 1444, which is broader 
than just PTSD claims and would provide a relaxed evidentiary standard 
for all types of physical and psychological diseases and injuries 
allegedly incurred in or aggravated by service in a theater of combat 
operations. In this regard, the subjective psychiatric symptoms 
associated with a traumatic experience are not always immediately 
manifested or apparent and thus are not subject to ready documentation. 
For example, a Veteran who witnesses a traumatic event may show no 
immediate observable signs of the mental trauma resulting from the in-
service incident. On the other hand, a physical injury is more readily 
observable to lay witnesses and more likely to have been documented 
even in a combat theater.
    In addition, this bill may unduly complicate the adjudication 
process by requiring separate determinations of whether a Veteran 
served on active duty in a theater of combat operations during a period 
of war or served on active duty in combat against a hostile force 
during a period of hostilities, questions that VA typically does not 
address. The need to make such determinations may delay claim 
processing for all Veterans.
    Furthermore, on August 24, 2009, VA proposed a rule that would 
liberalize the evidentiary standard for establishing the required in-
service stressor for entitlement to service connection for PTSD. The 
amendment to VA's adjudication regulations governing service connection 
of PTSD would eliminate the requirement for corroborating evidence that 
the claimed in-service stressor occurred if the stressor claimed by a 
Veteran is related to the Veteran's fear of hostile military or 
terrorist activity and a VA psychiatrist or psychologist confirms that 
the claimed stressor is adequate to support a diagnosis of PTSD, 
provided that the claimed stressor is consistent with the places, 
types, and circumstances of the Veteran's service, and that the 
Veteran's symptoms are related to the claimed stressor. This proposed 
rule has been lauded by many Veterans service organizations and 
Congress and would improve in the same area as this bill.
    VA is unable to provide a cost estimate for this bill because we 
cannot estimate the number of Veterans who would be granted service-
connection based on the provisions of this bill.
  s. 1483 ``designating the alexandria, minnesota outpatient clinic''
    S. 1483 would designate the Department of Veterans Affairs 
Outpatient Clinic in Alexandria, Minnesota as the ``Max J. Beilke 
Department of Veterans Affairs Outpatient Clinic.'' Mr. Beilke died in 
service to his country at the Pentagon on September 11, 2001. The 
Department has no objection to this proposal and defers to Congress in 
the naming of Federal property.
        s. 1518 ``caring for camp lejeune veterans act of 2009''
    S. 1518 would amend title 38 to extend eligibility for hospital 
care, medical services and nursing home care for certain Veterans 
stationed at Camp Lejeune during a period in which well water was 
contaminated notwithstanding that there is insufficient medical 
evidence to conclude that a particular illness is attributable to such 
contamination. It would also make family members of those Veterans who 
resided at Camp Lejeune eligible for the same services, but only for 
those conditions or disabilities associated with exposure to the 
contaminants in the water at Camp Lejeune, as determined by the 
Secretary.
    VA takes the Camp Lejeune matter very seriously but has concerns 
with the legislation as written. S. 1518 would provide a very broad 
enrollment and treatment authority for servicemembers and their 
families. As the legislation is written, any condition that cannot be 
specifically eliminated as related to the contaminated water at Camp 
Lejeune would require VA to provide treatment. We note this authority 
is broader than that conferred on radiation-exposed Veterans. Moreover, 
the legislation would also require VA to provide medical services and 
nursing home care to those family members who either consumed 
contaminated water or were in utero at the time of consumption if the 
condition or disability can be associated with exposure to contaminated 
water at Camp Lejeune.
    From the 1950s through the mid-1980s, persons residing or working 
at the U.S. Marine Corps Base Camp Lejeune were potentially exposed to 
drinking water contaminated with volatile organic compounds. Two of the 
eight water treatment facilities supplying water to the base were 
contaminated with either tricholoroethylene (TCE) or 
tetrachloroethylene (perchloroethylene, or PCE). The Department of 
Health and Human Services' Agency for Toxic Substances and Disease 
Registry (ASTDR) estimated that the level of PCE in drinking water 
exceeded current standards from 1957 to 1987 (when the contaminated 
wells were shut down) and represented a potential public health hazard.
    An ATSDR study begun in 2005 is evaluating whether children of 
mothers who were exposed while pregnant to contaminated drinking water 
at Camp Lejeune are at an increased risk of spina bifida, anecephaly, 
cleft lip or cleft palate, and childhood leukemia or non-Hodgkin's 
lymphoma. The results of this report have not yet been released. In the 
same year, a panel of independent scientists convened by ATSDR 
recommended the agency identify cohorts of individuals with potential 
exposure, including adults who lived or worked on the base and children 
who lived on the base (including those that may have been exposed while 
in utero), and conduct a feasibility assessment to address the issues 
involved in planning future studies at the base.
    In October 2008, the Department of the Navy issued a letter to 
Veterans who were stationed at Camp Lejeune while in military service 
between 1957 and 1987. This letter informed Veterans that the Navy had 
established a health registry and encouraged them to participate. VA 
currently provides Veterans with information about this issue and 
referrals to the Navy registry. Veterans who are a part of this cohort 
may also apply for enrollment if they are otherwise eligible, and are 
encouraged to discuss any specific concerns they have about this issue 
with their health care provider. Veterans are also encouraged to file a 
claim for VA disability compensation for any injury or illness they 
believe is related to their military service. VA environmental health 
clinicians can provide these Veterans with information regarding the 
potential health effects of exposure to volatile organic compounds and 
VA's War-Related Illness and Injury Study Centers are also available as 
a resource to providers.
    It is unclear exactly how many people were potentially affected, 
but some estimates place the number at one million Veterans and family 
members. Though the Department of the Navy has attempted to contact all 
servicemembers who were stationed at Camp Lejeune during the three 
decades of potential exposure, it is possible not everyone was reached 
or identified. Records over a half-century old may not be available, 
and the legislation leaves open-ended what ``resided'' or ``stationed'' 
means because there is no limitation such as a minimum time requirement 
on the base. Consequently, a broad definition of these terms may mean 
VA's estimates of 500,000 Veterans and 500,000 family members are too 
conservative.
    Because of these concerns, VA recommends that if any enhanced 
Veteran care is authorized, it should be modeled upon the authority 
providing for benefits and services for radiation-exposed Veterans and 
limited to conditions that can be associated with consumption of 
contaminated water. VA also would recommend that any care for 
potentially eligible family members be provided by DOD as the exposure 
is directly related to service at Camp Lejeune.
    VA estimates the legislation, as written, would cost $299.7 million 
in FY 2010, $319.5 million in FY 2011, $1.71 billion over 5 years and 
$4.16 billion over 10 years.
 s. 1531 ``department of veterans affairs reorganization act of 2009''
    S. 1531 would amend 38 U.S.C. 308 to increase the number of 
Assistant Secretaries in the Department from seven to eight. It would 
also increase the number of Deputy Assistant Secretaries from 19 to 27. 
The bill would also require that one Assistant Secretary be appointed 
Assistant Secretary for Acquisition, Logistics, and Construction and 
would cap the number of Deputy Assistant Secretaries the Secretary may 
appoint to manage programs relating to construction, facilities, asset 
management, and IT. In addition, S. 1531 would modernize some of 
nomenclature relating to construction and acquisition functions in 38 
U.S.C. 308.
    VA generally supports this legislation. Elevating the construction 
and acquisition function to the Assistant Secretary (AS) level will 
help ensure consistent and sound business decisions are made in VA's 
acquisitions, logistics, and construction programs. This position will 
also further transform and modernize VA's business practices and 
processes. Similarly, expanding the number of Deputy Assistant 
Secretaries (DAS) is necessary given the size, scope, and complexity of 
VA's missions and geographic distribution. However, VA opposes language 
in S. 1531 which specifies the title and responsibilities of the AS and 
which caps the number of DAS assigned to certain functions as this 
limits the agency's flexibility to address changing needs and demands.
    s. 1547 ``zero tolerance for veterans homelessness act of 2009''
    S. 1547 proposes to alter and expand a number of authorities 
available to VA with regard to preventing and reducing Veteran 
homelessness. VA has initiated an ambitious plan to end homelessness 
among Veterans and supports the Committee's interest in providing 
additional services and assistance to homeless Veterans. However, VA 
needs additional time to evaluate S. 1547. We will provide views and 
costs on these provisions as soon as they are available.
                s. 1556 ``veterans voting support act''
    S. 1556 would to require VA to support Veterans in registering to 
vote and voting. While VA is committed to helping Veterans exercise 
their right to vote, the agency needs additional time evaluate S. 1556. 
We will provide views and costs to the Committee as soon as they are 
available.
            s. 1607 ``wounded veteran security act of 2009''
    S. 1607 would amend title 38 to establish certain employment rights 
for persons absent from work for treatment of a service-connected 
disability. VA defers to the Department of Labor on this legislation as 
it concerns rights and benefits of 
employment.
           s. 1668 ``national guard education equality act''
    S. 1668 would amend section 3301 of title 38, United States Code, 
to add to the definition of ``active duty'' under the Post-9/11 GI 
Bill, full-time duty served under title 32, United States Code, by 
members of the Army National Guard or Air National Guard of any State, 
thereby making this service qualifying service for purposes of the 
Post-9/11 GI Bill. This would include, but not be limited to, active 
duty (1) under orders from the Governor of a State or Territory of the 
United States in response to a domestic emergency; (2) as part of the 
Active Guard Reserve; (3) as part of Air Sovereignty Alert; (4) as part 
of Operation Jumpstart; (5) in response to Hurricane Katrina; (6) as 
part of an airport security mission; or (7) as part of a counterdrug 
activity.
    A bill similar to S. 1668 (H.R. 3554) was introduced in the House 
of Representatives on September 10, 2009. H.R. 3554 also proposes to 
amend the Post-9/11 GI Bill to include Army National Guard and Air 
National Guard active-duty service under title 32, United States Code, 
as qualifying service for the Post-9/11 GI Bill. However, H.R. 3554 
would also allow individuals who served at least 30 continuous days in 
a Reserve Component and were released for a service-connected 
disability to be eligible for the Post-9/11 GI Bill.
    VA does not oppose S. 1668, subject to Congress identifying offsets 
for the additional benefit costs; however, we would prefer to see a 
provision in this measure similar to the one in H.R. 3554, noted above, 
that would authorize eligibility under the Post-9/11 GI Bill for 
certain individuals released from active duty for service-connected 
disabilities.
    On average, the Army National Guard has the largest number of 
beneficiaries in the Reserve Educational Assistance Program (REAP), as 
well as the Montgomery GI Bill--Selected Reserve program (MGIB-SR). The 
Air National Guard has the third largest number of beneficiaries in 
these programs. Enrollments in these programs would be reduced if title 
32 active-duty service became qualifying service under the Post-9/11 GI 
Bill.
    Servicemember and service-period data are electronically exchanged 
between VA and DOD for some members who served under title 32 and 
became eligible for either the MGIB--Active Duty, REAP, or MGIB-SR. 
However, VA and DOD would need to manually verify this data until it 
could be electronically exchanged. Additionally, administration of the 
Post-9/11 GI Bill would be impacted by the anticipated increase in the 
number of individuals who would qualify for the Post-9/11 GI Bill.
    VA estimates that the enactment of S. 1668 would result in a 
benefits cost to VA of $120.6 million in FY 2011, $1.1 billion over 5 
years, and $2.3 billion over 10 years.
 s. 1752 ``presumption of service-connection for parkinson's disease''
    S. 1752 would add Parkinson's disease manifested to a degree of 10 
percent or more to the list of diseases presumed service-connected in a 
Veteran who served in Vietnam.
    VA supports the objective of this bill. Based on an independent 
study by the Institute of Medicine, the Secretary announced on October 
13, 2009, that VA would add Parkinson's disease to the list of 
presumptive diseases associated with herbicide exposure. However, this 
provision is unnecessary based on the Secretary's recent determination.
    VA cannot provide a cost estimate on this bill at this time because 
sufficient data are not yet available. With the Chairman's permission, 
we will provide a cost estimate in writing for inclusion in the record.

    This concludes my prepared statement. I would be pleased to answer 
any questions you or any of the Members of the Committee may have.

    Chairman Akaka. Thank you. Thank you very much, Dr. Cross 
and Mr. Mayes.
    Dr. Cross, VA has stated in the past that it does not 
support legislation on expanding voting registration activities 
because such mandates would be overly burdensome. What kind of 
directive does VA currently have in place that addresses voter 
registration 
activities?
    Dr. Cross. Senator, we think that voting for veterans is 
very important and are doing what we can within our 
organization--as a health care organization, speaking for my 
part--to encourage them and to support them in that effort to 
vote. We have taken this seriously. I want to hold up before 
you, and we can provide this to the Committee, a directive that 
was issued September 8, 2008, supporting that initiative. Now I 
will ask my colleague from General Counsel to comment on that 
in more detail.
    Chairman Akaka. Mr. Hall?
    Mr. Hall. Yes, sir. This directive was issued prior to the 
election last year. It went through a couple of iterations, but 
this is the final version that was in place during the election 
season last year. It requires that each facility have a written 
policy on how we are going to take care of veterans, who 
because they are residents or patients at a VA facility are 
unable to access their own voter regulation facilities.
    It requires that we give them access to voting, whether it 
is by absentee ballot or by giving them leave from the VA 
facility to go vote. It requires that information on the Voting 
Assistance Program be provided to every inpatient who comes 
into a VA hospital, that we post information on how and where 
veteran patients who are in our facilities can get voter 
registration and voting information within the facility. It 
makes provision for allowing local voter registrars, officials 
from the offices of the Secretaries of State, and nonpartisan 
voter registration organizations to come into VA facilities to 
register our veteran patients.
    As I said, it was in place during the election last year 
and we think we met with great success. We registered a great 
number of veterans--both our inpatients and outpatients--and 
assisted a number of them with their absentee balloting.
    Chairman Akaka. Thank you very much, Mr. Hall.
    Dr. Cross, it is the view of the American Academy of 
Physician Assistants that PAs, unlike doctors or nurses, are 
not considered a critical occupation in VA. What is your view 
about that?
    Dr. Cross. Well, my view is I do consider them to be a 
critical occupation. They are great health care providers. I 
wouldn't want to startup one of our hospitals without them. 
Every day, they go to work providing superior care to our 
veterans and working as part of the team, part of a team of 
health care providers within the organization.
    I don't have the exact number that we have on duty today, 
but as I recall, the last time I checked, it was over 1,600. 
That is a very important resource for us. I am proud that I 
have had opportunities to work with the PAs and attend their 
meetings. We have created the PA Advisor position, and their 
professional organizations come to visit me at least, I think, 
once a year where we discuss issues. I think it has been a good 
relationship.
    Chairman Akaka. Dr. Cross, I understand that PAs now make 
up 30 percent of all mid-level providers in VA. Why are there 
fewer PAs than other types of mid-level providers in VA?
    Dr. Cross. I think what you are referring to, Senator, if I 
understand your question, is that we have more Nurse 
Practitioners than PAs. I don't really have a specific answer 
for that. I think that the PAs do a great job--are very 
competitive--as do the Nurse Practitioners. Often, when we open 
up positions, as I recall from when I was in primary care, we 
advertise it for both and we are happy to do that.
    Chairman Akaka. Dr. Cross, Senator Pryor's reorganization 
bill would establish within VA one Assistant Secretary for 
Acquisition, Logistics, and Construction. VA supports this 
bill. Help me understand the rationale for including 
construction issues within the purview of this new Assistant 
Secretary.
    Dr. Cross. Senator, I will defer to Mr. Hall for that 
answer.
    Mr. Hall. Yes, sir. All construction done by VA is, of 
course, done through contracting, whether it is planning or 
design, most of that is done by contract and certainly all the 
construction that we do. We don't have an actual construction 
activity within the Department. It is all done through 
contracting.
    In determining where oversight of construction best fit--
since this is an activity that is carried out entirely through 
contracting--it was determined that closer contact with the 
organization that had the best understanding of the needs of 
the contract activity was the place it best fit, where it could 
get the best oversight, and the best supervision.
    Chairman Akaka. Well, thank you very much.
    I would like to call on our Ranking Member for his 
questions.
    Senator Burr. Thank you, Mr. Chairman.
    Dr. Cross, thank you and I thank all of you today for the 
service you provide this country.
    If I understand it, your concerns with S. 1518 is that it 
gives broader enrollment and treatment authority than exists 
for radiation-exposed veterans. However, my legislation was 
modeled after the existing treatment authority Congress 
conferred on participants of Project Shipboard Hazard and 
Defense, or SHAD--a series of chemical and biologic warfare 
tests conducted between 1962 and 1993. Why do you recommend 
that my legislation be modeled after the Radiation-Exposed 
Veterans versus Project SHAD?
    Dr. Cross. I think there were two things that came to mind 
as we were working on this. By the way, Senator, let me say 
that I brought the book with me. This is something I am 
personally reading. The work that we are doing with it on the 
task force which we have put together as a joint effort between 
all of the people that you see here--Brad Mayes, myself, the 
General Counsel--to move this forward. And we are putting our 
best scientists to work on this type of toxic exposure, to move 
this Lejeune issue forward.
    I want to give you my personal commitment up front before I 
get into the details of the discussion, along with Brad and 
along with the General Counsel, we are going to move this 
forward, get the analysis done, make some recommendations, 
whatever they may be, to our leadership within the 
organization.
    The way the bill is constructed, and what I think caused 
concerns with some of the staff, is, in fact, that the language 
was very broad. We found that the work that was done on the 
radiologic exposure was more precise than tying it to perhaps 
level of exposure and to determining exactly who should get the 
benefit.
    I noticed that in the way the legislation is constructed 
right now, as I understand it, anyone who was there for any 
amount of time would basically be treated the same as someone 
who lived there and resided there in housing for perhaps a 
period of years. That might be a bit of something that we could 
talk about with your staff offline, to work on that part of it.
    I will ask my colleagues to comment on this, as well.
    Senator Burr. Mr. Mayes?
    Mr. Mayes. Yes, Senator. On the benefits side, as a follow-
up to the hearing 2 weeks ago, we are trying to get that 
registry. I think the point you were trying to make is that we 
need to know who potentially was impacted by contaminated 
drinking water. So we have asked for the names and the 
identifying information of those servicemembers who potentially 
were exposed.
    We need to sensitize our field personnel that are 
adjudicating these claims to the fact that if somebody is 
coming into one of our offices with a claim for a disease 
related to consuming contaminated drinking water, they need to 
know that, in fact, this servicemember was there. That would be 
helpful for us.
    As Dr. Cross said, we are participating in the special work 
group that is evaluating the science that is in that Institute 
of Medicine report to determine if, for example, a presumption 
of service connection would be in order. The IOM has identified 
some conditions where there is at least limited suggestive 
evidence of causation of certain diseases with exposure to PCE 
and TCE in the drinking water.
    So, those are the things we are doing. I also had 
reiterated this point of sympathetically looking at these 
claims on a call we had, as a matter of fact, last week, and we 
talked about sodium dichromate at Qarmat Ali and all of the 
exposures that, Mr. Chairman, you and Senator Burr had raised 
in the hearing 2 weeks ago.
    Senator Burr. One follow-up comment. Clearly, the studies 
that have been done up until this time didn't take into account 
benzene, or to the same level of concern, TCE and/or PCE. That 
may not be determined until additional studies are conducted or 
the conclusions of those studies are finished. This is a call 
we have to make as to whether the science says exposure to 
benzene, not specifically benzene exposure at Camp Lejeune, 
could be the cause of certain health conditions like male 
breast cancer.
    I would only remind you from the standpoint of the scope of 
the bill, though it is broad, it is directly linked to a health 
condition that might be the result of exposure. Therefore, it 
is impossible to disqualify somebody because they lived there 6 
months and at 39 developed breast cancer, or 6 years and at 55 
developed breast cancer as a male. So I think there are some 
unknowns and I would hope that we could err on the side of 
coverage of individuals that have health conditions that 
science suggests may be the cause of exposure to these 
contaminants.
    You have raised an issue about whether there is a 
Department of Defense responsibility for family members. Let me 
just ask you, I think, an obvious question. Should we be more 
focused on providing care needed or who pays for it?
    Dr. Cross. Senator, you and I both know the answer to that. 
We take care of the patient and take care of the veteran----
    Senator Burr. Thank you.
    Dr. Cross [continuing]. But we will work that out.
    Senator Burr. Mr. Mayes, you alluded to the fact that you 
have requested the registry.
    Mr. Mayes. I had asked Dr. Postlewaite following that 
hearing 2 weeks ago for the names, and a formal request is on 
its way, over to Navy. There have been a lot of exchanges 
between individuals between both agencies.
    Senator Burr. Would you provide for the Committee when that 
formal request is made and then notify the Committee when they 
have fulfilled or denied the request?
    Mr. Mayes. Yes, sir, Senator. We will do that.
    [The response for the record follows:]
Response to Request Arising During the Hearing by Hon. Richard Burr to 
  Bradley G. Mayes, Director, Compensation and Pension Service, U.S. 
                     Department of Veterans Affairs





    Senator Burr. Thank you. Additionally, in that hearing we 
talked about the regional offices being fully informed. You 
alluded to that. Do you feel that sufficient notification has 
been made to the regional offices of this exposure and this 
population?
    Mr. Mayes. Sir, we have reinforced this information again, 
but I don't think we have done enough yet. We still have a 
formal policy guidance that is in concurrence, which I owe the 
Committee once it is issued. What I would like to do, ideally, 
is at the time of issuance of that guidance, provide access, 
possibly through a link, to the names on the registry. That is 
what I would really like to do. I don't know if I am going to 
have the names of servicemembers who were potentially exposed 
by the time that goes out. We will issue it one way or the 
other.
    Senator Burr. We will do everything we can to help you get 
that.
    Mr. Mayes. Thank you, Senator.
    Senator Burr. My last question, Dr. Cross. We continually 
talk about the homelessness issue. I personally believe we have 
to focus on prevention to stop the cycle before it begins. We 
must look at the short- and long-term housing needs, job 
training needs, medical, dental, substance abuse, and much 
more. Share with us where you currently see gaps in our ability 
to end homelessness with our veterans.
    Dr. Cross. Your comment, I think, is precisely what we are 
focusing on. There are two broad groups I look at in the 
homeless community: the chronically homeless; and those who, 
for some short period of time during the course of a year, may 
experience homelessness. Prevention is far better than trying 
to deal with it after it occurs.
    When we look at the veterans who we see that are homeless, 
mental health issues come to the fore. That is a critical 
component of substance abuse. Then there are issues about 
access to housing. There are issues occasionally about economic 
factors, loss of jobs, and those kinds of things. But mental 
health and substance abuse are really at the core of this, 
particularly in talking about severe mental illness, 
schizophrenia and those conditions, and ongoing substance 
abuse.
    That is why I think with our mental health programs we have 
to make a difference before homelessness occurs. We are going 
to make a tremendous effort to identify everyone who is 
homeless right now and do something about it. One hundred 
thirty-one thousand veterans--we believe from the last 
nationwide survey--were homeless. The good news is that was 
down from what it was the year before, and that was down from 
the year before that. It has been going down steadily. That may 
reflect some effort on the part of our mental health folks, but 
there is much more to be done there.
    The Secretary's announcement on homelessness has captured 
our imagination. It has captured the enthusiasm of my staff. We 
want to make this a success. We feel that there is no reason 
why we should ever see a veteran on the street with a sign that 
says, ``homeless veteran.''
    Senator Burr. Thank you, Dr. Cross, and Mr. Chairman. If I 
might add to that, I would love to see this Committee and the 
VA have a roundtable on mental health issues and mental health 
services--not an official hearing, but one where we don't have 
the formalities that we've got here--where we can exchange 
ideas, and hear the concerns within the system. And I hope if 
we get an opportunity to do that, you would also be prepared to 
talk to us about the possible expansion of telemedicine as a 
mental health tool, and our ability to reach people that we 
currently can't get into a site that has the services in-house, 
and how we might be able to use that technology to treat mental 
health problems. Thank you.
    Dr. Cross. Sir, we would accept that invitation with 
enthusiasm.
    Senator Burr. Thank you.
    Chairman Akaka. Thank you very much, Senator Burr.
    Now, we will have questions from Senator Murray.
    Senator Murray. Thank you very much, Mr. Chairman. I share 
Senator Burr's concern about exposure issues and ensuring the 
VA knows who is affected, whether it is a base here in the 
United States, a base abroad, or it is on the battlefield. We 
have been down this road before--whether it is Agent Orange or 
Gulf War Syndrome--and making sure the VA has access to those 
names is critical. So I want to thank Senator Burr and work 
with him on that.
    On the issue of homelessness, as you know, the Homeless 
Women Veterans and Homeless Veterans with Children Act of 2009 
is before the Committee today. The Ranking Member, Senator 
Burr, asked you about the question of why people are homeless. 
Well, two of the growing populations are: women; and both women 
and men with children, which is who we are trying to address in 
this legislation. I appreciate the VA's support of that bill 
before this Committee today.
    Can you talk specifically about some of the things you are 
doing currently to make sure that women veterans in particular, 
and women and men with children, understand that there are 
services and how we can accommodate those groups in a better 
way?
    Dr. Cross. I think in so many of the program efforts that 
we are making right now, we have identified as a key element 
the increasing numbers of women veterans that we expect to 
receive in our health care systems over the coming years. When 
we look at the active duty force and the percentage of women in 
the force, comparing it to the patients that we have right now 
who are female, we see a steady rise over time.
    So here is what we are doing. We don't think that our 
facilities and our staff were always really focused and well 
prepared to address the specific issues that are important to 
women. We want to make sure that privacy is clearly taken care 
of. We want to make sure we have a welcoming, friendly 
environment that specifically meets the needs of our women 
veterans. We want to make sure that we do anything we can do 
down the road in finding ways to support them with health care 
providers who are uniquely trained to address their needs.
    So one of the things that we have done to accomplish that, 
for instance, on that last point, is to create many 
residencies, training, special training, intensive training 
specifically focused on nothing except the unique care that we 
want to provide women veterans. We have digitalized all of our 
mammography systems so that they are state-of-the-art in that 
regard. We have so many different things that we are doing to 
offer a better, more welcoming environment. I could go on for 
some time. I would be happy to discuss that further.
    Senator Murray. Thank you. It is welcome news to my ears to 
have the VA recognize that this is an issue and talk about what 
they are doing, making sure it reaches VA facilities at every 
level where it really is important. I want to work with all of 
you to make sure it is not just rhetoric from the top, but that 
it truly creates a better atmosphere for women. They are a 
growing population in the VA. They come in with unique 
challenges. If they walk in a door and it is all men, they are 
going to turn around and go back out. That doesn't help 
anybody. And the privacy issue that you mentioned is an 
important part of that. Making sure that they have child care 
is critical, because women often trot in with kids and they are 
not going to leave them sitting in a waiting room.
    So, we need to address these issues. My bill begins that 
effort. I know you are making efforts, as well, and I think if 
we continue at all levels, we will make progress.
    Dr. Cross. Senator, I forgot to mention one of our key 
efforts, and that is the Women's Coordinators at our medical 
centers.
    Senator Murray. Correct. Does the VA have those at every 
facility now?
    Dr. Cross. One hundred forty-four.
    Senator Murray. That is a huge leap forward from where we 
were even a year ago, so I appreciate that very much.
    I have to get to another committee to be the 12th vote to 
vote some nominees out. I will go do that, Mr. Chairman, and 
return in order to be here for the second panel, but I want to 
thank the VA for its testimony today.
    Chairman Akaka. Thank you very much, Senator Murray.
    And now we will take questions from Senator Johanns.
    Senator Johanns. Thank you, Mr. Chairman.
    Dr. Cross, if I could call your attention to the VA 
Hospital Quality Report Card Act, I appreciate in your 
testimony your indication that in spirit, at least, you support 
this legislation, if not the actual legislation itself. Let me 
just ask you, something like a grading system, where literally 
it was A through F, don't you think that would be beneficial to 
the average veteran who doesn't want to try to peel through 
thick reports and all of the things you do, which I think is 
very important? Don't you think that would be beneficial to a 
veteran?
    Dr. Cross. Conceptually, yes. What we wanted is to match up 
with what is being done in the civilian sector, and I think in 
the written testimony, we noted that they are not using so much 
a letter grade as we had in high school or college, but that 
they are using other types of indicators for patients.
    I think one issue that we have in the bill that we think is 
very strong in its intent, and we support the intent very 
strongly; it is just that we want to match up nicely with our 
civilian colleagues so that we can be compared more directly. 
That direct comparison is where we want to go. We are not 
afraid of that. The Secretary has told me he wants us to do 
this. I have got staff working on making sure this happens. We 
are going to use programs like Hospital Compare. We are going 
to publish more data than has ever been published before.
    I wanted to point out a couple of things, if I might. We 
work with many different agencies, but this is the CBO report. 
The Congressional Budget Office did a complete review of health 
care quality at the VA. This was published in August of this 
year. Not suitable for patients to utilize--very technical--but 
still a very important document.
    Another area where we compare ourselves to the private 
sector every day--including Medicare and Medicaid and the 
commercial sector--is our outpatient scores on how we are doing 
on process measures and actually outcome measures. This is very 
important for the staff and for the Committee to understand. I 
would love to provide copies of this. Again, its very 
technical; not what patients need.
    I think as we design what we are going to do beyond 
Hospital Compare, beyond those initiatives, we have to meet 
with our stakeholder and see what they would prefer that we 
utilize. That would be our VSOs, particularly, and the patients 
themselves.
    So two things. We want to compare to our civilian 
colleagues. And number 2, we want to make sure that our 
stakeholder support the way that we are going to present the 
information.
    Senator Johanns. I am a joint sponsor on this so I would 
certainly want to consult with Senator Wyden, but from my 
standpoint, all I am looking for is something that is an easy 
reference for the patient. Absolutely, we want the VSOs to be 
involved. I don't see offhand any problem in trying to match 
this with what is going on in the private sector.
    So, I guess what I would say to you is that I am hoping we 
can work together on the right process, the right approach, 
because just as you testify, it seems to me that you are trying 
to accomplish what we are trying to accomplish.
    Dr. Cross. And the Secretary wants this to happen quite 
soon.
    Senator Johanns. OK.
    Dr. Cross. Sir, if you can work with us, we can work with 
your staff to show what we are doing, see if it meets your 
approval, and then move on from there.
    Senator Johanns. OK. We would welcome that.
    My last question. I ran into this situation when I was 
making my way around the State for the August recess, which 
relates to S. 1444. Again, I appreciate your concern about 
expanding the evidentiary standard and potentially making it 
too broad. It relates to injuries, or Post Traumatic Stress 
Disorder, actually, when you are not actually on the 
battlefield. This is what I ran into.
    I spoke to a woman whose husband had been in Iraq, and his 
job was literally to clean up the equipment. So you think about 
that job and you think to yourself, gosh, that can't be so 
stressful compared to being in combat. But then you come to 
realize that this person was dealing with the aftermath of 
combat and you can only imagine the horror that that individual 
and others were seeing every day in cleaning up that equipment. 
This person came back and is suffering from Post Traumatic 
Stress Disorder, but struggled to get through the process to 
get the help they needed to deal with this issue.
    Tell me how we work our way through those kinds of 
problems. I understand the desire for clean lines and, you 
know, you are not in combat so these conclusions result. So, 
how would you suggest we deal with that, because to me, that is 
very real, and that person had a very, very real condition as a 
result.
    Dr. Cross. I will kick that over to my colleague, Brad 
Mayes, who deals with this from the compensation point of view. 
That is the bill that they are dealing with.
    As a physician, though, I understand one particular aspect 
of this. Each patient is different----
    Senator Johanns. Yes.
    Dr. Cross [continuing]. And the stressors that affect them, 
they react to differently. We have to understand that and be 
sensitive to that. I want all of my examiners who do the C&P 
exams for Brad to convey that sensitivity and that awareness.
    Mr. Mayes?
    Mr. Mayes. Thank you, Dr. Cross. First of all, we, too, 
have come to recognize that we needed to do something regarding 
the process which we were following to establish service 
connection for Post Traumatic Stress Disorder. The basic 
elements of establishing service connection have not changed, 
and one is that we need to have a diagnosis of PTSD, which is 
strictly a medical determination, not a legal determination on 
the benefit side. We need to have what we term ``credible 
supporting evidence'' of a stressor--something in service that 
precipitated the disorder. Then we need the medical link 
between that diagnosis and that stressor, again, something 
provided by the professional medical person.
    So, where we were hung up on the legal side, on the 
benefits side, was establishing this so-called credible 
supporting evidence of the stressor. We were following the 
words and the regulations very strictly and trying to place an 
individual in a specific event in service that would have 
caused these symptoms to manifest either immediately, or in 
some cases, many years after the veteran suffered from exposure 
to this event. We were finding, as you found, Senator, that we 
were spending an inordinate amount of time and not being 
sensitive to the fact that just being deployed--given the 
changing nature of warfare over there, and some would argue the 
nature of warfare even in previous conflicts--leads to 
certainly more intense potential for harm because of exposure 
to IEDs, mortar attacks, and terrorist activity.
    We said, let us get out of the business of trying to prove 
that somebody was at a specific place. If they assert that they 
had a stressor, and it is consistent with the types, places, 
and circumstances of their service--which, by the way, is the 
threshold in the statute that allows the reduced evidentiary 
burden for combat veterans--so we are applying the same 
evidentiary standard for PTSD claims; then we are going to move 
it on to Dr. Cross and to his psychiatrists and psychologists. 
We are not going to question that. Then we let the psychiatrist 
or psychologist examine the veteran to determine if we have 
PTSD and the medical link between that stressor and the Post 
Traumatic Stress Disorder.
    Dick, do you want to add to that? I might have missed 
something there.
    Mr. Hipolit. I just wanted to add that for our proposed 
rule which Mr. Mayes is referring to, the comment period closes 
this Friday. After that we will be able to move forward toward 
a final rule.
    Senator Johanns. I appreciate your efforts. We are way out 
of time here, and I don't want to impose on my colleagues. But, 
boy, you run into these real situations and it is just 
heartbreaking to see what is happening to the family if there 
isn't some kind of treatment provided. So I really appreciate 
any effort you could focus here, which it sounds like the rule 
is headed in the right direction, if not the right direction. 
So we will follow that closely. Thank you.
    Chairman Akaka. Thank you, Senator Johanns.
    Now we will take questions from Senator Begich.

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

    Senator Begich. Thank you, Mr. Chairman. I will just have a 
few questions. Let me just make sure I understand on the voting 
legislation, which was S. 1556. You are doing something now, 
but you don't support the legislation; help me make sure I am 
clear on what the position was.
    Dr. Cross. I believe the position, Senator, is that we are 
not ready to officially State a position for the hearing today 
and will do so.
    Senator Begich. OK. When will you do that?
    Dr. Cross. Time is always the question----
    Mr. Hall. Yes, it is a problem. We will do it as quickly as 
possible. It is developing a position and getting a number of 
people----
    Senator Begich. To review it.
    Mr. Hall [continuing]. To review and agree that that is the 
way to go.
    Senator Begich. OK. So, quickly, could----
    Mr. Hall. It is sort of out of our immediate control, but 
hopefully, within the next couple of weeks.
    Senator Begich. OK. Very good.
    In regards to the chiropractic care legislation, I think it 
is S. 1204, if I can just make sure I am, again, on the same 
path. You don't think that bill is necessary, if I read the 
notes right. You feel you are already providing the care that 
is requested, or at least the capacity, at this point, is 
that----
    Dr. Cross. Generally. May I comment on that just a little 
more?
    Senator Begich. Absolutely.
    Dr. Cross. You know, I commented earlier about the PAs and 
all of our professional groups, and we value them all and their 
dedication. The work that they do on behalf of our veterans is 
very important and our veterans really appreciate it. I think 
one of the issues here is how prescriptive and how narrowly 
directive Congressional legislation might be at times resulting 
in the real loss of flexibility that we have.
    Each site that we have within the VA has to carry on 
business that meets the needs of their own population. 
Sometimes we do this by care within house--particularly with 
the chiropractic specialty--and sometimes we do it by engaging 
with the community and working with civilian non-VA providers 
in the community; we send patients out there.
    Senator Begich. Right.
    Dr. Cross. I think the VA has been very positive in 
welcoming this group of professionals. In fact, I heard from 
one of our leaders in chiropractic just recently who actually 
did a video for the organization about how the VA is the best 
place for them to practice. So, I want to keep up that positive 
approach, and I also want to give my hospital directors 
flexibility, because if you bring the position in-house, that 
can be valuable at times. Other times, engagement with the 
community is also very valuable.
    Senator Begich. I agree. I know in Alaska, that is what you 
do--you engage the community. So, as a user of chiropractic 
care, I think it is important. But I know your time span for 
service provided to a patient can be up to 30 days, and there 
is one thing I know about chiropractic care: if you wait 30 
days, you are in worse shape; you are in more pain. So, is 
there a way we could look at this legislation to support your 
efforts of both in-house and out-house. I don't want to say 
outhouse, but----
    [Laughter.]
    Senator Begich. There is the Alaska component in me that 
just came out. [Laughter.]
    About the contracted services. Is there a way to support 
that, because I think the services are important. My worry is 
the time gap, especially with chiropractic care, because it is 
not just one visit and you are done. I hope--because I enjoy my 
chiropractic, but there are times when I wish I didn't have to 
go--it is frequency that is important. If you are on a 30-day 
cycle, that is not going to do the job with this type of care. 
So, is there a way, through this legislation, to support your 
efforts to do both what you have just described and also speed 
up the process of a client receiving services?
    Dr. Cross. I understand your question precisely, I believe. 
We have really worked hard to apply the same standards to this 
professional group as to all others. The 30-day standard is the 
same standard that we apply to cardiology, oncology, and 
primary care. So, we are fitting them in as part of the team; 
and applying the same standards that we measure across the 
board. Now, that is for routine care.
    Senator Begich. Right.
    Dr. Cross. Understood. Whether it be cardiology or anything 
else, if the veteran--the patient--has a more acute need, the 
30-day standard is irrelevant.
    Senator Begich. Right.
    Dr. Cross. We have to meet their needs. Ultimately, what we 
have to judge our success by is the satisfaction of our 
patients, and right now--broadly speaking, not specifically in 
relation to chiropractors--regarding patient care, our 
satisfaction levels are very good. We can look at this more 
specifically in regard to that cohort.
    Senator Begich. Very good. My time is up. I am not sure yet 
where I am on the quality report card idea, but let me throw 
out something that is happening right now that Consumer Reports 
is about to do. They are engaged in a pretty extensive effort 
to analyze and measure hospitals, as well as professionals 
within the hospital. I worry about the statement that we want 
to measure up to the measurements that current hospitals or 
other physicians are using, because as we are dealing with 
health care, we are not sure those measurements are the best 
measurements, to be very frank with you, because they are not 
outcome-based. They are sometimes process-based, which is not 
the right way to measure.
    So, as you evaluate this--I know you had kind of a back-
and-forth discussion a little bit here on that--would you be 
willing to engage--again, Consumer Reports is doing a national 
measurement standard that, if you have ever used Consumer 
Reports, you know it is easy to understand. It is consumer 
friendly. So, they have taken this on as an initiative to 
measure quality care for hospitals and physicians within those 
hospitals. I think it is a very intriguing project that would 
make sense to our veterans because they might get care from two 
providers--private as well as VA--so they can measure apples to 
apples.
    I don't know if that is of interest to you. Our office 
could provide you with the contacts out of New York that are 
undertaking this effort.
    Dr. Cross. Senator, if you will give me the contact, we 
will invite them this afternoon and set up a meeting either by 
phone or in person.
    Senator Begich. Excellent.
    Dr. Cross. If they want us to come to New York, we will go 
to New York. 


    Senator Begich. Excellent. I think it is a very interesting 
idea they are pursuing. I think it is going to be benefiting 
the whole health care system, and VA is obviously a huge piece.
    I know I said that was my last question, Mr. Chairman. This 
is probably a yes or no. About the interagency on homelessness 
out of the White House--are you part of that interagency 
organization----
    Dr. Cross. Yes.
    Senator Begich. I thought your answer was going to be yes. 
Good. Thank you very much.
    Chairman Akaka. Thank you very much, Senator Begich.
    Dr. Cross, you say in your testimony that there is not 
enough patient demand to justify putting a chiropractor in 
every VA hospital. Could this be perceived as lack of demand or 
a lack of availability of these services in VA hospitals?
    Dr. Cross. I would like to phrase that slightly 
differently. We provide chiropractic services either through 
the community or through the VA by in-house staff at all of our 
facilities. So we send thousands of patients out to engage in 
the civilian community to buy services; to work with our 
colleagues in the civilian community, wherever that might be.
    We see this as a valuable, balanced, and flexible approach. 
It lets us tailor the needs to each location. The facility 
director can then make the decision, say the demand is such 
that he wants to hire staff within the hospital, or he can say 
we have very good services within the community. Patients are 
satisfied. Let us continue doing that. This balanced approach 
and this flexibility that our facility directors and VISN 
directors have is very important to maintain.
    Chairman Akaka. Dr. Cross, at the Committee's recent 
hearing on contract health care regarding ambulatory care 
solutions, you testified that they already had pay-for-
performance requirements in their contracts. Would it be fair 
to say you have already put these requirements in place in some 
of your clinic contracts?
    Dr. Cross. I don't have the precise number. I believe about 
roughly one-third, perhaps a little less than one-third of our 
clinics are contract clinics. The contracts have a great deal 
of information in terms of requirements as to what they have to 
do. Where they have not met those standards, we have been quite 
aggressive in actually eliminating those contracts and going to 
a different provider at a different location. We are doing this 
already. We think that we will take the Committee's 
recommendation and expand that capacity, as well. But I wanted 
the Committee to be reassured that within our contracts, we do 
take action if they don't meet the requirements, even right 
now.
    Chairman Akaka. In S. 1427, which is the Hospital Quality 
Report Card Act of 2009, it shares many provisions with S. 692, 
a bill sponsored by then-Senator Obama during the 110th 
Congress. In May 2007, you testified that VA opposed the bill 
because it duplicated existing efforts. But today, and I say 
this with a smile, you testified that VA opposes the bill 
because some of the requirements may not be possible. Can you 
shed any light on this thinking?
    Dr. Cross. Senator, I am always surprised when we bring up 
my old testimony. [Laughter.]
    The important message here in regard to the hospital report 
card is we are all for this. We are strongly in support of 
this--not the specific legislation, but the concept. We think 
our patients have a right to know how well their services are 
being provided. We think that that is fundamental and we have 
to do a better job of communicating that. We have to do it in 
language that they understand.
    We posted 46,000 articles and research--that was four-six-
zero-zero-zero--over the past 7 years, but they are not things 
that patients really read. We need to give them understandable, 
accessible information about the quality and accessibility of 
the health care that we provide. We want to do a better job of 
that than anybody else.
    And let me be very clear--we are not afraid of the 
comparison. And as quickly as we can move out on this, we will; 
and the Secretary fully supports this.
    So I think that what we are going to do, you will be proud 
of. I think that it will meet the intent of this legislation. 
Some of the language in the legislation was very precise, might 
require some IT configuration, in some cases engagement with 
Medicare and Medicaid Services, and would be calling for data 
that they can't provide us. And so we found technical issues in 
the legislation that would be very difficult for us to achieve.
    Chairman Akaka. Of course, this is building on what Senator 
Johanns was asking, having to do with the kind of information 
that is made available to the public about the quality of care 
provided in individual VA hospitals and clinics. You just 
stated that there are about 46,000 articles that are sent out. 
Are there any other kinds of information that are sent out?
    Dr. Cross. We sent to Congress last year a hospital report 
card. It was a fairly comprehensive review. It was the first 
time that we have done that. I was proud of that document 
because it didn't just point out the great things that we are 
doing, it also pointed out some of the problems that we face. 
So, it wasn't just the good things. We sent that to Congress 
about a year ago. The new one has just been finished. I think 
it is about to be released within days, and we will be 
forwarding that over to the Committee, too.
    Chairman Akaka. Specifically, what information do you give 
the public and the patients?
    Dr. Cross. On the Web sites that we have with the Joint 
Commission, we publish our data, as do other hospitals. The 
Joint Commission has data relative to our hospitals as well as 
others so that the patients can go look that up.
    On our Web sites, we have information about our programs. 
Quite frankly, I think a lot of the information that we put out 
there is quite technical. I think that the average veteran 
would often have difficulty reading it and understanding what 
it really means.
    And some of the information that we put out has no 
comparison in the civilian sector. Because of our Electronic 
Health Record, I can produce statistics that are simply not 
available in the civilian sector.
    I think what we have to do is a much better job of 
communicating in the veteran patients' own understandable 
language much better than we have. Hospital Compare, I think, 
will be a step in the right direction.
    Chairman Akaka. My final question to you is having to do 
with the Mental Health Commission. You testified that creating 
a Mental Health Commission was unnecessary. Can you expand a 
little bit about how this bill would duplicate existing efforts 
in VA?
    Dr. Cross. Sir, we are always willing to welcome another 
committee, but there are many committees already that we engage 
with; and we engage with our Veterans Service Organizations, 
our patients, in many different forms.
    Let me give you a list of some of the Committees that we 
have right now. The Special Committee on Serious Mental Illness 
reports to the Under Secretary for Health. The Special 
Committee on PTSD reports to the Under Secretary for Health. 
The Advisory Committee on Homeless Veterans, to the Secretary. 
The Advisory Committee on Women Veterans, Office of Mental 
Health Services, and to the Secretary of VA. The Advisory 
Committee on Minority Veterans, the Longitudinal GPRA Study on 
Mental Health, to the Under Secretary of Health. And then the 
many OIG and GAO 
reviews.
    We have tremendous engagement with our stakeholders. We 
have many committees, FACAs and others, that oversee, look at, 
and provide advice. We get lots of input from veterans 
themselves. We are not lacking in this endeavor and we value 
the input that we have, which is substantial.
    Chairman Akaka. Thank you.
    Senator Burr, any further questions?
    Senator Burr. No.
    Chairman Akaka. Senator Murray, anything further?
    Senator Murray. No.
    Chairman Akaka. Senator Begich?
    Senator Begich. No.
    Chairman Akaka. Fine. Well, I want to thank this panel very 
much for your responses and I would like to welcome the second 
panel. Thank you, Dr. Cross.
                                ------                                


Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to 
 Dr. Gerald M. Cross, M.D., FAAFP, Acting Under Secretary for Health, 
  Veterans Health Administration, U.S. Department of Veterans Affairs

    Question 1. VA's written testimony stated that VA did not 
have ``views and estimates on several bills including S. 1109, 
S. 1467, S. 1556, S. 1753, and a draft bill regarding exposure 
to chemical hazards referred to in the list of bills provided 
in the Committee's witness letter of October 8.'' It also 
stated VA would forward those as soon as they are available. 
Please provide VA's views and estimates on S. 1109, S. 1467, 
S. 1556, S. 1753, and S. 1779 within 30 days of this request.
    Response. VA provided views on S. 1467 ``Lance Corporal 
Josef Lopez Fairness for Servicemembers Harmed by Vaccines Act 
of 2009'' and S. 1753 ``Disabled Veteran Caregiver Housing 
Assistance Act of 2009'' on March 23, 2010. (See below.) VA is 
in the process of finalizing views on several other bills, 
including, S. 1109 ``Providing Real Outreach for Veterans Act 
of 2009'', S. 1556 ``Veteran Voting Support Act of 2009'', and 
S. 1779 ``Health Care for Veterans Exposed to Chemical Hazards 
Act of 2009.''











    Question 2(a). GAO reported (GAO-09-637R) on June 15, 2009 
to Members of Congress that VA has processed nine TRA grants 
since its creation on June 15, 2006 through a period ending 
February 28, 2009. During the same period, VA processed 2,431 
SAH and SHA grants. This is a substantial difference in the 
number of applications for each program. Have any more of these 
grants been processed since February?
    One possible explanation for this difference is that TRA is 
deducted from the maximum benefit of SAH and those eligible 
want to maintain the maximum benefit of SAH for when they 
obtain permanent housing. Another explanation is that each TRA 
grant counts as one of the three grant usages allowed under 
either SAH or SAH.
    Response. Since the inception of the TRA grant program, 
VA's Loan Guaranty Service has fully disbursed a total of 17 
TRA grants and has approved an additional five for processing. 
In an effort to increase grant usage, VA has expanded outreach 
to all eligible individuals on at least an annual basis. VA 
also conducted a survey of eligible individuals in FY09, to 
which respondents stated that they were not ready to make a 
decision and had deferred grant use to some future date or that 
the cost to install even a few of the necessary adaptations can 
quickly exceed the maximum TRA grant amount. As a result, 
eligible individuals may choose to forego necessary 
adaptations, pay for them with personal funds, or acquire them 
through the generosity of others.

    Question 2(b). Does VA see any reasons not to make them two 
separate grants?
    Response. VA does not anticipate any programmatic concerns 
should Congress choose to separate the TRA grants from the 
maximum allowable usages for the Sec. 2101(a) or Sec. 2101(b) 
grants. Additional PAYGO costs would be incurred if the TRA 
grants were separated from the current maximum dollar limits 
for the SAH and SHA grants.
                                ------                                

Response to Post-Hearing Questions Submitted by Hon. Roger F. Wicker to 
 Dr. Gerald M. Cross, M.D., FAAFP, Acting Under Secretary for Health, 
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Question 1. Senator Wyden's bill, S. 1429, the Servicemembers 
Mental Health Care Commission Act, would establish a commission to 
oversee programs dealing with Post Traumatic Stress Disorder (PTSD), 
Traumatic Brain Injury (TBI), or other mental health disorders caused 
by military service. Absent in this proposed legislation is any 
reference to military chaplains. I feel that servicemembers are far 
more likely to discuss these types of topics with their chaplain than 
with their chain of command. Does the VA provide training to chaplains 
to help them recognize symptoms of mental health problems?
    Response. Yes. The VA National Chaplain Center (NCC) has an 
extensive program to provide ongoing continuing education for VA 
Chaplains on the specific health care issues most often experienced by 
our Veteran population. Chaplains are trained about Post Traumatic 
Stress Disorder (PTSD); Traumatic Brain Injury (TBI); substance abuse 
treatment; and acute mental health issues, including: depression, 
bipolar disorders, suicide ideation and suicide prevention; as well as 
dual diagnosis often associated with homelessness at the National 
Chaplain Training Center. The NCC is working closely with the Office of 
Mental Health Services to provide ongoing training to Chaplains as the 
spiritual care providers on the Mental Health Teams. The Office of 
Mental Health provides a psychiatrist from the Durham Mental Illness 
Research Education and Clinical Center (MIRECC) as a consultant for 
curriculum development and instruction.

    Question 2. Are there areas where VA and DOD can work together to 
make sure that our chaplains are properly trained in this regard?
    Response. Yes. The National Chaplain Center is currently 
negotiating with the National Guard Bureau to provide Clinical Pastoral 
Education (CPE) for Army and Air Guard Chaplains. Since 1994, the NCC 
has had a similar Resource Sharing Agreement with the Navy Chaplain 
Corps to provide CPE for Navy Chaplains in these specialty areas, 
specifically, PTSD and substance abuse treatment. In November 2009, the 
NCC began collaboration with the Center for PTSD in Palo Alto to 
provide a series of three day training seminars for VA and National 
Guard Chaplains to be held at four Veterans Integrated Service Networks 
(VISN) national locations. The planning committee is anticipating the 
first seminar will occur in March/April 2010. Although still in the 
planning stages, the plan is to complete the seminars by the end of the 
4th quarter FY2010 and carry the training into FY2011.

    Question 3. If Senator Wyden's bill is enacted, would military 
chaplains be candidates to serve on a Mental Health Care Commission?
    Response. Military Chaplains who are clinically trained to 
understand mental health issues and the role of spirituality and 
religion would be appropriate to serve on a Mental Health Care 
Commission. Experience on a health care treatment team should also be 
required inasmuch as not all military chaplains have health care 
experience. VA defers to DOD to provide their position on this question 
also.

    Chairman Akaka. I would like to welcome Mr. Robert Jackson, 
Assistant Director of the National Legislative Service for the 
Veterans of Foreign Wars. We have Mr. Ian DePlanque, who is 
Assistant Director for the Claims Service of the Veterans 
Affairs and Rehabilitation Commission at the American Legion. 
Also, I want to welcome Mr. John Driscoll, President and CEO 
for the National Coalition for Homeless Veterans, and Dr. Rick 
McMichael, President of the American Chiropractic Association. 
Finally, Mr. William Fenn, Vice President of the American 
Academy of Physician Assistants is also here with us today.
    Mr. Jackson, will you please begin with your statement.

   STATEMENT OF ROBERT JACKSON, ASSISTANT DIRECTOR, NATIONAL 
         LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS

    Mr. Jackson. Mr. Chairman, Ranking Member Burr, Members of 
the Committee, on behalf of the 2.2 million men and women of 
the Veterans of Foreign Wars, I thank you for the opportunity 
to provide testimony today on pending veterans legislation. 
Because the Committee is considering so many bills this 
morning, I am going to focus my testimony on three or four 
bills, as time allows.
    The first bill I would like to talk about is S. 1302, the 
Veterans Health Care Improvement Act. The VFW appreciates and 
supports the intent of this legislation, which aims to improve 
the contract services provided by VA's Community-Based 
Outpatient Clinics, or CBOCs. As you know, many CBOCs are 
administered by private contractors under the supervision of 
regional VA medical centers. VA's method for creating these 
contracts varies from medical center to medical center with 
little uniformity on how they are structured. This legislation 
would create a pilot program for pay-for-performance contracts 
as opposed to the per capita system.
    In the Independent Budget, we have argued for stronger 
oversight in management of the contracts VA uses, especially 
with respect to CBOCs. Among the recommendations we have made 
is that there needs to be an aggregation of CBOC contracting 
authority at the medical center or network level so as to 
ensure consistency of care, cost, performance measures, and 
simplification of oversight and administration.
    The next bill I would like to comment on is S. 1547, the 
Zero Tolerance for Veterans Homelessness Act. The VFW strongly 
supports this legislation, which would provide many necessary 
changes to ensure America's servicemembers do not find 
themselves homeless in the country they have fought so bravely 
to defend. This legislation takes proactive measures. 
Particularly, it would institute flexible funding in which VA 
could provide short-term rental assistance, housing relocation 
and stabilization, security deposits, utility payments, and 
costs associated with moving. Additionally, this legislation 
would provide financing for capital projects while better 
aligning health care services payments with the actual health 
care cost.
    Furthermore, this bill would create a Special Assistant for 
Veterans Affairs within HUD to ensure veterans have access to 
HUD's assistance programs while providing better data 
collection to accurately track and count America's homeless 
veterans. It would also require the VA to develop a 
comprehensive plan for ending veterans' homelessness within 1 
year of the bill's enaction.
    The third piece of legislation I would like to comment on 
is S. 1668, the National Guard Education Equality Act. The VFW 
also strongly supports this bill, which would qualify certain 
members of the Army National Guard who were activated under 
Title 32 orders but were excluded from Chapter 33 benefits. 
More than 30,000 members of the National Guard currently do not 
enjoy the benefits of the Post-9/11 G.I. Bill, but were 
activated in defense of our Nation for critical purposes and at 
critical times. In regards to Post-9/11 G.I. Bill improvements, 
this is the VFW's number 1 priority. Certain veterans who 
should be eligible for the benefit are not, and the VFW 
strongly encourages Congress to address this issue as quickly 
as possible.
    And finally, the VFW supports S. 1204, the Chiropractic 
Care Available to All Veterans Act, which would provide 
veterans with direct access to chiropractic health care. 
Currently, chiropractic care is offered to veterans with 
injuries, but on a limited basis. In many instances, veterans 
are paying out of their own pocket for chiropractic care 
outside of the VA for service-related injuries. This 
legislation would require 75 VA medical centers to provide 
chiropractic services by the end of 2010 and at all VA medical 
centers by the end of 2012. We believe this legislation to be 
of great need, considering the known injuries many veterans 
have received in battle. Chiropractic care can help with pain 
management and encourage more active physical therapy and VFW 
believes that this type of treatment will offer veterans 
another option in their health care recovery.
    I have got a couple of seconds left. I would like to just 
throw in a few comments about S. 1467. VFW supports this bill 
and encourages the Senate to pass this legislation to provide 
justice to servicemembers severely disabled by DOD vaccines 
through the extension of Servicemembers' Group Life Insurance 
Traumatic Injury Protection Program (TSGLI) coverage.
    Mr. Chairman, thank you again for the opportunity to 
provide my testimony at this important hearing. This concludes 
my statement. Thank you.
    [The prepared statement of Mr. Jackson follows:]
   Prepared Statement of Robert Jackson, Assistant Director National 
   Legislative Service Veterans of Foreign Wars of The United States
    Chairman Akaka, Ranking Member Burr and Members of the Committee: 
Thank you for the opportunity to provide testimony on pending veterans' 
benefits legislation. The 1.8 million men and women of the Veterans of 
Foreign Wars of the U.S. appreciate the voice you give them at this 
important hearing.
                s. 977, the prisoner of war benefits act
    The VFW supports this legislation, which would dramatically improve 
the benefits this Nation provides to those who are former Prisoners of 
War (POWs).
    First, it would repeal the 30-day minimum period of detainment or 
internment for a POW to be eligible for presumptive conditions, as well 
as adding Type-2 Diabetes and expanding eligibility for a presumption 
for osteoporosis. These worthwhile additions recognize the special 
circumstances POWs had to endure. The 30-day standard is an arbitrary 
one, and even a few hours of confinement is enough to increase 
dramatically the stresses and strains upon a servicemember's body.
    The second major change the bill would make is that it lays out a 
process by which the Secretary can consider new diseases to be presumed 
service-connected for POWs. The VFW supports these changes, believing 
that the evidence required will, if applied properly, lead to fair 
treatment for those who have given so much to this country.
         s. 1109, the providing real outreach for veterans act
    The VFW certainly supports the idea behind the Providing Real 
Outreach for Veterans Act. This legislation would essentially automate 
much of VA's initial outreach efforts, better informing separating 
servicemembers about the benefits and services available to them 
through the Department of Veterans Affairs.
    To achieve this, it would require VA and DOD to share electronic 
data that includes enough information so that VA can determine whether 
a veteran is eligible for basic benefits, as well as information to 
determine the likelihood that veterans would be ultimately eligible for 
other benefits with more complex eligibility requirements.
    Based upon that information, VA would then be required to send 
notices to veterans to inform them of the benefits for which they are 
likely to be eligible. The VFW thinks that a tailored approach--
highlighting those things specifically applicable--would be more likely 
to be successful than a general overview of all benefits.
    While this exact bill might not be achievable in the short-term, it 
perfectly lays out the kind of approach VA should be taking over the 
long-term. The Department must leverage technology and the information 
available to it in any manner necessary, and a targeted approach to 
outreach would greatly assist veterans toward a more seamless 
transition.
                                s. 1118
    The VFW supports this legislation, which would provide increased 
Dependency and Indemnity Compensation (DIC) to the surviving spouses of 
those who died from injuries or disabilities incurred while serving in 
the military.
    It would also reduce, by two years, the age at which a widow or 
widower of a veteran could remarry without having to forfeit DIC.
    Section 2 would allow the surviving spouse of a veteran who dies of 
a non service-connected disability to be eligible for DIC if the 
veteran has been totally disabled from a service-connected disability 
for at least five years. Current law requires ten years for DIC 
eligibility.
    The VFW believes that a family of a totally disabled veteran 
suffers financial hardship and is often solely reliant on the income 
provided by VA. A totally disabling service-connected condition 
frequently contributes to and may even hasten death. Under current law, 
families who have depended on VA benefits as their primary income lose 
everything unless the veteran lives longer than 10 years after being 
found to be totally disabled from disabilities related to service. This 
bill would provide some financial stability to surviving spouses and 
their children.
                                s. 1155
    This legislation would require VA to appoint a full-time Director 
of Physician Assistant Services to report to the Under Secretary of 
Health with respect to the training, role of, and optimal participation 
of Physician Assistants (PA). We are pleased to support it.
    Congress created a PA advisor role when it passed the Veterans 
Benefits and Healthcare Improvement Act of 2000 (P.L. 106-419). The law 
required the appointment of a PA Advisor to work with and advise the 
Under Secretary of Health ``on all matters relating to the utilization 
and employment of physician assistants in the Administration.'' Since 
that time, however, the Veterans Health Administration (VHA) has not 
appointed a full-time advisor; instead, it has utilized the skills of 
someone already employed who serves in a part-time capacity in addition 
to his or her regularly scheduled duties. We doubt that this is what 
Congress envisioned when it created the role. The current PA advisor 
has had little voice in the VA planning process, nor has VA appointed 
the PA advisor to any of the major health care strategic planning 
committees.
    With the role that PAs play in the VA health care process, it only 
makes sense to invite their participation and perspective. VA is the 
largest employer of PAs in the country, with approximately 1,600. They 
provide health care to around a quarter of all primary care patients, 
treating a wide variety of illnesses and disabilities under the 
supervision of a VA physician. Since they play such a critical role in 
the effective delivery of health care to this Nation's veterans, they 
should have a voice in the larger process. We urge passage of this 
legislation and the creation of a full-time PA Director position within 
the VA Central Office.
      s. 1204, the chiropractic care available to all veterans act
    The VFW supports this legislation, which would provide veterans 
with direct access to chiropractic healthcare. Currently, chiropractic 
care is offered to veterans with injuries but on a limited basis. In 
many instances, veterans are paying for chiropractic care outside of 
the VA for service-related injuries out of their own pocket.
    This important legislation would require 75 VA medical centers to 
provide such services no later than December 31, 2010, and at all VA 
medical centers by no later than December 31, 2012. We believe this 
legislation to be of great need considering the known injuries many 
veterans have received in battle. Chiropractic care can help with pain 
management and encourage more active physical therapy. It puts special 
emphasis on spinal cord stress while offering wellness and lifestyle 
modifications to help promote physical and mental strength. VFW 
believes that this type of treatment will offer veterans another option 
in their health care recovery.
    s. 1237, the homeless women veterans and homeless veterans with 
                              children act
    The VFW is pleased to support this legislation, which focuses on 
helping homeless women veterans and homeless veterans with children.
    Specifically, this legislation would authorize the Department of 
Veterans Affairs to make Special Needs Grants to facilities to provide 
services and care for male veterans that are homeless with their 
children and to the children of all homeless veterans. Under current 
law, those groups are not covered by the Grant and Per Diem program's 
Special Needs Grants.
    The bill would also extend the Department of Labor's Homeless 
Veterans' Reintegration Program (HVRP) to provide workforce training, 
job counseling, childcare services and placement services including 
literacy and skills training to homeless women veterans and homeless 
veterans with children to give these men and women every possible 
opportunity to lead satisfying and productive lives.
           s. 1302, the veterans health care improvement act
    The VFW appreciates the intent of the Veterans Health Care 
Improvement Act. This legislation aims to improve the contract services 
provided by VA's Community-Based Outpatient Clinics (CBOCs).
    Many CBOCs are administered by private contractors under the 
supervision of regional VA medical centers. VA's method for creating 
these contracts varies by medical center to medical center, with little 
uniformity on how they are structured. In this case, this legislation 
would create a pilot program for pay-for-performance contracts, as 
opposed to a capitated system.
    If the contract is designed poorly, it can create disincentives to 
high-quality, proper care. The bill's sponsor, Senator McConnell, 
points out that a capitated system places the emphasis on the number of 
patients seen, not the outcomes. We certainly agree that that places 
the emphasis in the incorrect spot. Optimal patient outcomes should be 
at the forefront of all health care delivery systems and processes.
    In the Independent Budget, we have argued for stronger oversight 
and management of the contracts VA uses, especially with respect to 
CBOCs. Page 81 of the FY 2010 Independent Budget contains our 
discussion on CBOC contracting.
    Among the recommendations we made is that there needs to be an 
aggregation of CBOC contracting authority at the medical center or 
network level so as to ensure consistency of care, cost, performance 
measures and simplification of oversight and administration.
    This legislation could serve as a step toward that, but we would 
ask the Committee to consider a wider range of possibilities, 
especially with its continued interest in contract oversight.
            s. 1394, the veterans entitlement to service act
    The VFW supports this legislation, which would require VA to 
acknowledge, through either mail or email, when it receives certain 
types of correspondence related to veterans' claims for medical 
service, disability compensation or pensions.
    With all the uncertainty that surrounds the claims process, 
especially the black box a veteran on the outside of the system sees, 
this is a small measure that would do much to alleviate concern and 
worry that a veterans' records and requests are not being taken care 
of. With the recent shredding incidents at various Regional Offices 
throughout the country, it would also provide veterans with extra 
assurance that their claim has been received and is being treated 
properly and fairly.
 s. 1427, department of veterans affairs hospital quality report card 
                                  act
    The VFW is pleased to support the VA Hospital Quality Report Card 
Act, legislation that would require VA to develop and implement a 
system to measure data about its health care facilities.
    VFW believes the data would be of great service. It would allow 
veterans to compare the quality of service VA provides, letting them 
make informed judgments about their health care. It would allow VA to 
identify areas of improvement, and it would provide critical data for 
Congress to better use its essential oversight authority.
     s. 1429, the servicemembers mental health care commission act
    The VFW supports this bill, which recognizes the many challenges 
faced by veterans suffering from PTSD, TBI and many other mental health 
issues, especially from those returning from Iraq and Afghanistan.
    This bill would create a Commission, with members appointed by VA 
and DOD that would oversee the treatment of veterans suffering from 
these conditions. It would require the Commission to study the long-
term effects of these disabilities, as well as how well VA and DOD are 
doing at treating individuals and any barriers to proper mental health 
care that may exist, especially with respect to the stigma associated 
with care that many Active Duty servicemembers face.
    The Commission would make regular recommendations and report its 
findings to Congress.
    With all that is unknown about the true effects of these 
conditions, as well as with how critical it is for these two 
Departments to properly manage and administer programs that provide 
effective treatment to servicemembers and veterans, it is clear that 
the oversight powers of an organization such as this Commission are 
needed.
    Should this bill become law, the VFW would hope that Congress 
carefully considers and acts upon the Commission's well thought-out 
recommendations so that all who need care receive high-quality service 
whenever and wherever they may need it.
                      s. 1444, the combat ptsd act
    The VFW strongly supports this legislation, which would make much-
needed changes to current law to allow veterans who served in combat 
areas to have easier access to the benefits VA provides to those 
suffering from PTSD. It would changed the definition of ``combat with 
the enemy'' so that veterans who served in a theater of combat 
operations during a period of war or against a hostile enemy in a 
period of hostilities no longer have to provide explicit evidence of 
the exact enemy and exact location an incident occurred.
    The wars in Iraq and Afghanistan are wars with no true front lines. 
Incidents and danger lay everywhere, and this legislation acknowledges 
that events can happen anywhere at any time, and the stresses and 
strains of sustained action in undefined combat zones dramatically 
affect those who serve.
    We appreciate and support VA's proposed regulation on this issue, 
but see no harm in codifying it into law.
  s. 1467, the lance corporal josef lopez fairness for servicemembers 
                         harmed by vaccines act
    The VFW supports this legislation, which would amend the Traumatic 
Servicemembers' Group Life Insurance (TSGLI) to prevent the exclusion 
of a qualifying loss experienced by a servicemember as a result of an 
adverse reaction to a vaccination administered by the Department of 
Defense (DOD), whether voluntarily or involuntarily, for the purposes 
of military training or deployment.
    This legislation was introduced in response to a situation 
involving Marine Lance Cpl. Josef Lopez, who went into a coma with a 
rare adverse reaction to a smallpox vaccination he received just before 
deploying to Iraq, leaving him permanently and seriously disabled. 
However, since he was felled by the vaccine and not ``combat,'' he is 
ineligible for special disability funds to help seriously wounded 
troops (for such expenses as modifying a home to accommodate a 
disability).
    We believe that our government is obligated to care for those 
servicemembers who are seriously and permanently disabled while in 
service to their country, regardless as to how, when or where the 
disabling injury occurred. It is for that reason we strongly support 
this legislation.
                                s. 1483
    This legislation designates the Department of Veterans Affairs (VA) 
outpatient clinic in Alexandria, Minnesota as the Max J. Beilke 
Department of Veterans Affairs Outpatient Clinic. The VFW has no 
objection to this proposal.
             s. 1518, caring for camp lejeune veterans act
    The VFW is pleased to support the Caring for Camp Lejeune Veterans 
Act of 2009, which would require the Department of Veterans Affairs 
(VA) to provide health care to servicemembers, veterans, and their 
family members who have experienced adverse health effects as a result 
of exposure to well water contaminated by human carcinogens at Camp 
Lejeune.
    Thousands of Navy and Marine veterans and their families who lived 
on Camp Lejeune have fallen ill with a variety of cancers and diseases 
believed to be attributable to their service at the base before the 
Environmental Protection Agency (EPA) designated it a Superfund site in 
1988. Additionally, the National Research Council recently reported 
numerous adverse health effects associated with human exposure to the 
chemicals known to have been in water at the Marine installation.
    This legislation would allow a veteran or military family member 
who was stationed at Camp Lejeune during the time the water was 
contaminated to receive needed health care at a VA facility. We believe 
the government has a moral obligation to provide care for those 
affected by contaminated water at Camp Lejeune.
     s. 1531, the department of veterans affairs reorganization act
    This legislation would create a new Assistant Secretary for 
Acquisition, Logistics and Construction, consolidating and eliminating 
the functions of the Director of Construction and Facilities 
Management. The VFW has no objection to this proposal.
   s. 1547, the zero tolerance for veterans homelessness act of 2009
    The VFW strongly supports this legislation, which would provide 
many necessary changes to ensure America's heroes do not find 
themselves homeless in the country they fought so bravely to defend. 
President Obama addressed the VFW at our National Convention last 
month. He stated ``I've directed Secretary Shinseki to focus on a top 
priority--reducing homelessness among veterans. After serving their 
country, no veteran should be sleeping on the streets. No veteran. We 
should have zero tolerance for that.''
    We have faith that this administration, and this Congress, will 
fully and immediately address this issue, by eradicating homelessness 
for America's heroes forever.
    This measure would take a positive step toward the President's 
goal. This legislation takes proactive measures in preventing 
homelessness. Particularly, it would institute flexible funding in 
which VA could provide short-term rental assistance, housing relocation 
and stabilization, security deposits, utility payments, and costs 
associated with moving for homeless veterans. This would allow the VA 
to take necessary actions to help homeless veterans and those at risk 
from being homeless get off the streets.
    Additionally, this legislation would provide financing for capital 
projects, while better aligning health care services payments with the 
actual health care cost.
    The bill would also authorize a much-needed increase of up to 
60,000 HUD-VASH vouchers in which participating veterans receive case 
management. These services include assistance in locating housing and 
accessing benefits and health services.
    Furthermore, S. 1547 would create a Special Assistant for Veterans 
Affairs within HUD to ensure veterans have access to HUD's assistance 
programs while providing better data collection to accurately track and 
count America's homeless veterans.
    Finally, this legislation would require the VA to develop a 
comprehensive plan for ending veterans' homelessness within one year of 
the bill's enactment. The VFW applauds this measure and strongly urges 
Congress to pass this important measure that will help us get every 
American veteran off the streets.
                s. 1556, the veteran voting support act
    The VFW offers our support for S. 1556, the Veteran Voting Support 
Act.
    This important legislation would require the Secretary of Veterans 
Affairs to permit facilities of the Department of Veterans Affairs to 
be designated as voter registration agencies. Specifically, the 
legislation would require the VA to provide voter registration forms 
whenever veterans enroll in the VA health care system, or change their 
status or address in that system, and provide veterans with access to 
and receive assistance with absentee ballots at VA facilities.
    Additionally, the legislation would allow nonpartisan groups and 
election officials to provide nonpartisan voter information and 
registration services to veterans. It would also require Attorney 
General enforcement through civil suits and injunctions and require an 
annual report to Congress from the VA on progress related to this 
legislation.
    The VFW has long been deeply committed to ensuring that all 
veterans have the opportunity to vote in Federal elections. Veterans 
have dedicated their lives to protecting our country and they deserve 
every commitment from the government to offer them the opportunity to 
participate in the political process.
             s. 1607, the wounded veteran job security act
    The VFW supports the intent behind the Wounded Veteran Job Security 
Act, but we have some concerns about the impact it would have should it 
be passed into law.
    This legislation would allow disabled veterans to receive any 
necessary service-related health care without facing any repercussions 
from their places of employment. Essentially, it ensures that veterans 
who need time off from work for service-connected treatments are able 
to receive it without fear of losing their job.
    Clearly, that is something we should strive for. But as written, it 
could create problems.
    The legislation makes no distinction for the level of disability 
nor for the size or demands of an employer. So, for example, in the 
case of a small business with just a handful of employees, the employer 
would have to allow a disabled veteran all the time off he or she 
needed to receive treatment, no matter the impact upon the business.
    While that is of great benefit to the veteran, it could potentially 
create a barrier to a veterans' employment in the future. If an 
employer knows and understands that hiring a disabled veteran--
especially one with severe disabilities--is going to create a hardship 
for that business, it is a strong disincentive for that employer to 
choose a veteran over a non-veteran in the first place.
    The VFW believes that protections for service-disabled veterans are 
a worthy goal, but our concerns about the incentives and disincentives 
created by this bill prevent us from supporting it.
           s. 1668, the national guard education equality act
    The VFW strongly supports this legislation, which would qualify 
certain members of the Army National Guard who were activated under 
Title 32 orders but were excluded from Chapter 33 benefits.
    More than 30,000 members of the National Guard currently do not 
enjoy the benefits of the Post-9/11 GI Bill but were activated in 
defense of our Nation for critical purposes and at critical times. In 
regards to Post-9/11 G.I. Bill fixes, this is the VFW's number one 
priority. Certain veterans who should be eligible for the benefit are 
not and the VFW strongly encourages Congress to address this issue as 
quickly as possible.
                                s. 1752
    The VFW applauded the Secretary Shinseki's recent decision to add 
Parkinson's disease to the list of diseases presumed to be service-
connected due to their relationship with herbicide agents amongst 
certain veterans serving in Vietnam. We continue to urge the Secretary 
and this Committee to look at all available scientific research, as 
well as to continue researching these conditions, especially as the 
impact of their long-term effects are becoming increasingly clear. To 
that end, we certainly support the inclusion of this disease within 
Title 38.
 s. 1753, the disabled veteran caregiver housing assistance act of 2009
    VFW supports this vital legislation that would more than double the 
amount of specially adapted housing assistance available to veterans 
residing temporarily in housing owned by a family member.
    Many disabled veterans are being cared for by family members that 
have had to make structural changes to their homes in order to provide 
the best possible care and support. In today's economy even small 
changes to structures in a home can be expensive. By providing this 
increase you will be making a difference in the quality of life for 
many disabled veterans and their families.

    This concludes my statement. I would be happy to answer any 
questions you may have.
                                 ______
                                 
  Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to Robert 
Jackson, Assistant Director, National Legislative Service, Veterans of 
                              Foreign Wars
    Question 1. Veterans register to vote and vote at a significantly 
higher rate than their civilian counterparts. Have your members 
experienced problems with registering to vote or actually voting? If 
so, what have those problems been?

    Question 2. What is the VFW doing to help your members, as well as 
other veterans, register to vote and to vote?

    Question 3. What do you anticipate the cumulative costs would be 
for VA to: 1) provide a mail voter registration application form to 
each veteran who seeks to enroll in the VA health care system, and to 
each enrolled veteran any time there is a change in the enrollment 
status of address change of the veteran; 2) provide each veteran with 
information and assistance with voter registration; 3) accept completed 
voter registration application forms and transmit them to the 
appropriate State election official, and ensure that all of the 
information and assistance with voter registration is nonpartisan; 4) 
provide assistance in voting by absentee ballot to veterans residing 
the medical or community living centers; and 5) prepare an annual 
report to compliance report to Congress?

    Question 4. What exactly about the current VA directive dated 
September 8, 2008 regarding voter registration and voting do you find 
insufficient?

    Question 5. Do you support the provision of S. 1556 which states 
that subject to reasonable time, place and manner restrictions, the 
Secretary shall not prohibit any election administration official from 
providing voting information to veterans at any (emphasis added) VA 
facility, even if that includes national cemeteries?

    [The Committee had not received responses by press time.]

    Chairman Akaka. Thank you very much, Mr. Jackson.
    Mr. Ian DePlanque.

   STATEMENT OF IAN DePLANQUE, ASSISTANT DIRECTOR FOR CLAIMS 
                  SERVICE, THE AMERICAN LEGION

    Mr. DePlanque. Good morning, Mr. Chairman, Members of the 
Committee. On behalf of the American Legion, I would like to 
thank you for the opportunity to testify on a broad spectrum of 
legislation being considered before this Committee this 
morning. Because of the large number of bills before the 
Committee, I would note that you have our written testimony on 
the full slate of legislation and instead I will focus on a 
select few.
    The Veterans Health Care Improvement Act provides for an 
introduction of pay-for-performance compensation mechanisms 
into the contracts of VA with Community-Based Outpatient 
Clinics for the provision of health care services and so forth. 
The Community-Based Outpatient Clinics have greatly enhanced 
the ability of VA providers to provide veterans with more ready 
access to medical care. This is particularly important with the 
large percentage of veterans in rural communities who lack 
access to the more central urban existing VA facilities. 
However, due to findings of an inaccuracy of fee adjustment for 
care, as is mentioned in Section 2 of the piece of legislation, 
we believe the incorporation of pay-for-performance 
compensation mechanism into agreements between VA and the 
contractors is essential to ensure veterans receive adequate 
and timely care.
    Regarding two of the bills that deal with homelessness, the 
Homeless Women Veterans and Homeless Veterans with Children Act 
and also the Zero Tolerance for Homelessness Act, they 
highlight an area of great concern for the American Legion. The 
unique circumstances that women veterans are facing present 
challenges to assist them. We must continue to recognize the 
changing face of the American veteran. Women are deploying in 
support of our forces in greater numbers than ever before and 
have unique issues associated with their transition that are 
different from those anticipated previously in the system.
    One of the bills would establish a grant program for the 
reintegration of homeless women veterans and homeless veterans 
with children, expanding the grant program, as well, for 
homeless veterans with special needs to include the male 
homeless veterans with minor dependents. The American Legion 
supports the efforts of public and private sector agencies and 
organizations with resources necessary to aid homeless veterans 
and their families.
    Approximately 200,000 female Operation Iraqi Freedom 
veterans are isolated during and after deployment, making it 
difficult to find gender-specific peer-based support. As was 
mentioned earlier by Senator Murray, approximately one in ten 
homeless veterans under the age of 45 is now a woman. Access to 
gender-appropriate care for these veterans is essential.
    We are also looking at the growing numbers of homeless 
among veterans and it is very important for these people who 
have proven their value to society by standing up for their 
country, that they not be allowed to slip through the cracks. 
And I will come back and mention one more point on that in a 
moment.
    But first, I would like to talk about the Combat PTSD Act. 
This centers on a much-needed legislative change to how VA 
implements Section 1154(b) of Title 38 of the U.S. Code. The 
section was originally created in special recognition of the 
unique challenges of recordkeeping under the conditions of 
combat. Section 1154(b) is there precisely because the ability 
to clearly document each individual event or occurrence under 
combat conditions can be an extreme challenge.
    VA has already made a step forward with their proposed 
regulation which will help veterans suffering from PTSD. 
However, there is a tendency with this to focus too narrowly on 
PTSD and on the present conflict. This legislation is more 
important because it focuses on the bigger picture--what 
1154(b) was intended to do.
    I would like to give an example of other veterans who would 
be affected by this bill but not by the current proposed 
regulation. When I was working at the Board of Veterans 
Appeals, I was working on behalf of a veteran who was a 
communications soldier in the U.S. Army in Vietnam. He was 
working with the Military Assistance Command in Vietnam and as 
a part of that spent almost all of his time seconded out, or 
assigned out to Vietnamese units--units from the Republic of 
Vietnam. Obviously, it is very difficult to get unit records 
for the South Vietnamese Army. So, because he was a 
communications soldier, he didn't have access to things like a 
combat infantry badge that would have enabled VA to give him 
the full provisions of 1154(b) and say that the events that he 
described occurred in combat.
    This legislation would expand that to all soldiers in 
unique conditions. It is easy to say unique conditions when we 
recognize that it actually applies to so many different 
soldiers. War is an unusual place. This would expand it to all 
of them and it is a much needed benefit.
    The VA stated a number of times that they are concerned 
about being too broad with a regulation, but we should ask 
ourselves if we are being broad enough, if we are casting a 
wide enough net. So, I come back to the homelessness situation. 
It is a clear example in front of us where veterans are 
slipping through those nets, where we have not been broad 
enough. Thus, for measures such as the Combat PTSD Act or for 
the various legislation to address homelessness--or really any 
legislation--we shouldn't ask if it is too broad. We should be 
asking if it is broad enough.
    Thank you. I will be happy to answer any questions that may 
come up.
    [The prepared statement of Mr. DePlanque follows:]
   Prepared Statement of Ian DePlanque, Assistant Director, Veterans 
       Affairs and Rehabilitation Commission, The American Legion
    Mr. Chairman and Members of the Committee: Thank you for this 
opportunity for The American Legion to present its views on the broad 
list of veterans' legislation being considered by this Committee.
              s. 977, prisoner of war benefits act of 2009
    This bill addresses the addition of presumptive conditions 
specifically as they relate to those veterans formerly held as 
Prisoners of War. The bill would add certain conditions to the list of 
presumptive disabilities and would provide for the updating of such 
list as sound medical evidence determines that a positive association 
exists between being a Prisoner of War and the occurrence of a disease 
in humans. Should such conditions be determined the bill directs the 
Secretary of Veterans Affairs to add them to the presumptive list of 
disabilities.
    This is in accordance with presumptions of disabilities with 
medical findings as is found in other situations, such as harmful 
dioxin in the chemical herbicide Agent Orange, and represents a sound 
commitment to the veterans of this country by utilizing constant 
reevaluation to determine the most current medical understanding and 
applying it to the disability claims process.
    The American Legion is supportive of enhancing the manner in which 
the former Prisoners of War are treated, and to ensuring that they 
receive the benefits to which they are due, based on the accumulated 
sum of medical science.
                     s. 1109, pro-vets act of 2009
    This bill seeks to provide improved transfer of information 
capabilities between the Department of Defense (DOD) and the Department 
of Veterans Affairs (VA), as well as to increase awareness among 
veterans of the benefits to which they may be entitled. By identifying 
key data points within a veteran's military records, the data could be 
used to assist in the determination of which benefits each veteran may 
likely be eligible to receive.
    Veterans would then receive notification explaining the benefits to 
which they are entitled, along with an explanation of those benefits. 
This would ultimately provide for a more streamlined process in the 
application for benefits by veterans transitioning from service.
    The American Legion is strongly supportive of enhancements to the 
transition process and of increased communication and data sharing 
between DOD and VA. Such enhancements are vital to ensuring that 
veterans of this Nation receive all benefits to which they are 
entitled. Furthermore, information sharing and swift transmittal of 
information between these two departments is a vital element in fairly 
adjudicating the claims of veterans. Without access to complete and 
detailed military records, proving a claim can be difficult for many 
veterans, so enhancements to the sharing of this information can be 
vital.
                                s. 1118
    The purpose of this bill is to amend title 38, United States Code 
(U.S.C.), to provide for an increase in the amount of monthly 
Dependency and Indemnity Compensation payable to surviving spouses by 
VA. The bill would provide a more equitable distribution of this 
benefit among surviving spouses, and would lower the age at which 
remarrying surviving spouses could marry and still retain their 
benefit.
    This bill represents an improvement to the surviving spouses of 
veterans, and The American Legion is supportive of this enhancement of 
their benefit.
s. 1155, a bill to amend title 38, united states code, to establish the 
position of director of physician assistant services within the office 
          of the undersecretary of veterans affairs for health
    This bill seeks to amend title 38, U.S.C., to establish the 
position of Director of Physician Assistant Services within the Office 
of the Under Secretary of Veterans Affairs for Health.
    The American Legion supports legislation to establish a Director of 
Physician Assistant (PA) Services within VA. It is The American 
Legion's contention that the elevation of the current position of PA 
Advisor to Director is a necessity to increase veterans' access to 
quality medical care by ensuring efficient utilization of the VA's 
programs and initiatives, in addition to providing proper oversight 
from the policy level.
    The American Legion urges Congress to act on the matter immediately 
to ensure that the approximately 2,000 PAs within VA have sufficient 
and full-time representation at the policy level.
    s. 1204, chiropractic care available to all veterans act of 2009
    This bill seeks to make chiropractic care available to veterans at 
all VA medical centers. The American Legion supports legislation that 
definitively stands to provide all veterans with adequate medical 
service throughout the entire VA health care system.
      s. 1237, homeless women veterans and homeless veterans with 
                          children act of 2009
    This bill seeks to amend title 38, U.S.C., to expand the grant 
program for homeless veterans with special needs to include male 
homeless veterans with minor dependents and to establish a grant 
program for reintegration of homeless women veterans and homeless 
veterans with children.
    The American Legion supports the efforts of public and private 
sector agencies and organizations with the resources necessary to aid 
homeless veterans and their families. Homeless veterans' service 
providers' clients have historically been almost exclusively male. This 
is changing as more women veterans, especially those with young 
children, have sought help. Additionally, approximately 200,000 female 
Operation Iraqi Freedom veterans are isolated during and after 
deployment making it difficult to find gender-specific peer-based 
support. Reports show that one of every ten homeless veterans under the 
age of 45 is now a woman. Access to gender appropriate care for these 
veterans is essential.
    Community Homelessness Assessment, Local Education and Networking 
Groups (CHALENG) sites continue to report increases in the number of 
homeless veterans with families (i.e., dependent children) being served 
at their programs. It reports that 118 sites (85 percent of all sites) 
reported a total of 1,282 homeless veterans with families seen. This 
was a 24 percent increase over the previous year's 1,038 homeless 
veterans with families (FY 2008 VA CHALENG report). This legislation is 
a tremendous step forward with addressing the special needs that come 
with being a homeless veteran with families. The American Legion 
supports this legislation, because it will provide medical, 
rehabilitative and employment assistance to homeless veterans with 
families.
         s. 1302, veterans health care improvement act of 2009
    The purpose of this bill is to provide for the introduction of pay-
for-performance compensation mechanisms into VA contracts with 
Community Based Outpatient Clinics (CBOCs) for the provision of health 
care services, and for other services.
    The American Legion supports the CBOC concept s because they 
improve access to VA healthcare. However, due to findings of an 
inaccuracy of fee adjustment for care, as mentioned in Section 2 of 
this piece of legislation, we believe the incorporation of the pay-for-
performance compensation mechanism into agreements between VA and 
contractors is essential to ensure veterans receive adequate and timely 
care.
          s. 1394, veterans entitlement to service act of 2009
    The purpose of this bill is to provide for notification 
acknowledgement from the Secretary of Veterans Affairs of the receipt 
of medical, disability and pension claims. It requires notification of 
the receipt of such claims, as well as clarification of the date such 
claims are received.
    VA has recently taken a ``black eye'' in the handling of documents 
submitted by veterans through the ``shredder scandal'' of late 2008. 
Much must be done to regain the trust of American veterans. They must 
be convinced that their claims are being handled with the 
professionalism, attention and care due to them. This would provide an 
important protection to veterans. A written record could assist 
veterans in establishing key aspects of their claims if documentation 
issues arise in the future.
    The American Legion is supportive of this legislation.
           s. 1427, department of veterans affairs hospital 
                    quality report card act of 2009
    The American Legion supports legislation that would seek to ensure 
the quality of care for the veterans of this Nation. In addition, The 
American Legion also concurs with this measure to assist with 
sustaining quality at VA medical centers.
    For example, The American Legion's Resolution 206, ``Annual State 
of VA Medical Facilities,'' serves a synonymous purpose. The American 
Legion, national staff and Task Force Members visit VA Medical 
Facilities, compile reports of findings, and advocate on behalf of 
veterans before Congress for adequate and timely funding for the VA.
    This piece of legislation, with the proper oversight, would provide 
a more definitive system of checks and balances within VA and ensure 
quality care is constantly maintained. However, it should be measured 
alongside inspections by other organizations, such as the Joint 
Commission on the Accreditation of Healthcare Organizations (JCAHO), to 
provide corroboration. The American Legion is supportive of this 
direction provided that the due diligence is followed.
       s. 1429, servicemembers mental health care commission act
    This bill is to establish a Commission on Veterans and Members of 
the Armed Forces with Post Traumatic Stress Disorder (PTSD), Traumatic 
Brain Injury (TBI), or other mental health disorders. Also to enhance 
the capacity of mental health care providers and assist such veterans. 
Finally, to ensure such veterans are not discriminated against, and for 
other purposes.
    The American Legion supports this legislation that strengthens the 
consortium of continuity of care between DOD and VA. We feel such a 
commission would be required to monitor the care of these individuals 
who are suffering from PTSD, (TBI), and other mental disorders, as they 
move from DOD to VA.
    As Congress considers this piece of legislation, we urge that 
further thought be placed into the Section 2(f), Authorization of 
Appropriations, of this bill to ensure adequate and appropriate funding 
is provided.
                        s. 1444, combat ptsd act
    The purpose of this bill is to clarify the definition of ``combat 
with the enemy'' as used by VA under section 1154(b), title 38, U.S.C. 
This bill would define ``combat with the enemy'' as including service 
or active duty in a theater of combat operations (as determined by the 
Secretary [of the Department of Veterans Affairs] in consultation with 
the Secretary of Defense) during a period of war; or in combat against 
a hostile force during a period of hostilities. The American Legion has 
long been supportive of such change due to the changing realities of 
modern warfare and war fighting.
    VA recently proposed a regulation change which would liberalize the 
process of proving the occurrence of stressor events in combat zones 
for veterans suffering from PTSD. The measure taken by the VA does not 
address entirely the root cause of the problems many veterans have 
faced due to the difficulty of record keeping in a combat zone. Section 
1154(b), title 38, U.S.C. was created in recognition of the fact that 
in combat it is very difficult to document every single occurrence with 
precise accuracy.
    The provisions of that section were put into place to recognize 
this, and to allow servicemembers who had experienced combat to provide 
lay testimony alone to document the occurrence of events. It requires 
that the events described were consistent with the hardships and 
circumstances of combat, and that there was no clear evidence to the 
contrary that such events took place. The flaw in the original 
regulation was that an inordinate amount of benefit is given to those 
servicemembers who could easily document combat, such as Infantry 
soldiers. Those servicemembers with non-traditional combat specialties 
were often left with an even more difficult task of proving that the 
combat took place, let alone the events described in combat.
    As recognition of the non-linear, asymmetric battlefield of modern 
warfare has increased, it has become clear that combat is no longer 
something clearly ascribable to combat specialists such as Infantry 
alone. Clerks and chefs were assigned guard duty in remote outposts in 
Vietnam. Military Police currently perform convoy duty on Improvised 
Explosive Device (IED) riddled convoy routes in Iraq. Air Force ground 
personnel were subject to mortar fire in Bosnia.
    This bill can provide one simple benefit to servicemembers: 
recognition that their experiences and sacrifices in a hostile 
environment are understood. This is not a blanket dispersal of 
benefits. It would provide assistance in proving the one elusive piece 
of evidence needed to receive benefits to which they are entitled. A 
veteran must still provide evidence of a current condition and they 
must still provide evidence of a medical linkage between their current 
condition and the events they maintain took place in combat. This 
proposed legislation is a much needed change to assist in establishing 
the occurrence of events that caused their medical conditions. The 
American Legion supports this legislative change.
   s. 1467, lance corporal joseph lopez fairness for service members 
                     harmed by vaccines act of 2009
    The purpose of this bill is to amend title 38, U.S.C., to provide 
coverage under Traumatic Servicemembers' Group Life Insurance for 
adverse reactions to vaccinations administered by the DOD. The 
legislation recognizes the situation of Lance Corporal Josef Lopez, a 
Marine from Springfield, Missouri, who, in September 2006, as a result 
of a smallpox vaccination administered by DOD just prior to a 
deployment to Iraq. One week after his arrival in Iraq, Lance Corporal 
Lopez suffered complete paralysis, a coma, and the loss of two 
activities of daily living, all of which were subsequently diagnosed as 
resulting from a rare adverse reaction to the smallpox vaccine.
    The struggles of his family to deal with the situation within the 
current system are well documented. This legislation is an important 
step forward to attempt to remedy that system.
    The American Legion believes a fundamental inequity exists in the 
TSGLI program when insured individuals who suffer a traumatic physical 
injury and qualifying loss are treated differently because one injury 
is medically induced and the other is not. Some situations should be 
considered qualifying injuries under the TSGKI Schedule of Losses, such 
as adverse reactions to military vaccines, and negative results of 
surgical mistakes, incorrect diagnoses, and incorrect drug 
prescriptions. However, other situations, such as disease or illnesses 
or possible adverse effects of regular and accepted medical procedures 
when properly conducted, would be more readily directed toward 
alternative compensation programs such as VA Compensation.
    TSGLI was formulated by using the Dismemberment portion of the 
private sector Accidental Death and Dismemberment (AD&D) insurance 
industry as a guide. The goal was to maintain lower costs by limiting 
coverage definitions to a low frequency of occurrences for a large 
number of the insured. At the time the enabling legislation was 
developed, we were advised by the VA that Congress wished to keep the 
premiums for this coverage in the vicinity of $1 per month. Expanding 
the definition of injuries for TSGLI may very well require increases. 
Potentially substantial premiums paid by servicemembers, and increased 
government costs may result. It is incumbent upon Congress to take into 
consideration this possibility and insure the TSGLI program is not put 
in a position of financial jeopardy. The American Legion strongly 
supports the continuation of the TSGLI program, as well the right to VA 
Compensation following discharge from active duty.
    In considering only vaccinations, the incidence of cases so severe 
as to fall within the scope of TSGLI's qualifying losses seems limited, 
and would probably not impose a burden on the program. The Vaccine 
Injury Compensation Program (VICP) (military personnel do not qualify) 
as adjudicated by the U.S. Court of Federal Claims, offers compensation 
maximums in excess of TSGLI benefits. The American Legion strongly 
believes benefit programs for servicemembers and veterans be 
administered in a fair and equitable manner, and that TSGLI benefits 
should be available to insured servicemembers.
    The American Legion supports S. 1467, Lance Corporal Josef Lopez 
Fairness for Servicemembers Harmed by Vaccines Act of 2009.
    s. 1483, a bill to designate the department of veterans affairs 
  outpatient clinic in alexandria, minnesota, as the ``max j. beilke 
          department of veterans affairs outpatient clinic.''
    The American Legion has no position on this piece of legislation.
         s. 1518, caring for camp lejeune veterans act of 2009
    The purpose of this bill is to amend title 38, U.S.C., and to 
furnish hospital care, medical services, and nursing home care to 
veterans who were stationed at Camp Lejeune, North Carolina, while the 
water was contaminated.
    This bill would require VA to provide health care to veterans and 
their family members who have experienced adverse health effects as a 
result of exposure to well water contaminated by human carcinogens at 
Camp Lejeune.
    The American fully supports this bill and urges VA to conduct 
further scientific studies of the residents who were affected by those 
contaminants.
   s. 1531, department of veterans affairs reorganization act of 2009
    The purpose of this bill is to amend title 38, United States Code, 
to establish within VA the position of Assistant Secretary for 
Acquisition, Logistics, and Construction, and for other purposes.
    The American Legion has no position on this bill.
     s. 1547, zero tolerance for veterans homelessness act of 2009
    This bill seeks to amend title 38, U.S.C., and the United States 
Housing Act of 1937, to enhance and expand the assistance provided by 
VA and the Department of Housing and Urban Development (HUD) to 
homeless veterans and veterans at-risk of homelessness. Homelessness is 
the end result of problems that an individual cannot resolve without 
assistance.
    Generally, these problems can be grouped into three categories--
health issues, economic hardships, and lack of affordable housing. 
These impact all homeless individuals, but veterans face additional 
challenges when trying to overcome these obstacles. Prolonged 
separation from traditional supports such as family and close friends, 
highly stressful training and occupational demands can affect their 
personality, self esteem and ability to communicate with people in the 
civilian sector after separation from military duty. Over 131,000 
veterans are affected by homelessness and are in desperate need of 
assistance.
    With S. 1547, specific programs are outlined to help combat 
homelessness for veterans such as: helping to resolve credit issues; 
assistance with moving costs; housing relocation; short-term housing 
assistance; and, financial assistance with security or utility 
payments. In addition, S. 1547 authorizes $200 million for FY 2010 and 
any sums that are necessary for FY 2011 to FY 2014. The American Legion 
supports taking this necessary action to combat and aid in eliminating 
homelessness among the veterans' population. S. 1547 also outlines the 
program manager's responsibilities, roles in creating an environment 
conducive for successful case management services, and counseling for 
veterans and their families. If enacted, this bill will provide 
veterans who are at high risk for, or are already affected by, 
homelessness with the housing and supportive services they need in 
order to return to mainstream society. In this volatile economy, with 
the thousands of men and women who are returning from Iraq and 
Afghanistan, it is paramount that Congress pass legislation that 
provides resources for homeless veterans so they can return to 
financial independence and a high quality of life.
    The American Legion strongly supports S. 1547 and its goals to end 
homelessness within the veterans' community.
              s. 1556, veteran voting support act of 2009
    This bill would facilitate improved voter registration for veterans 
enrolling in the VA Health Care System, as well as those already 
enrolled. The overall effect would be an improvement of voter 
registration within the veterans' community. The bill specifically 
cites the unique qualifications of veterans to understand issues of 
war, foreign policy, and government support of veterans and cites the 
importance of furthering their opportunities to voice their 
understanding through voting.
    The American Legion has a national ``Get Out the Vote'' program 
that consists of three elements: voter registration; voter education; 
and, voter participation. Clearly, this legislation would advance the 
voter registration element advocated by this program. However, The 
American Legion stresses the nonpartisan and nonpolitical participation 
in all three elements. Voter registration is provided for all eligible 
potential voters. Voter education is strictly encouragement of 
registered voters to be ``informed voters'' on issues important to 
them. Voter participation encourages getting registered voters to the 
polls or assist with participation in absentee voting consistent with 
individual state laws and regulations.
           s. 1607, wounded veteran job security act of 2009
    The purpose of this bill is to protect the rights and benefits of 
those veterans absent from employment for certain periods, enabling 
them to receive medical treatment for service-connected disabilities. 
Veterans disabled in service to the country already bear an inordinate 
burden as these disabilities impact their employment. Further impact 
from the lost time at work that the treatment of these disabilities 
requires can only worsen the problem.
    While a service-connected veteran is compensated through the 
disability system for their individual conditions, the disability 
schedule can easily fail to address the other obstacles faced by 
disabled veterans in their career path. Many disabilities require 
regular medical appointments and can easily overwhelm the normal sick 
leave granted by employers as is consistent with long term disability. 
For veterans who have already sacrificed so much, it would seem worse 
to ask them to sacrifice even more of their career options when some 
obstacles could be removed and they could be given the assistance that 
they deserve.
    The American Legion is supportive of this legislation.
             s. 1668, national guard education equality act
    This bill amends title 38, U.S.C., to provide for the inclusion of 
certain active duty service in the Reserve components as qualifying 
service for purposes of Post-9/11 Educational Assistance Program. This 
legislation will extend benefits to title 32, U.S.C., Active Guard 
Reserve (AGR) servicemembers under the Post-9/11 GI Bill. Many AGR 
personnel were called to active duty via title 32, U.S.C., in support 
of the response to the attacks on America on September 11, 2001, in 
addition to deploying to the United States--Mexico border during 2007 
and 2008 for Operation Jump Start. Thus, AGR servicemembers have 
answered the Nation's call to arms and should receive equal education 
benefits for their service. When enacted, this bill would provide a 
full four-year college education to members of the National Guard, who 
are discharged with a service-connected disability.
    The American Legion fully supports enacting the National Guard 
Education Equality Act.
                                s. 1752
    The purpose of this bill is to amend title 38, U.S.C., to direct 
the Secretary of Veterans Affairs to provide wartime disability 
compensation for certain veterans with Parkinson's disease. This bill 
would add a presumption of service connection for those veterans who 
have served in the Republic of Vietnam and who have Parkinson's disease 
manifest to a degree of 10 percent disabling.
    The American Legion notes that VA has added Parkinson's disease to 
the list of presumptive disabilities for veterans with service in the 
Republic of Vietnam. This action has the same effect as that proposed 
in this legislation and would thus seem to obviate the need for this 
bill. However, the American Legion notes that VA must continue to pay 
heed to and adjust the rolls of presumptive disability according to 
current medical findings such as the published reports of the Institute 
of Medicine in their studies of Agent Orange.
   s. 1753, disabled veteran caregiver housing assistance act of 2009
    This bill would amend title 38, U.S.C., to increase assistance for 
disabled veterans who are temporarily residing in housing owned by a 
family member. With the rising costs of adaptive housing construction, 
it has become necessary to allocate funding for these veterans and 
their families that will pay for the special equipment they require, 
due to their service-connected disabilities. These veterans are in need 
of temporary support from family members in order to receive adequate 
care and readjust back into mainstream society. Maintaining a level of 
stability and housing provided by loved ones is a necessity for these 
veterans who are returning with severe disabilities. By increasing the 
amount of funds that these injured veterans receive for residential 
home cost-of-construction; it will give them the ability to get the 
basic/crucial equipment they need to get on the path of living a high 
quality of life.
    The American Legion supports this legislation.
draft discussion on health care for members of the armed forces exposed 
                    to chemical hazards act of 2009
    This draft bill would amend title 38, U.S.C., to direct the 
Secretary of Defense to establish and administer a registry of members 
and former members of the Armed Forces who were exposed to occupational 
and environmental hazards in the line of duty on or after September 11, 
2001.
    This draft bill would also require the Secretary of Defense to 
notify members and former members of the Armed Forces who may have been 
exposed to such hazards and provide a complete physical and medical 
examination. In addition, the draft bill would authorize the Secretary 
to enter into an agreement with the Institute of Medicine (IOM) to 
conduct a scientific review(s) of the evidence related to health 
consequences as a result of exposure.
    This draft would also authorize such veterans to be eligible for 
hospital care, medical services, and nursing home care through VA for 
any disability, notwithstanding insufficient medical evidence, to 
conclude, the disability and its possible association with such 
exposure.
    The American Legion Fully supports this draft bill.
    As always, The American Legion appreciates the opportunity to 
testify and represent the position of its 2.5 million wartime veterans. 
We hope that we also express what is in the best interests of the 
totality of veterans in this country.

    Mr. Chairman, this concludes my formal testimony.
                                 ______
                                 
Response to Post-Hearing Question Submitted by Hon. Daniel K. Akaka to 
Ian DePlanque, Assistant Director, Veterans Affairs and Rehabilitation 
                    Commission, The American Legion
    Question 1. Veterans register to vote and vote at a significantly 
higher rate than their civilian counterparts. Have your members 
experienced problems with registering to vote or actually voting? If 
so, what have those problems been?
    Response: The American Legion has a national ``Get Out the Vote'' 
campaign that consists of three components: voter registration, voter 
education, and voter participation. This program is executed through 
the 14,000 local American Legion Posts around the world.
    Nationally, The American Legion has not experienced complaints 
about voter registration; however, absentee voting by American citizens 
overseas and military servicemembers still seems to generate 
uncertainties as to whether individual ballots were actually received 
in a timely manner and/or counted.

    Question 2. What is the American Legion doing to help your members, 
as well as other veterans, register to vote and to vote?
    Response: In 1920, during The American Legion National Convention 
in Cleveland, the organization went on record urging all American 
Legion members to become qualified voters. Since then, the organization 
has passed countless similar resolutions advocating Legionnaires to not 
only exercise their constitutional responsibility to vote, but to also 
encourage others to do the same.
    The Legion's ``Get Out the Vote'' program encourages all Americans 
to register and vote in all elections. In addition, Legionnaires, 
posts, districts, and departments are encouraged to fully involve 
themselves in the electoral process by serving as poll volunteers, poll 
workers and by encouraging and assisting others to register and vote.
    Information about how to run a successful ``Get Out the Vote'' 
campaign is available through The American Legion's Americanism 
Division. The American Legion can provide a copy of the most recent 
publication geared to the 2008 election.

    Question 3. What do you anticipate the cumulative costs would be 
for VA to: 1) provide a mail voter registration application form to 
each veteran who seeks to enroll in the VA health care system, and to 
each enrolled veteran any time there is a change in the enrollment 
status of address change of the veteran; 2) provide each veteran with 
information and assistance with voter registration; 3) accept completed 
voter registration application forms and transmit them to the 
appropriate State election official; and ensure that all of the 
information and assistance with voter registration is nonpartisan; 4) 
provide assistance in voting by absentee ballot to veterans residing 
the medical or community living centers; and 5) prepare an annual 
report to compliance report to Congress?
    Response: Voter registration is handled by state guidelines; 
therefore, there is not a ``cookie-cutter'' response to this question.
    1) The American Legion would recommend simply notifying each 
veteran who seeks to enroll in the VA health care system or a change of 
address that voter registration assistance is available through the 
Department of Veterans Affairs upon request. This should minimize costs 
and eliminate sending voter registration forms to veterans already 
registered to vote.
    2) The American Legion would recommend simply notifying veterans 
via various communications venues that voter registration assistance is 
available.
    3) The American Legion would recommend that return of voter 
registration applications be sent directly to the state's voter 
registration offices by the veteran.
    4) The American Legion and other veterans' and military service 
organizations are actively involved in VA's Volunteer Services. Such 
nonpartisan organizations could be a valuable resource in assisting VA 
in fulfilling this important activity. http://www4.va.gov/vaforms/
medical/pdf/vha-10-0462-fill-9-08.pdf
    5) The American Legion would recommend each VA facility be given 
the opportunity to develop its own reporting procedure to comply with 
this requirement with each Regional Office. Regional Office would in 
turn report results to VA Central Office to comply with this directive. 
Again, a ``cookie-cutter'' approach would seem inappropriate. http://
www.coatesville.va.gov/news/PressReleases/Oct15_PressRelease_
Voter_Registration.pdf

    Question 4. What exactly about the current VA directive dated 
September 8, 2008 regarding voter registration and voting do you find 
insufficient?
    Response: VHA Directive 2008-053, appears sufficient; however, it 
directs each individual facility director to have a written published 
policy; inconsistencies may exist from facility to facility. Outreach 
appears limited to just the facility's physical plant.

    Question 5. Do you support the provision of S. 1556 which states 
that subject to reasonable time, place and manner restrictions, the 
Secretary shall not prohibit any election administration official from 
providing voting information to veterans at any (emphasis added) VA 
facility, even if that includes national cemeteries?
    Response: The American Legion supports S. 1556 legislative intent 
was to meet the needs of veterans seeking assistance in voter 
registration or assistance in 
voting.

    Chairman Akaka. Thank you very much, Mr. DePlanque.
    Mr. John Driscoll.

   STATEMENT OF JOHN DRISCOLL, PRESIDENT AND CHIEF EXECUTIVE 
       OFFICER, NATIONAL COALITION FOR HOMELESS VETERANS

    Mr. Driscoll. Thank you, Mr. Chairman, Ranking Member Burr, 
and distinguished Members of the Committee. The National 
Coalition for Homeless Veterans is honored to appear before 
this Committee to comment on what we believe are two of the 
most important bills in the history of the homeless veteran 
assistance movement. That is quite a statement for me. We have 
attempted to be the Nation's primary liaison between community- 
and faith-based organizations that help homeless veterans, 
Congress, and the Federal agencies that are invested in the 
campaign to end veteran homelessness for 20 years.
    VA officials have testified before Congress that this 
partnership is largely responsible for the phenomenal reduction 
in the number of homeless veterans on the streets of America, 
from about 250,000 in fiscal year 2004 to 131,000 today. Ending 
veteran homelessness is a priority of the Obama administration 
and our Federal partners are mobilizing their departments to 
make sure that this happens. We believe these bills figure 
prominently in our collective chances to succeed.
    I will start with the Homeless Women Veterans and Homeless 
Veterans with Children Act. For the first time in American 
history, women comprise 11 percent of this Nation's combat 
forces currently serving in Iraq and Afghanistan. Included 
among them are 30,000 women with dependent children. Women 
account for 15 percent, or will account for 15 percent of our 
Nation's veterans within the next 10 years.
    Currently, 5 percent of the veterans who request homeless 
veterans assistance through VA facilities and the organizations 
NCHV represents are women. The majority of them are between the 
ages of 20 and 29. The majority represent minority communities. 
And roughly 24 percent are disabled. More than 10 percent of 
these women have dependent children.
    Senators Murray, Johnson, and Reed, in introducing this 
bill, recognize that the same difficulties faced by single 
female parents are experienced by single male parents. We have 
learned that during the last 2 years, more than 11 percent of 
the men who receive assistance through the HUD-VASH program are 
single parents with dependent children. According to VA, the 
highest unmet needs of these single veteran parents are: child 
care assistance; legal aid for credit repair; child support 
issues; and access to affordable housing.
    S. 1237 would authorize up to $10 million in grants to 
commu-
nity- and faith-based organizations through the Department of 
Labor and VA to provide critical specialized supports for these 
deserving men and women as they work their way out of 
homelessness. There are 200 community-based grant per diem 
programs across the country that have services for women; and 
there are 90 community-based veteran employment and training 
service grants who provide training assistance and placement 
for homeless veterans under the Homeless Veterans Reintegration 
Program, which is one of the most successful programs in the 
Department of Labor portfolio.
    The point here is that the value that won't necessarily 
show on the bottom line if this bill is passed is that the 
infrastructure is already there. These dollars would go 
directly to services to immediately help homeless women 
veterans and veteran single parents with dependent children. 
For that, we urge the Committee to consider pushing this bill 
forward.
    The Zero Tolerance for Veteran Homelessness Act is 
probably, we believe, the most comprehensive bill ever 
submitted. For several years, NCHV has realized there can be no 
end to veteran homelessness until we develop a national 
strategy that addresses the needs of former guardians before 
they become homeless. We believe this Act, introduced by 
Senators Reed, Bond, Murray, Johnson, Kerry, and Durbin, and 
cosponsored by 12 Senators, has the potential to set this 
Nation on course to finally achieve victory in the campaign to 
end veteran homelessness in the United States.
    Victory in the campaign requires success on two fronts: 
intervention, which we believe has come a long way in the last 
20 years; and prevention strategies, which only now is seeing 
light. We believe this Act addresses both needs. It provides an 
expansion of HUD-VASH housing for chronically homeless 
veterans, to the level of 60,000 over the next 5 years. 
According to analysis of data by the National Alliance to End 
Homelessness, about 63,000 veterans can be classified as 
chronically homeless. This measure alone would, therefore, 
effectively end chronic veteran homelessness as we understand 
it today.
    The Act would also authorize $50 million annually to 
provide supportive services for low-income veterans to reduce 
the risks of becoming homeless and to help those who are 
homeless find housing. The provisions include, as you have 
heard, short- to medium-term rental assistance, repair of poor 
credit rating histories, housing search and relocation 
assistance, and help with security and utility deposits. For 
many of the Nation's 630,000 veterans living in extreme 
poverty, this could mean the difference between achieving 
stability or continuing the downward spiral into homelessness. 
It is key to a national prevention strategy.
    The Act would modernize the highly successful VA grant per 
diem program to allow for innovative project funding, including 
the use of low-income housing tax credits and matching funds 
from other Federal sources to hasten project development and 
expansion.
    For years, service providers have appealed for a system 
that reflects the actual costs of providing services to 
homeless veterans rather than a flat per diem rate based on the 
reimbursements paid to State veterans homes. We know that many 
VA officials agree with this request, and NCHV endorses giving 
the new Secretary of the Department of Veterans Affairs time to 
study the issue.
    The Act calls for an increase in the annual authorization 
for grant per diem to $200 million beginning in 2010, which 
could immediately provide additional funds for outreach through 
community-based service centers and mobile service vans in 
rural areas--both of which are allowed under current law--while 
continuing to increase bed capacity at VA's partners. These 
outreach initiatives will play a key role as the VA forwards 
its prevention strategies.
    In closing, the homeless veteran assistance movement we 
represent is now 20 years old, but much of the success we have 
realized together has been realized in only the last 10 years. 
The partnership between VA, DOL, HUD, and the 1,600 community-
based organizations NCHV represents, has presented this Nation 
with an infrastructure necessary to end veteran homelessness.
    The Zero Tolerance for Veterans Homelessness Act of 2009 
represents an historic opportunity for those who sacrificed 
some measure of their lives in service to our country. They 
shall not be abandoned in their greatest hour of need.
    Personally, I would like to convey my appreciation and 
gratitude to the Members of this Committee and also to your 
staffs for the work that you have done to bring us to this hour 
and this place. On behalf of all who serve our Nation's 
veterans in crisis, we humbly applaud you for what we believe 
is a defining moment in this Nation's history. I truly believe 
the entire nation is ready to support you in this cause. Thank 
you.
    [The prepared statement of Mr. Driscoll follows:]
  Prepared Statement of John A. Driscoll, President and CEO, National 
                    Coalition for Homeless Veterans
    Chairman Senator Akaka, Ranking Member Senator Burr, and 
Distinguished Members of the Committee: The National Coalition for 
Homeless Veterans (NCHV) is honored to appear before this Committee 
today to comment on what we believe are two of the most important bills 
in the history of the homeless veteran assistance movement we 
represent.
    For 20 years, NCHV has worked diligently to serve as the Nation's 
primary liaison between the community- and faith-based organizations 
that help homeless veterans, the Congress, and the Federal agencies 
that are invested in the campaign to end veteran homelessness in the 
United States. Department of Veterans Affairs (VA) officials have 
testified before the Congress that this partnership, despite 
considerable financial pressures due to war and economic uncertainty, 
is largely responsible for the phenomenal reduction in the number of 
homeless veterans on the streets of America each night--from about 
250,000 in FY 2004 to 131,000 today, according to the annual VA 
Community Homelessness Assessment, Local Education and Networking 
Groups (CHALENG) Reports.
    The VA and U.S. Department of Labor, through some of the most 
innovative and successful grant programs in the Federal arsenal, have 
jointly nourished a nationwide, community-based homeless veteran 
assistance network that provides transitional housing and services 
support for more than 100,000 veterans each year. The U.S. Department 
of Housing and Urban Development has become the third critical partner 
in this campaign through the HUD-VA Supportive Housing Program (HUD-
VASH) for veterans with serious mental illness and other disabilities, 
and by incentivizing the inclusion of homeless and extreme low-income 
veterans in local Continuum of Care funding applications.
    The success of these Federal agencies and the community- and faith-
based service partners NCHV represents over the last five years offers 
proof that the campaign to end veteran homelessness can be won. The 
President has established this as a priority of his Administration; and 
VA Secretary Eric Shinseki is mobilizing his Department to strengthen 
its intervention programs and expand its support of local prevention 
strategies.
        s. 1237--homeless women veterans and homeless veterans 
                       with children act of 2009
    One of the most daunting challenges in the campaign to end veteran 
homelessness is presented by the changes in the demographics of this 
special needs population. For the first time in American history, women 
comprise more than 11% of the forces deployed to serve in the wars in 
Iraq and Afghanistan, according to Department of Defense (DOD) figures 
early this year, including more than 30,000 single women with dependent 
children (DOD, March 2009). The VA anticipates women will account for 
15% of the Nation's veterans within the next 10 years.
    Because of the Nation's reliance on Reserve and National Guard 
personnel, men and women must leave their families at the highest rate 
since World War II--approximately half of them for multiple 
deployments. This places considerable strain on family relationships, 
which in turn makes the difficult process of readjustment to civilian 
life after wartime service even more stressful.
    Currently more than 5% of veterans requesting assistance from VA 
and community-based homeless veteran service providers are women. 
According to VA officials, more than half of these veterans are between 
the ages of 20-29, a majority represent minority communities, and 
roughly 24% are disabled or were medically retired from the service. 
More than 10% of these women have dependent children.
    Senators Murray, Johnson and Reed, in introducing this bill, 
recognize the same readjustment difficulties for single women veteran 
parents are experienced by single male parents. During the last two 
years, more than 11% of male veterans receiving housing vouchers in the 
HUD-VASH program are single parents with dependent children.
    According to VA data in its annual CHALENG Reports, the highest 
unmet needs of homeless single veterans with dependent children are:

     Child care assistance
     Legal aid for credit repair and child support issues
     Access to affordable permanent housing

    S. 1237 would authorize up to $10 million in grants to community- 
and faith-based organizations to provide critical, specialized supports 
for these deserving men and women as they work their way out of 
homelessness. There are about 200 homeless veteran assistance providers 
under the VA Homeless Providers Grant and Per Diem Program (GPD) that 
offer housing assistance for women veterans. More than 90 community-
based programs offer job preparation and placement assistance to 
homeless veterans under the Homeless Veterans Reintegration Program--
one of the most efficient, effective programs in the Department of 
Labor portfolio.
    These programs provide irrefutable evidence that stable, safe 
transitional housing--with access to health and employment services--
empowers the great majority of homeless veterans to achieve self-
sufficiency within their eligibility limits. The addition of child care 
assistance promises to enhance those successful outcomes through 
supports that will enable veteran parents to pursue their employment 
goals without having to worry about the health and safety of their 
children.
    NCHV believes this funding level would allow for immediate 
implementation of an employment assistance program for single parents 
with dependent children within an existing and highly successful 
service provider community, and allow for evaluation of the 
effectiveness of this innovative strategy. We strongly urge the 
Committee to champion this cause in the 111th Congress for the sake of 
our Nation's veterans in crisis, and for their families.
     s. 1547--zero tolerance for veterans homelessness act of 2009
    For several years the homeless veteran assistance movement NCHV 
represents has realized there can be no end to veteran homelessness 
until we, as a Nation, develop a strategy to address the needs of our 
former guardians before they become homeless--victims of health and 
economic misfortunes they cannot overcome without assistance.
    The causes of all homelessness can be grouped into three primary 
categories: health issues, economic issues, and lack of access to safe, 
affordable housing for low and extreme-low income families in most 
American communities. This has been a chronic problem since the birth 
of the Great Society during the Johnson administration.
    The additional stressors veterans experience are prolonged 
separation from family and social support networks while engaging in 
extremely stressful training and occupational assignments; war-related 
illnesses and disabilities--both mental and physical; and the 
difficulty of many to transfer military occupational skills into the 
civilian workforce.
    NCHV believes the Zero Tolerance for Veteran Homelessness Act of 
2009, introduced by Senators Reed, Bond, Murray, Johnson, Kerry and 
Durbin--with the support of 12 cosponsors--has the potential to set 
this Nation on course to finally achieve victory in the campaign to end 
veteran homelessness in the United States.
    Victory in this campaign requires success on two fronts--effective, 
economical intervention strategies that help men and women rise above 
adversity to regain control of their lives; and prevention strategies 
that empower communities to support our wounded warriors and their 
families before they lose their ability to cope with stressors beyond 
their control.
    We believe the Zero Tolerance for Veteran Homelessness Act 
addresses needs on both fronts.

     The Act provides for the expansion of HUD-VASH to a total 
of 60,000 housing vouchers for veterans with serious mental and 
emotional illnesses, other disabilities, and extreme low-income veteran 
families that will need additional services to remain housed. According 
to an analysis of data by the National Alliance to End Homelessness, 
about 63,000 veterans can be classified as chronically homeless. This 
Act would, therefore, effectively end chronic veteran homelessness 
within the next five years.
     The Act provides authorization for up to $50 million 
annually to provide supportive services for low-income veterans to 
reduce their risks of becoming homeless, and to help those who are find 
housing. Provisions include short- to medium-term rental assistance, 
poor credit history repair, housing search and relocation assistance, 
and help with security and utilities deposits. For many among the 
Nation's 630,000 veterans living in extreme poverty (at or below 50% of 
the Federal poverty level), this aid could mean the difference between 
achieving stability and continuing on the downward spiral into 
homelessness.
     The Act would modernize the extremely important and 
successful VA Grant and Per Diem Program (GPD) to allow for the 
utilization of innovative project funding strategies--including the use 
of low-income housing tax credits and matching funds from other 
government sources to facilitate and hasten project development.
     The Act calls for the Secretary of Veterans Affairs to 
study the method of reimbursing GPD community providers for their 
program expenses and report to Congress, within one year, his 
recommendations for revising the payment system. For years service 
providers have appealed for a system that reflects the actual cost of 
providing services to veterans with multiple barriers to recovery 
rather than a ``per diem'' rate based on reimbursements paid to state 
veterans' homes.
     The Act calls for an increase in the annual GPD 
authorization to $200 million, beginning in FY 2010, which could 
provide additional funds for outreach through community-based veteran 
service centers and mobile service vans for rural areas, while 
continuing to increase the bed capacity of VA's community-based 
partners. These outreach initiatives will likely play a pivotal role as 
the VA's veteran homelessness prevention strategy moves forward.
     The Act would establish within HUD a Special Assistant for 
Veterans Affairs to ensure veterans have access to housing and homeless 
assistance programs funded by the Department.
                               summation
    The homeless veteran assistance movement NCHV represents is now 20 
years old, but much of the success we have seen in reducing the number 
of homeless veterans has been realized in just the last decade. The 
partnership between the Departments of Veterans Affairs, Labor and 
Housing and Urban Development, and our 1,600 community- and faith-based 
associates has presented this Nation with the infrastructure necessary 
to end veteran homelessness through innovative intervention programs 
and low-level supports that can serve as the foundation for a 
nationwide prevention strategy.
    Never before in the history of this Nation have we been better 
prepared to support the men and women who serve in harm's way to 
preserve our freedom and prosperity. The Zero Tolerance for Veteran 
Homelessness Act of 2009 represents a historic opportunity to ensure 
that those who sacrifice some measure of their lives to serve our 
country will not be abandoned in their greatest hour of need.
    We owe the Committee a great debt of gratitude for bringing us to 
this hour and place, where we can focus on prevention far wiser than we 
were when the campaign to end veteran homelessness began. On behalf of 
all who serve our Nation's veterans in crisis, we humbly applaud you 
for bringing us to this moment in history, and express profound 
appreciation and gratitude for your leadership.

    Chairman Akaka. Thank you very much, Mr. Driscoll.
    Now, we will receive the statement of Dr. Rick McMichael.

    STATEMENT OF RICK McMICHAEL, D.C., PRESIDENT, AMERICAN 
                    CHIROPRACTIC ASSOCIATION

    Dr. McMichael. Chairman Akaka, Ranking Member Burr, Members 
of the Committee, I am Rick McMichael, a Doctor of Chiropractic 
from Canton, Ohio, and current President of the American 
Chiropractic Association. On behalf of the ACA, I thank you for 
providing an opportunity to testify today in support of 
S. 1204, the Chiropractic Care Available to All Veterans Act.
    The ACA provides professional and educational opportunities 
for Doctors of Chiropractic, supports research, and offers 
leadership for the advancement of the profession. ACA promotes 
the highest standards of ethics and patient care, contributing 
to the health and well-being of millions of chiropractic 
patients.
    The ACA wholeheartedly supports S. 1204, as introduced by 
Senator Patty Murray, and believes it will assist veterans in 
receiving quality care, especially for the treatment of very 
prevalent musculoskeletal injuries and conditions. Painful and 
disabling joint and back disorders continue to be reported as 
the top health problems of veterans returning from Iraq and 
Afghanistan, according to Department of Veterans Affairs 
statistics. The most recent numbers from VA now show that over 
half of our returning veterans seek VA care due to 
musculoskeletal ailments.
    Chiropractic benefit had theoretically been available 
within the VA system for many years, but Congress took action 
when it became apparent the VA had failed to take any 
reasonable steps to provide veterans with chiropractic care. As 
a result of legislation in the 107th and 108th Congress, as 
well as recommendations issued by a Congressionally-mandated 
advisory committee of which I was a member, the VA now provides 
chiropractic care at 36 major treatment facilities in the U.S. 
Doctors of Chiropractic practicing at these VA facilities have 
become an integrated part of the VA health care team and regard 
it as a valuable source of safe and effective care for 
veterans.
    Speaking with Dr. Cross a little bit earlier, we agreed 
that chiropractic services have been a positive addition to the 
VA health care team and that the VA is supporting that process 
and that integration of chiropractic.
    By all accounts, the care provided by DCs in the VA 
produces positive outcomes and high levels of patient 
satisfaction and is cost efficient. In addition, Doctors of 
Chiropractic bring new ideas and viewpoints to patient-centered 
care, clinical research, and education. These new perspectives 
help strengthen the VA and the care of veterans.
    Despite this progress, the overwhelming majority of 
America's eligible veterans continue to be denied access to 
chiropractic care because the VA has not taken steps to provide 
these services at approximately 120 additional major VA 
facilities. Detroit, Denver, and Chicago are just a few 
examples of major metropolitan areas still lacking a Doctor of 
Chiropractic at the local VA medical facility. In my home State 
of Ohio, the only VA site that offers chiropractic care is the 
Columbus facility. There is another that is looking to be stood 
up in Dayton, but major health care facilities of the VA in 
Chillicothe, Cincinnati, and Cleveland still do not employ DCs, 
and veterans in those areas are limited to chiropractic care 
via outside referrals, which are spotty, at best. I frequently 
take calls from our doctors across the country asking how they 
can get their veteran patients referred for chiropractic care, 
and it is not a simple process in many cases.
    As referenced earlier, in a VA report released just this 
month, with 52 or nearly 52 percent of veterans returning from 
Iraq and Afghanistan seeking care at the VA for musculoskeletal 
ailments, we need to remember that Doctors of Chiropractic 
offer expert conservative care for many of these ailments, 
commonly caused by injuries in combat, heavy gear, motor 
vehicle accidents, and blast injuries. Clearly, the need for 
expanded access to Doctors of Chiropractic and our high-touch 
care has never been more crucial. Without a Congressional 
directive, further expansion to VA facilities will happen only 
on a case-by-case basis and more than likely will be 
excruciatingly slow.
    Veterans want, need, and deserve access to chiropractic 
care and our goal should be to ensure that chiropractic is 
available and accessible at every major VA health care 
facility. The chiropractic profession welcomes the opportunity 
to serve our Nation's veterans. It is an honor to serve those 
who have given so much for us.
    Passage of the Chiropractic Care Available to All Veterans 
Act will ensure that our veterans receive the highest level of 
care possible. The American Chiropractic Association urges 
Congress to pass this legislation immediately.
    I thank the Chairman for the opportunity to testify today 
and look forward to any questions from the Committee. Thank 
you.
    [The prepared statement of Dr. McMichael follows:]
   Prepared Statement of Rick McMichael, Doctor of Chiropractic and 
              President, American Chiropractic Association
in support of s. 1204, the chiropractic care available to all veterans 
                                  act
    Chairman Akaka, Ranking Member Burr, and Members of the Committee: 
I am Dr. Rick McMichael, a Doctor of Chiropractic from Canton, Ohio, 
and current President of the American Chiropractic Association. On 
behalf of the ACA, I thank you for providing an opportunity to testify 
today in support of S. 1204, the Chiropractic Care Available to All 
Veterans Act.
    The ACA provides professional and educational opportunities for 
doctors of chiropractic, supports research, and offers leadership for 
the advancement of the profession. ACA promotes the highest standards 
of ethics and patient care, contributing to the health and well-being 
of millions of chiropractic patients.
    The ACA wholeheartedly supports S. 1204, as introduced by Senator 
Patty Murray, and believes it will assist veterans in receiving quality 
care, especially for the treatment of very prevalent musculoskeletal 
injuries and conditions. Painful and disabling joint and back disorders 
continue to be reported as the top health problems of veterans 
returning from Iraq and Afghanistan, according to Department of 
Veterans Affairs' statistics. The most recent numbers from the VA now 
show that over half of our returning veterans seek VA care due to 
musculoskeletal ailments.\1\
---------------------------------------------------------------------------
    \1\ Analysis of VA Health Care Utilization Among U.S. Global War on 
Terrorism Veterans, Oct. 2009
---------------------------------------------------------------------------
    A chiropractic benefit has theoretically been available within the 
VA system for many years, but Congress took action when it became 
apparent that VA had failed to take any reasonable steps to provide 
veterans with chiropractic care. As a result of legislation in the 
107th and 108th Congress,\2\ as well as recommendations issued by a 
congressionally mandated advisory committee--of which I was a member--
the VA now provides chiropractic care, at 36 major VA treatment 
facilities within the United States.
---------------------------------------------------------------------------
    \2\ Public Law 107-135 and Public Law 108-170
---------------------------------------------------------------------------
    Doctors of chiropractic, practicing at these VA facilities, have 
become an integrated part of the VA health care team and are regarded 
as a valuable source of safe and effective care for veterans.
    By all accounts, the care provided by DCs in the VA produces 
positive outcomes and high levels of patient satisfaction, and is cost-
efficient. Additionally, doctors of chiropractic bring new ideas and 
viewpoints to patient-centered care, clinical research and education. 
These new perspectives help strengthen the VA and care of veterans.
    Despite this progress, the overwhelming majority of America's 
eligible veterans continue to be denied access to chiropractic care 
because the VA has not taken steps to provide these services at 
approximately 120 additional major VA facilities. Detroit, Denver, and 
Chicago are just a few examples of major metropolitan areas still 
lacking a Doctor of Chiropractic at the local VA medical facility. In 
my home state of Ohio, the only VA site that offers chiropractic care 
is the facility in Columbus. Another VA facility, Dayton, will soon 
begin to offer chiropractic services. However, major VA medical centers 
in Chillicothe, Cincinnati, and Cleveland do not employ DCs, and 
veterans in those areas are limited to chiropractic care via outside 
referrals, which are spotty at best.
    As referenced earlier, in a VA report released just this month, 
nearly 52 percent of veterans returning from Iraq and Afghanistan, who 
have sought VA health care, were treated for musculoskeletal ailments--
the top complaint of those tracked for the report. Doctors of 
chiropractic offer expert conservative care for many of these ailments, 
commonly caused by injuries from combat, heavy gear, motor vehicle 
accidents, and blast injuries. Clearly, the need for expanded access to 
doctors of chiropractic and their high-touch care has never been more 
crucial. Without a congressional directive, further expansion to VA 
facilities will happen only on a case-by-case basis and more than 
likely will be excruciatingly slow.
    Veterans want, need and deserve access to chiropractic care, and 
our goal should be to ensure that chiropractic is available and 
accessible at every major VA health care facility. The chiropractic 
profession welcomes the opportunity to serve our Nation's veterans. It 
is an honor to serve those who have given so much for us.
    Passage of the Chiropractic Care Available to All Veterans Act will 
ensure that our veterans receive the highest level of care possible. 
The American Chiropractic Association urges Congress to pass this 
legislation immediately. I thank the Chairman for the opportunity to 
testify today, and look forward to any questions from the Committee.

    Chairman Akaka. Thank you very much, Dr. McMichael.
    Dr. Fenn, your statement.

    STATEMENT OF WILLIAM FENN, PH.D., P.A., VICE PRESIDENT, 
            AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS

    Mr. Fenn. Good morning. Chairman Akaka, Ranking Member 
Burr, and other Members of the Committee on Veterans' Affairs. 
Mahalo and thank you for inviting the American Academy of 
Physician Assistants to present testimony on S. 1155, a bill to 
establish a full-time Director of Physician Assistant Services 
within the Office of the Under Secretary of Veterans Affairs 
for Health.
    My name is Bill Fenn and I am a PA. I am also Vice 
President of the American Academy of PAs and currently a PA 
professor at Western Michigan University. I received my 
education as a PA in the U.S. Air Force where I ultimately 
retired as a Lieutenant Colonel. I am also personally familiar 
with the VA from two fronts. Since I have an active duty-
related disability, I have, from time to time, received care 
from the VA. In addition to being a patient, I have also been 
employed as a clinician through the VA, working in one of the 
first VA rural health demonstration programs.
    The AAPA represents more than 75,000 clinically practicing 
PAs in the United States. My testimony today also represents 
the views of the Veterans Affairs Physician Assistant 
Association, which represents PAs who are employed by the 
Department of Veterans 
Affairs.
    AAPA and VAPAA are very appreciative of Senators Susan 
Collins and Daniel Inouye for their leadership in introducing 
this important legislation and we thank Members of the 
Committee who have added their names as cosponsors or indicated 
their support for the legislation. We also thank the many 
Veterans Service Organizations who have urged passage of this 
important legislation.
    We believe that enactment of S. 1155 is essential to 
improving patient care for our Nation's veterans, ensuring that 
the nearly 1,900 PAs employed by the VA are most appropriately 
utilized.
    PAs are fully integrated into the health care systems of 
the Armed Services and virtually all other public and private 
health care systems. PAs are on the front line in Iraq and 
providing immediate medical care for wounded members of the 
Armed Forces. They provide care in all levels of medical 
facilities throughout the military, and are covered providers 
in TRICARE.
    In the civilian world, PAs work in virtually every area of 
medicine and surgery and are covered providers within the 
overwhelming majority of public and private health insurance 
plans. PAs play a key role in providing medical care in 
medically underserved communities. In some rural communities, 
in fact, the PA is the only health care professional available.
    Currently, each branch of the Armed Services designates a 
PA Consultant to their Surgeon General, and many major medical 
institutions credit their integration of PAs into an effective 
workforce to a Director of PA Services. To name just a few, the 
Cleveland Clinic, Geisinger Clinic, the University of Texas 
M.D. Anderson Cancer Center, and New Orleans Oschner Clinic 
Foundation all have Directors of PA Services. We believe that 
what works for the Armed Services and the private sector will 
also work well for the VA.
    Approximately 40 percent of PAs currently employed by the 
VA are eligible for retirement in the next 5 years and the VA 
is simply not competitive with the private sector for new 
graduates. The U.S. Bureau of Labor Statistics, U.S. News and 
World Report, and Money Magazine all speak to the growth, 
demand, and value of the PA profession. In fact, recently, 
Money Magazine ranked the PA profession as its number 2 best 
job. Recruitment and retention of non-physician patient care 
providers, especially physician assistants, will be critical to 
meeting VA's primary care and other patient care needs.
    We consider the Director of PA Services to be essential for 
VA recruitment and retention. We believe that the VA should 
formally designate PAs alongside physicians and nurses as 
critical occupations. This designation would allow priority in 
scholarships and loan repayment programs that are not currently 
available to PAs. Additionally, we believe that PAs should also 
be included in VA special locality pay bands so PA salaries may 
be regularly tracked and reported accurately by the VA.
    The current position of PA Advisor to the Under Secretary 
for Health has been filled as a part-time field position with 
no designated administrative support. Prior to the law 
requiring the PA Advisor in 2000, the VA had never had a 
representative within VHA with sufficient knowledge of the PA 
profession. This lack of knowledge resulted in an inconsistent 
approach toward PA practice and underutilization of PA skills 
and abilities.
    Although the PAs who have served as the VA's part-time 
field-based PA Advisor have indeed made progress on the 
utilization of PAs within that agency, there continues to be 
inconsistency in the way that local medical facilities use PAs 
and barriers to quality care delivery by PAs. The Academy 
believes that the elevation of the PA Advisor to a full-time 
Director of PA Services, located and accessible in the VA 
central office, consistent with the professions of similar size 
and scope, is necessary to increase veterans' access to quality 
medical care by ensuring efficient utilization of PAs in VHA 
patient care programs and initiatives.
    PAs are a valuable resource in the transition from active 
duty to veterans health care. As health care professionals with 
a longstanding history of providing care in medically 
underserved communities, PAs also provide an invaluable link in 
enabling veterans who live in underserved communities to 
receive timely access to quality medical care.
    Thank you very much for the opportunity to testify in 
support of this important legislation, S. 1155. Both AAPA and 
VAPAA are eager to work with the Committee on Veterans' Affairs 
to improve the availability and quality of medical care to our 
Nation's veteran population.
    I would be happy to provide additional information on our 
profession and/or respond to any questions you might have.
    [The prepared statement of Mr. Fenn follows:]
  Prepared Statement of William Fenn, Ph.D., Physician Assistant, and 
     Vice President, American Academy of Physician Assistants and 
     representing Veterans Affairs Physician Assistant Association
    Good morning, Chairman Akaka, Ranking Member Burr, and other 
Members of the Committee on Veterans' Affairs, thank you for inviting 
the American Academy of Physician Assistants to present testimony on 
S. 1155, a bill to amend title 38, United States Code, to establish the 
position of Director of Physician Assistant Services within the office 
of the Under Secretary of Veterans Affairs for Health.
    My name is Bill Fenn. I'm a physician assistant, and I'm Vice 
President of the AAPA. I received my training as a physician assistant 
while I was in the Air Force. I'm familiar with the VA from two fronts. 
Since I have an active-duty related disability, I have received care, 
from time to time, from the VA. In addition to being a patient, I've 
also been employed as a clinician through the VA. I worked in one of 
the first VA rural health demonstration programs.
    The AAPA represents the more than 75,000 clinically practicing 
physician assistants in the United States. My testimony today also 
represents the views of the Veterans Affairs Physician Assistant 
Association. The VAPAA represents physician assistants who are employed 
by the Department of Veterans Affairs.
    AAPA and VAPAA are very appreciative of Senators Susan Collins and 
Daniel Inouye for their leadership in introducing this important 
legislation. We thank Members of the Committee who have added their 
names as cosponsors and/or have indicated their support for the 
legislation. And, we also thank the veteran service organizations who 
have urged passage of S. 1155. (The annual Veteran Service
    Organizations Independent Budget, endorsed by 35 professional and 
veteran service organizations, has recommended enactment of this 
legislation.)
    AAPA and VAPAA believe that enactment of S. 1155 is essential to 
improving patient care for our Nation's veterans, ensuring that the 
nearly 1,900 PAs employed by the VA are fully utilized and removing 
unnecessary restrictions on the ability of PAs to provide medical care 
in VA facilities. Additionally, the associations believe that enactment 
of S. 1155 is necessary to advance recruitment and retention of PAs 
within the Department of Veterans Affairs.
    Physician assistants are licensed health professionals, or in the 
case of those employed by the Federal Government, credentialed health 
professionals, who--

     practice medicine as a team with physicians
     exercise autonomy in medical decisionmaking
     provide a comprehensive range of diagnostic and 
therapeutic services, including performing physical exams, taking 
patient histories, ordering and interpreting laboratory tests, 
diagnosing and treating illnesses, suturing lacerations, assisting in 
surgery, writing prescriptions, and providing patient education and 
counseling
     may also work in educational, research, and administrative 
settings.

    Physician assistants' educational preparation is based on the 
medical model. PAs practice medicine as delegated by and with the 
supervision of a physician. Physicians may delegate to PAs those 
medical duties that are within the physician's scope of practice and 
the PA's training and experience, and are allowed by law. A physician 
assistant provides health care services that were traditionally only 
performed by a physician. All states, the District of Columbia, and 
Guam authorize physicians to delegate prescriptive privileges to the 
PAs they supervise. AAPA estimates that in 2008, over 257 million 
patient visits were made to PAs and approximately 332 million 
medications were prescribed or recommended by PAs.
    The PA profession has a unique relationship with veterans. The 
first physician assistants to graduate from PA educational programs 
were veterans, former medical corpsmen who had served in Vietnam and 
wanted to use their medical knowledge and experience in civilian life. 
Dr. Eugene Stead of the Duke University Medical Center in North 
Carolina put together the first class of PAs in 1965, selecting Navy 
corpsmen who had considerable medical training during their military 
experience as his students. Dr. Stead based the curriculum of the PA 
program in part on his knowledge of the fast-track training of doctors 
during World War II. Today, there are 142 accredited PA educational 
programs across the United States. Nearly 1,900 PAs are employed by the 
Department of Veterans Affairs, making the VA the largest single 
employer of physician assistants. These PAs work in a wide variety of 
medical centers and outpatient clinics, providing medical care to 
thousands of veterans each year. Many are veterans themselves.
    Physician assistants (PAs) are fully integrated into the health 
care systems of the Armed Services and virtually all other public and 
private health care systems. PAs are on the front line in Iraq and 
Afghanistan, providing immediate medical care for wounded men and women 
of the Armed Forces. They provide care in all levels of medical 
facilities throughout the military. PAs are covered providers in 
TRICARE. In the civilian world, PAs work in virtually every area of 
medicine and surgery and are covered providers within the overwhelming 
majority of public and private health insurance plans. PAs play a key 
role in providing medical care in medically underserved communities. In 
some rural communities, a PA is the only health care professional 
available.
    Why are PAs so fully integrated into most public and private health 
care systems? We believe it's because they foster the use and inclusion 
of their PA workforce. Each branch of the Armed Services designates a 
PA Consultant to the Surgeon General. And, many major medical 
institutions credit their integration of PAs in the workforce to a 
Director of PA Services. To name just a few, the Cleveland Clinic, the 
Geisinger Clinic, the University of Texas MD Anderson Cancer Center, 
and New Orleans' Ochsner Clinic Foundation all have Directors of PA 
Services. We believe that what works for the Armed Services and the 
private sector will also work for the VA.
    How does the lack of a Director of PA Services at the VA relate to 
recruitment and retention of the VA workforce? As far as the AAPA can 
tell, there are no recruitment and retention efforts aimed toward 
employment of physician assistants in the VA. The VA designates 
physicians and nurses as critical occupations, and so priority in 
scholarships and loan repayment programs goes to nurses, nurse 
practitioners, physicians, and other professions designated as critical 
occupations. The PA profession has not been determined to be a critical 
occupation at the VA, so monies are not targeted for their recruitment 
and retention. PAs are not included in any of the VA special locality 
pay bands, so PA salaries are not regularly tracked and reported by the 
VA. We've been told that this has resulted in lower pay for PAs 
employed by the VA than for health care professionals who perform 
similar medical care. Why are PAs not considered a critical occupation 
at the VA? Is it possible they were overlooked, because there was no 
one to raise the issue?
    The outlook for PA employment at the VA does not differ from that 
for nurse practitioners and physicians. Approximately forty percent of 
PAs currently employed by the VA are eligible for retirement in the 
next five years, and the VA is simply not competitive with the private 
sector for new PA graduates. The U.S. Bureau of Labor Statistics, US 
News and World Report, and Money magazine all speak to the growth, 
demand, and value of the PA profession. In fact, Money magazine 
recently ranked the PA profession as its #2 best job. The challenge for 
the VA is that the growth and demand for PAs is in the private sector, 
not the VA.
    Despite the fact that the VA PA workforce has risen by 19% in the 
last 5 years, the PA percentage of the VHA mid-level practitioner 
workforce has dropped to 30%. We believe that this directly relates to 
recruitment and retention.
    The VA has acknowledged that an increasing physician shortage, 
especially in primary care, is expected at a time when the number of VA 
patients is expected to increase significantly. Recruitment and 
retention of non-physician patient care providers, especially, 
physician assistants, will be critical to meeting VA's patient care 
needs. Stationing the PA Advisor in the field creates a barrier to 
effectively addressing VA recruitment and retention issues, as well as 
to ensuring patient care initiatives and policies do not create 
additional, unintended barriers to optimal utilization of PAs.
    According to the AAPA's 2008 Census Report, PA employment in the 
Federal Government, including the VA, continues to decline. AAPA's 
Annual Census Reports of the PA Profession from 1991 to 2008 document 
an overall decline in the number of PAs who report Federal Government 
employment. In 1991, nearly 22% of the total profession was employed by 
the Federal Government. This percentage dropped to approximately 9% in 
2008. New graduate census respondents were even less likely to be 
employed by the government (17% in 1991 down to 5% in 2008).
    Unless some attention is directed toward recruitment and retention 
for PAs, the AAPA believes that the VA is in danger of losing its PA 
workforce. This is particularly critical because it is happening at a 
time when the U.S. and the VA are facing a primary care workforce 
shortage. The elevation of the PA Advisor to a full-time Director of PA 
Services in the VA Central Office is the first step in focusing the 
VA's efforts on recruitment and retention of PAs.
    The current position of Physician Assistant (PA) Advisor to the 
Under Secretary for Health was authorized through section 206 of Public 
Law 106-419 and has been filled as a part-time, field position. The 
position functions without any designated administrative support. Prior 
to Public Law 106-419, the VA had never had a representative within the 
Veterans Health Administration with sufficient knowledge of the PA 
profession to advise the Administration on the optimal utilization of 
PAs. This lack of knowledge resulted in an inconsistent approach toward 
PA practice, unnecessary restrictions on the ability of VA physicians 
to effectively utilize PAs, and an under-utilization of PA skills and 
abilities. The PA profession's scope of practice was not uniformly 
understood in all VA medical facilities and clinics, and unnecessary 
confusion existed regarding such issues as privileging, supervision, 
and physician countersignature.
    The PA Advisor currently reports to the Chief Consultant for 
Primary Care. The numbers of VA PAs of PAs practice in all disciplines 
of medicine in VHA, it is reasonable that the Director of PA Services 
report to the Under Secretary for Health. This reporting mechanism 
would be consistent with all other Federal agencies and the Department 
of the Defense.
    Although the PAs who have served as the VA's part-time, field-based 
PA Advisor have made progress on the utilization of PAs within the 
agency, there continues to be inconsistency in the way that local 
medical facilities use PAs. In one case, a local facility decided that 
a PA could not write outpatient prescriptions, despite licensure in the 
state allowing prescriptive authority. In other facilities, PAs are 
told that the VA facility cannot use PAs and will not hire PAs. These 
unfortunately common events are not based on any cohesive policy 
decision, but rather, a lack of appropriate PA utilization input at the 
Central Office level. These restrictions needlessly hinder PA 
employment within the VA, as well as deprive veterans of the skills and 
medical care PAs have to offer.
    The Academy also believes that the elevation of the PA Advisor to a 
full-time Director of Physician Assistant Services, located in the VA 
central office, is necessary to increase veterans' access to quality 
medical care by ensuring efficient utilization of the VA's PA workforce 
in the Veterans Health Administration's patient care programs and 
initiatives. PAs are key members of the Armed Services' medical teams 
but are an underutilized resource in the transition from active duty to 
veterans' health care. As health care professionals with a longstanding 
history of providing care in medically underserved communities, PAs may 
also provide an invaluable link in enabling veterans who live in 
underserved communities to receive timely access to quality medical 
care.

    Thank you very much for the opportunity to testify in support of 
S. 1155. Both AAPA and VAPAA are eager to work with the Committee on 
Veterans Affairs to improve the availability and quality of medical 
care to our Nation's veteran population.

    Chairman Akaka. Thank you very much, Dr. Fenn.
    Dr. Cross has testified that VA intends to make the current 
Director of PA Services full-time and to locate the position in 
the central office. Would this address your concerns?
    Mr. Fenn. Mr. Chairman, that certainly would represent a 
step forward and is a positive statement. However, such an 
action remains a discretionary action and we believe that the 
importance of this position in ensuring efficient and effective 
care is indeed too important to be discretionary and needs to 
be established by directive of Congress.
    Chairman Akaka. Mr. DePlanque and Mr. Jackson, VA has a 
directive providing for--let me come back to voter 
registration, education, and participation. Do you find this 
directive insufficient? Mr. Jackson?
    Mr. Jackson. Could you repeat that question, Mr. Chairman? 
I want to make sure I understand it correctly.
    Chairman Akaka. Yes. VA has a directive providing for voter 
registration, education, and participation. My question is, do 
you find this directive insufficient?
    Mr. Jackson. I don't think I can answer that. I can get 
back to you with it in writing. But I can say first, we support 
the legislation; second, we believe the VA needs to do more to 
make voting and registration much easier for patients and 
people using the facilities.
    Chairman Akaka. Thank you. As you know, it was presented by 
the doctor here.
    Mr. DePlanque?
    Mr. DePlanque. I would generally state, we support the 
legislation. We think it is an important step forward and we 
believe that veterans, specifically, as it is cited in the 
bill, have unique qualifications. Understanding a number of the 
aspects of the political system and the direct impact of those 
things, we think those are important.
    As to the specifics or a more detailed answer on what is 
and isn't addressed by the present state of affairs if this did 
not pass, again, I would have to defer to giving you a more 
detailed answer, but we would be happy to provide one in 
writing.
    Chairman Akaka. Please respond at a future date.

    [This information was received and is being held in 
Committee files.]

    Chairman Akaka. Dr. McMichael, do you know of specific 
cases where veterans have sought chiropractic care and had been 
denied that care under the current system? If so, could you 
tell us about these cases?
    Dr. McMichael. Thank you, Mr. Chairman. I have been made 
aware of numerous cases across the country. As to exact names 
and so forth, we could certainly attempt to get those for you. 
But there are many varied cases where veterans have been under 
chiropractic care or other forms of care within and outside the 
VA for years and have been unsuccessful at getting results with 
their pain levels and function, so they have requested 
referrals and have been unable to get those. So, the Doctors of 
Chiropractic will call me and ask if I can help them get that 
done. Usually, I try to refer them to their VA advocate at the 
site, but sometimes that is not getting the job done, either.
    Chairman Akaka. Well, will you please respond to this in 
the future.

    [This information was received and is being held in 
Committee files.]

    Chairman Akaka. Mr. Driscoll, of the many women veterans 
requesting assistance from VA and community-based homeless 
veteran service providers, how many of them have dependent 
children?
    Mr. Driscoll. Approximately 10 percent of the women who 
have requested homeless assistance have dependent children, and 
11 percent of single parent males in the HUD-VASH programs.
    Chairman Akaka. Having to do with salaries, Dr. Fenn, how 
do VA's salaries and benefits for PAs compare with the private 
sector?
    Mr. Fenn. Mr. Chairman, I have some selected information I 
can give you today. I would be happy to have our Academy 
prepare a more detailed analysis across the board.
    Perhaps the most important salaries in this time of growing 
demand are the entry-level salaries. The information we have 
currently is that the average salary for entry-level PAs in the 
VA is approximately $62,000. It goes as low as $47,000. That 
compares to entry-level salaries for other non-physician 
providers of the VA of $75,000 and an overall entry-level 
salary for PAs in the non-VA civilian world of approximately 
$74,500. But again, we will prepare a more detailed response 
and provide it promptly.
    Chairman Akaka. Thank you very much for that response.
    Mr. Driscoll, do you have any estimates on how many service 
providers have to turn away homeless women veterans or homeless 
veterans with dependent children because they cannot meet their 
needs?
    Mr. Driscoll. I don't have actual numbers, but I could 
suggest to the Committee that that is precisely the intent of 
this bill, because heretofore, males or females with dependent 
children have had virtually no access to supportive services 
and transitional housing where they can stay connected with 
their dependent children.
    Chairman Akaka. Thank you. Will you please provide that.
    [The response for the record follows:]
Response to Request Arising During the Hearing by Hon. Daniel K. Akaka 
to John A. Driscoll, President and CEO, National Coalition for Homeless 
                                Veterans
    Question. Do you have any estimates on how many service providers 
have to turn away homeless women veterans or homeless veterans with 
dependent children because they cannot meet their needs?
    Response. Approximately 200 of the 500 community-based 
organizations funded through the VA Homeless Providers Grant and Per 
Diem Program offer transitional housing and services to homeless women 
veterans, which means 60% of those programs must refer women veterans 
to other community programs. Of the 100,000 homeless veterans who 
receive help from VA-funded homeless programs each year, approximately 
5,400 are women. Of those, 10%--or approximately 540--have dependent 
children.
    Under current law, the VA is not allowed to provide direct services 
to the dependent children of single parent veterans. Therefore, 
virtually all VA Grant and Per Diem Program service providers must make 
other housing arrangements or find other funding for homeless women 
parents and single parent veterans with dependent children to keep 
families together. Only 7 Grant and Per Diem Programs currently have 
the capacity to serve women veterans with dependent children. The 
primary purpose of S. 1237 is to authorize both the VA and Department 
of Labor to provide assistance to single veterans and their dependent 
children, with funding dedicated for employment supports that--for the 
first time in U.S. history--include child care assistance.

    Chairman Akaka. Mr. Jackson, the Independent Budget VSOs, 
including VFW, supported consolidating VA contracts. Do you 
think this legislation would help to accomplish this goal? Why 
or why not?
    Mr. Jackson. I think it is probably a good step forward. I 
will refer to page 81 of the Independent Budget 2010, where we 
talk about centralizing the contract process. I think this bill 
probably gets us close, but we would probably want this 
Committee and VA to look a little bit broader range of 
solutions to the problem.
    Chairman Akaka. Mr. Driscoll, you stated in your testimony 
that 11 percent of male veterans receiving housing vouchers in 
the HUD-VASH program are single parents with dependent 
children.
    Mr. Driscoll. Yes, sir.
    Chairman Akaka. Do you have any idea of how many we are 
talking about?
    Mr. Driscoll. I could get that exact number for you. I 
believe the number is somewhere here, but rather than take a 
guess, I will get that exact number to you. We are in the 
second phase of the next 10,000 HUD-VASH vouchers which are 
being implemented now. I believe the number from the first 
10,000 in fiscal year 2008 were in excess of 8,000 that have 
been allocated. So, if that gives you some sense----
    Chairman Akaka. Fine.
    [The response for the record follows:]
Response to Request Arising During the Hearing by Hon. Daniel K. Akaka 
to John A. Driscoll, President and CEO, National Coalition for Homeless 
                                Veterans
    Question. Mr. Driscoll, you stated that 11 percent of male veterans 
receiving housing vouchers in the HUD-VASH programs are single parents 
with dependent children. Do you have any idea how many we are talking 
about?
    Response. Mr. Chairman, after conferring with VA homeless program 
officials, I need to correct my statement. The most recent information 
from VA shows that of first round of 10,000 HUD-VASH vouchers, 
approximately 8,000 have been allocated, with all 10,000 expected to be 
under lease by the end of 2009. Approximately 10% of those are being 
assigned to women veterans, and about 10% of ALL homeless veterans 
receiving HUD-VASH vouchers will be single parents with dependent 
children. This means approximately 900 of the first 10,000 HUD-VASH 
vouchers will be assigned to single male veterans with dependent 
children. The number will fluctuate some as veterans eligible for 
vouchers are actually placed in housing, but the VA expects the number 
of homeless single parents with dependent children receiving HUD-VASH 
vouchers to remain at that 10% level through the second round of 10,000 
voucher allocations.

    Chairman Akaka. Mr. Jackson and Mr. DePlanque, according to 
the Congressional Budget Office, nearly 80 percent of enrolled 
veterans have access to other health care coverage. What impact 
do you think quality report cards will have on whether a 
veteran decides to get health care in VA? Mr. DePlanque?
    Mr. DePlanque. Well, on the one hand, I would actually say 
that in a large number of areas, VA health care and the service 
that they are providing is still--with areas that need to be 
addressed--is still excellent health care that in many cases 
can be better than the private health care that is out there. 
So, in some ways it is encouraging to get veterans to take 
advantage of the health care that is trying to be provided for 
them. In areas where they were not being as well served, it is 
also important to identify that.
    I think, also, in terms of identifying individual areas, 
centers, so forth, and pointing out where the weak points are, 
grades--getting a failing grade is an opportunity for an 
improvement. That is a way to identify where you are weak and 
work at making you stronger. It is possible for a kid to get 
straight A's in school, and they should strive for that. If you 
have something that is very simply codified that is easy to 
understand by veterans, then they will be able to take 
advantage of that. It will also enable VA to determine where 
they need to address the most work and bring them all up to the 
A level which they should be providing.
    Mr. Jackson. I agree with Ian. Any time that you can have a 
standard to shoot for--as far as providing health care, quality 
health care for veterans--I think that is really important. It 
allows veterans to make choices on their own, as well. So, I 
agree with everything that Ian just said.
    Chairman Akaka. Thank you.
    Mr. Jackson and Mr. DePlanque, have you heard from any of 
your members about veterans who have been exposed to chemical 
toxins and then denied health care by VA? We have held a 
hearing here on exposures.
    Mr. Jackson. Yes, Mr. Chairman. Nothing has come across my 
desk about that. That is not to say that it hasn't taken place.
    Chairman Akaka. Any comment?
    Mr. DePlanque. Mr. Chairman, I don't have anything in terms 
of any hard and fast numbers. We have anecdotal accounts of 
servicemembers who were exposed to things and have difficulty, 
as often happens with any sort of thing where getting a direct 
connection made between being exposed--say, at Johnson Island 
or some other venue--to something, and then getting the medical 
science to align with a specific condition.
    There are numerous anecdotal occurrences of people who 
struggle from a wide variety of environmental hazards. 
Specifically on this, I couldn't break it down into any 
numbers, though, other than to say that this--and environmental 
hazards in particular are an area that our veterans have often 
had a hard time getting the connection that they need through--
which is one of the reasons we generally push so hard for 
presumptions when the medical evidence supports it.
    Chairman Akaka. Mr. Driscoll, from your organization's 
perspective, what still needs to be addressed in the area of 
homeless veterans that is not in either of these bills today?
    Mr. Driscoll. That is a good question. I would hesitate to 
say that the most critical needs aren't addressed. What I would 
like to clarify with respect to the Zero Tolerance bill is this 
is actually what homeless service providers envision as the 
solution to helping the chronically homeless get access to 
supportive housing plus the services that will allow them to 
keep that housing.
    If you look at a scale of 60,000 of those veterans in a 
service provider network which has the capacity to help 
approximately 100,000 veterans a year, then you could see where 
60,000 of them over the next 5 years getting into permanent 
housing would free up considerable capacity in the 
infrastructure that helps those veterans who need transitional 
assistance. We believe that is the solution. And then if you 
have community-based prevention strategies--which the Zero 
Tolerance begins to address and fund--that should, hopefully, 
provide a low-level support of assistance which will prevent 
most veterans from ever going down that downward spiral toward 
homelessness.
    [The response for the record follows:]
Response to Request Arising During the Hearing by Hon. Daniel K. Akaka 
to John A. Driscoll, President and CEO, National Coalition for Homeless 
                                Veterans
    Question 3. Mr. Driscoll. From your organization's perspective, 
what still needs to be addressed in the area of homeless veterans that 
is not in either of these bills today?
    Response. Mr. Chairman, Ranking Member Senator Burr, as I said 
during my testimony when you first asked that question, ``I would 
hesitate to say that the most critical needs aren't addressed.'' The 
proposed build-out of the HUD-VASH program to a level of 60,000 
vouchers by FY 2014 would effectively mean the end of chronic 
homelessness among veterans in this Nation. We believe that act alone 
would seal for the U.S. Senate in the 111th Congress, and your 
leadership, a special place of honor in American history.
    We would also submit that the HUD-VASH program is, oftentimes, the 
only assistance available to extreme low-income veteran families who 
would be homeless without access to this program. It is absolutely 
critical that the full HUD-VASH build-out prescribed in S. 1547 occurs.
    The only thing in the Zero Tolerance for Veteran Homelessness Act 
[S. 1547] that we would change is the process outlined for revising the 
payment policy by which community-based service providers are paid for 
the support they provide to homeless veterans through the Grant and Per 
Diem Program (GPD).
    Under current law, service providers are paid a flat ``per diem'' 
rate for each veteran enrolled in their programs, based on the 
prevailing rate paid to state veteran homes (or domiciliary 
facilities). VA officials have testified before both the Senate and the 
House of Representatives [H.R. 2735] they agree, in principal, that the 
reimbursement policy needs to be changed to cover the annual cost of 
services community-based organizations provide to help homeless 
veterans rebuild their lives rather than a flat rate based on custodial 
care models.
    H.R. 2735 authorizes this change in law immediately. S. 1547 would 
conditionally support the objective, but gives the VA Secretary a year 
to study the issue and report his recommendations to the Congress, 
which could delay action on this critical need for another two to three 
years.
    We respectfully submit this issue has been studied and discussed 
for more than three years; the community-based service providers NCHV 
represents and many of our Veteran Service Organization partners 
support and have testified in favor of this initiative; and VA 
officials have also testified in support of the intent of S. 1547. We 
urge this distinguished committee to adopt the language in H.R. 2735 on 
this issue, and authorize a change in the law. Then, once the Secretary 
and VA have developed a revised repayment policy, in accordance with 
the law, they will be able to implement it without delay.
    The only other great hope we have is that the Senate will rise up 
in unity to support the Homes for Heroes Act of 2009. This measure 
[S. 1160] was first introduced by then-Senator Barack Obama in the 
110th Congress, and has been overwhelmingly approved in the House of 
Representatives [H.R. 403 was approved 417-2].
    This bill would provide critical funding for the development of 
supportive housing and affordable housing units for homeless and 
extreme low-income veterans in communities where there is a critical 
shortage of housing options for these deserving men and women. The lack 
of this type of housing is a chronic problem in many American 
communities, and has been for many years. We believe the build-out of 
the HUD-VASH program, as well as the prevention initiatives envisioned 
in the Zero Tolerance for Veteran Homelessness Act depend, to a large 
degree, on final approval of the Homes For Heroes Act of 2009.
    We recognize the Act will not provide all of the development 
capital that will ultimately be needed to reach the goals of S. 1547, 
but it would provide an immediate infusion of public funds that would 
likely attract private investment dollars, create jobs, and most 
importantly, address a critical service and prevention need in many 
communities--safe, affordable housing for disabled and extreme low-
income veterans.
    In closing, I will once again express my gratitude for the 
opportunity to speak before the U.S. Senate Committee on Veterans 
Affairs on behalf of our former guardians who might otherwise have no 
voice. I was moved by Senator Burr's opening statement in the October 
21 hearing; and honored that you, Mr. Chairman, would seek our counsel.
    Many of us are veterans, and many have devoted our lives to this 
work. We would be proud to stand with you as this campaign moves 
forward.

    Chairman Akaka. Well, I want to thank you all very much; 
and for some of the questions some of you are willing to 
provide additional information on, we look forward to 
receiving. I just want to reemphasize that we are holding these 
hearings to discuss a wide range of needs that we feel our 
veterans have and we want to work on them together, and 
continue to bring sufficient services to help them.
    So, I want to thank all of our witnesses for appearing 
today. As Chairman, I am committed to ensuring that this 
Committee does all that it can to ensure that veterans and 
their families receive the benefits and services they have 
earned. I pledge my continued support for this goal as we move 
forward together. And I look forward to working with all 
Members of this Committee as we develop legislation based on 
today's hearing for a markup later this year. We will also be 
pressing forward with the critical legislation being held by 
one member of the Senate, but we hope to get that out.
    Again, I want to say thank you for your support in what we 
are doing.
    This hearing is now adjourned.
    [Whereupon, at 11:46 a.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


 Prepared Statement of Hon. Bernard Sanders, U.S. Senator from Vermont
    Thank you Mr. Chairman for holding this very important hearing. I 
want to welcome the witnesses here from the various veterans service 
organizations, the VA, and the various associations.
    I want to thank Chairman Akaka and his staff for continuing to work 
with my office as you move the larger omnibus veterans bills through 
the Senate. One of those bills, S. 728, contains two provisions I 
introduced to double the assistance provided to disabled veterans to 
purchase and adapt automobiles to accommodate their disabilities and a 
provision increasing the plot allowances from $300 to $745 with an 
index to the Consumer Price Index so that the level stays current over 
the years. I look forward to working with the Chairman to send this 
bill, and the others that we have completed, to the President for his 
signature as soon as possible, after completing conference with the 
House.
    Today I want to touch on two pieces of legislation that I have 
introduced. A third piece of legislation that I introduced a few weeks 
ago, S. 1752, to add Parkinson's disease to the list of diseases 
presumed to have been incurred in or aggravated by service in Vietnam 
due to Agent Orange exposure is no longer necessary and that's good 
news. As many of my colleagues may know, last week Secretary Shinseki 
announced that after years of pressure from Veterans groups the VA has 
decided to accept the connection between Agent Orange exposure and 
Parkinson's disease, B cell leukemias, and ischemic heart disease. As 
VA noted in their announcement of the policy change, Agent Orange was 
``[u]sed in Vietnam to defoliate trees and remove concealment for the 
enemy'' and ``left a legacy of suffering and disability that continues 
to the present. Between January 1965 and April 1970, an estimated 2.6 
million military personnel who served in Vietnam were potentially 
exposed to sprayed Agent Orange.''
    This policy change means that those veterans who have a presumed 
illness and served in Vietnam do not need to prove an association 
between their illness and their military service. I want to 
congratulate Secretary Shinseki for making this decision which will 
greatly simplify the application process for veterans and bring them 
the care they need and deserve. I also want to commend all of the 
veterans groups that pushed for this change, particularly the Vietnam 
Veterans of America, for their years of work on this issue.
    Let me briefly discuss two other pieces of legislation that I have 
introduced. They are S. 1753, the Disabled Veteran Caregiver Housing 
Assistance Act of 2009 and S. 1798, the Automatic Reserve Component 
Enrollment Act of 2009.
    S. 1753 would increase the amount of money a disabled veteran can 
receive to make physical improvements to accommodate their disabilities 
at their parent's home if they are living with them. This change to the 
law is supported by and recommended in the Independent Budget and I 
appreciate the support for this legislation by the American Legion and 
the VFW in their prepared testimony today. Last Congress I introduced 
legislation which, with the help of Chairman Akaka, we passed and was 
signed into law to help increase the amount of money a disabled veteran 
can receive to make repairs to his or her own home. But as we all know, 
when many of our younger veterans get injured and come home they live 
with their parents because they provide an incredibly supportive 
environment for a veteran to recover. The legislation I have introduced 
this Congress raises the assistance level from the current amount of 
$14,000 to $28,000 for veterans with severe service-connected 
disabilities. For veterans with service-connected blindness only or 
with loss or loss of use of both upper extremities, this legislation 
increases the payment from $2,000 to $5,000. Importantly, this 
legislation includes a cost-of-construction index so that this benefit 
will remain relevant in the years to come.
    The need for this piece of legislation came to my attention when a 
brave Vermonter, Private First Class Andrew Parker, was injured in a 
road side bomb attack in Afghanistan and was paralyzed from the chest 
down. Andrew returned home to Hyde Park, Vermont, to live with his 
parents but their home needed to be renovated to accommodate his 
disabilities. In this case, the wonderful Vermont community where 
Andrew lives, and really the entire state, pitched in to pay for the 
changes to the home as well as raising $100,000 to help Andrew 
generally. I commend these efforts but clearly, our government needs to 
take more responsibility to help pay for these repairs. Not every 
community will be or can be as generous as this community in Vermont. 
Current law provides $14,000 and that is just not enough. My 
legislation would increase the benefit to a reasonable level so that 
future veterans like Andrew Parker can come home and get the resources 
they need to make changes to their parent's home.
    The second bill I want to discuss is S. 1798, the Automatic Reserve 
Component Enrollment Act of 2009. I am proud that this legislation has 
the support of the 
National Guard Association of the United States and the Paralyzed 
Veterans of America.
    This legislation would require members of the National Guard and 
Reserve to be automatically enrolled into VA health and dental care 
programs at discharge or separation from active duty.
    As we all know, many members of the Guard and Reserve currently do 
not enroll in the VA health and dental care programs at demobilization 
because they are eager to get done with the paper work and see their 
families. By not signing up at this time, veterans sometimes miss 
certain windows of enrollment in VA programs such as the 180 day window 
after separation to sign up for dental care. Later, they go to sign up 
but may no longer be eligible or can't find the needed military 
records. This legislation would make the enrollment automatic at 
discharge but would not force the servicemember to use the VA and all 
the existing VA eligibility criteria would be remain unchanged.
    The VA is currently doing a version of enrollment assistance for 
Guard and Reserve in many places across the country, including Vermont, 
but it is not a consistent process from state to state. This bill would 
require Veterans Benefit Administration and Veterans Health 
Administration staff to assist with the automatic enrollment, require 
the Secretary of Defense to provide resources and space at the 
demobilization sites to make this happen, and have a reporting 
mechanism to Congress so that we make sure that, if needed, VA receives 
additional resources to compensate for any increased patient load given 
the automatic enrollment.
    As many of my colleagues may know, Secretary Shinseki is working on 
a larger concept that might include some form of this idea that he 
refers to as ``uniform registration.'' I support and commend those 
efforts. I believe this bill is a good beginning point for the VA to 
start to streamline enrollment during the move from the DOD to VA which 
is one part of the larger seamless transition efforts.
    I hope these two pieces of legislation will have the support of all 
of my colleagues and I look forward to working with you, Mr. Chairman, 
to move them forward.

    Thank you Mr. Chairman.
                                 ______
                                 
    Prepared Statement of Joy J. Ilem, Deputy National Legislative 
                  Director, Disabled American Veterans
    Mr. Chairman, Ranking Member Burr and other Members of the 
Committee: Thank you for inviting the Disabled American Veterans (DAV) 
to submit testimony at this legislative 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.
    We are providing testimony today on twelve bills that are concerned 
with health care, benefits and other services important to sick and 
disabled veterans who use the programs of the Department of Veterans 
Affairs (VA). This statement submitted for the record relates our 
positions on selected bills before you today, and we offer them for 
your consideration.
              s. 977--prisoner of war benefits act of 2009
    This bill would amend Federal veterans' benefits provisions for 
prisoners of war (POWs) by repealing the required 30-day minimum period 
of internment prior to the presumption of service connection for 
certain diseases for purposes of payment of a veteran's disability 
compensation. The bill also adds type 2 diabetes to the list of 
diseases and sets new rules for the Secretary in making these 
presumptions. It also requires the VA to consult with the POW advisory 
committee, where the Secretary must make a decision within 60 days 
after a recommendation from said committee related to presumptions 
being established for non-listed diseases. The measure specifies that 
if the Secretary removes a disease made presumptive by this bill, that 
any veteran or survivor who was previously granted either compensation 
or dependency indemnity compensation (DIC) associated with the 
presumption will maintain their compensation or DIC payments.
    DAV has long held, as referenced in Resolution 009, that former 
POWs suffered cruel and inhumane treatment, together with nutritional 
deprivation at the hands of their captors, which resulted in long-term 
adverse physical and/or psychological health effects. It is on the 
basis of their unique circumstance and sacrifices that DAV supports 
legislation that would add those medical conditions that are 
characteristically associated with or can be reasonably attributed to 
the POW experience as presumptive disorders for former POWs.
    While we support enactment of this bill, we would also respectfully 
request the Committee consider amending this legislation to also 
provide for the expanded eligibility for DIC to surviving spouses of 
certain former POWs, who died prior to September 30, 1999, and who were 
rated totally disabled at the time of death for a service-connected 
disability for a period of not less than one year.
 s. 1118--a bill to amend title 38, united states code, to provide for 
     an increase in the amount of monthly dependency and indemnity 
compensation payable to surviving spouses by the secretary of veterans 
                    affairs, and for other purposes.
    This bill would increase the monthly rates of veterans DIC which is 
payable to surviving spouses through the VA. It provides a phase-in of 
DIC payments in the case of veterans who die of a nonservice-connected 
disability, after being eligible for at least five years for VA 
compensation for a service-connected disability rated as total. This 
bill also reduces the age from 57 to 55 after which the remarriage of a 
surviving spouse shall not terminate DIC payments.
    At present, title 38, United States Code, Section 1318 (b)(1) 
provides DIC benefits for survivors of certain veterans rated totally 
disabled for ten or more years. DAV views this timeframe as creating 
undue financial hardship on surviving spouses who have devoted 
themselves to the care required by totally disabled veterans instead of 
a career outside the home. It is inherently unfair that surviving 
spouses should have this additional burden placed on them for 10 years 
or more before he or she can qualify for DIC when the veteran dies. In 
accordance with DAV Resolution No. 016, we support this legislation to 
reduce the ten-year rule for DIC qualification to a more reasonable 
period of time.
s. 1155--a bill to amend title 38, united states code, to establish the 
position of director of physician assistant services within the office 
         of the under secretary of veterans affairs for health.
    This bill would establish within the Veterans Health Administration 
(VHA) the full time position of Director of Physician Assistant 
Services at VA Central Office. This person must be a qualified 
physician assistant (PA) and shall be responsible to report directly to 
the VHA's Under Secretary of Health on all matters relating to the 
education and training, employment, appropriate utilization, and 
optimal participation of physician assistants within VHA programs and 
initiatives.
    The VA is the largest Federal employer of PAs, with approximately 
1,800 full-time PA positions. In the VA health care system, PAs are 
essential primary care providers working in ambulatory care clinics, 
emergency medicine and 22 other VA medical and surgical subspecialties. 
When the position of PA advisor was created in 2000, as authorized by 
the Veterans Benefits and Health Care Improvement Act of 2000, the 
position consisted of collateral administrative duties added to a 
field-based PA advisor's direct patient care responsibilities. In April 
2008, the PA Advisor function was finally converted to a full-time 
position, but the incumbent continues to be field-based at a VA health 
care facility, rather than located at the VA Central Office.
    DAV and the other veterans service organizations that coordinate 
the Independent Budget (IB) have urged that this position be made full-
time within VHA headquarters. This transition would allow for: an 
increase in scope of PA-specific clinical and human resources policy 
issues; the opportunity to participate in major VA strategic health 
care planning committees and functions; and inclusion in aspects of 
planning on seamless transition, polytrauma centers, Traumatic Brain 
Injury staffing and the work of the newly established Office of Rural 
Health.
    Additionally, PAs could assist in emergency disaster planning since 
34 percent of all VA-employed PAs are veterans or currently serve in 
the military reserves. In addition to supporting this bill, we urge 
that this occupation be included in any recruitment and retention 
legislation the Committee reports. By 2012, it is projected that 28 
percent of the VA PA workforce will be eligible for retirement. In our 
opinion, passage of this bill to require the PA Advisor to be located 
in VA Central Office on a full-time basis, would be a good start in 
addressing some of these human resources challenges.
    Although we do not have a specific resolution in support of this 
measure, the bill is consistent with recommendations outlined in the 
fiscal year (FY) 2010 IB and would help to ensure access to high 
quality health care services for veterans using the VA health care 
system. Therefore, DAV supports this bill and urges its 
enactment.
    s. 1204--chiropractic care available to all veterans act of 2009
    This bill seeks to amend the VA Health Care Programs Enhancement 
Act of 2001 to require a program under which the Secretary provides 
chiropractic care and services to veterans through VA medical centers 
and clinics to be carried out at no fewer than 75 medical centers by 
December 31, 2009, and all VA medical centers by December 31, 2011.
    VA was authorized to offer chiropractic care and services under the 
provisions of section 204 of Public Law 107-135, the Department of 
Veterans Affairs Health Care Programs Enhancement Act of 2001. We 
believe chiropractic care offers a valuable health care option to 
veterans and many support the system-wide availability of chiropractic 
services within the VA health care system.
    While we have no adopted resolution from our membership calling for 
broader availability of chiropractic care in the VA health care system, 
we would not object to the enactment of this bill.
      s. 1237--homeless women veterans and homeless veterans with 
                          children act of 2009
    This bill would expand the grant program for homeless veterans with 
special needs to include male homeless veterans with minor dependents 
and to establish a grant program for reintegration of homeless women 
veterans and homeless veterans with children. This measure would also 
require grants to be used to provide job training, counseling, job 
placement services, literacy and skills training, and child care 
services to expedite reintegration of these veterans into the work 
force. The Secretary would be required to monitor the expenditure of 
funds under the grant program and carry out the program through the 
Assistant Secretary of Labor for Veterans' Employment and Training, and 
include data or the results or outcomes of the services provided to 
each homeless veteran. This measure authorizes $10 million to be 
appropriated for each of the FYs 2010-2014.
    We are pleased to support this bill (S. 1237) and that there is 
specific emphasis on the needs of homeless women veterans and homeless 
veterans with children. We have greater numbers of women veterans 
coming to VA with post-deployment mental health issues due to combat 
exposure, which puts them at higher risk for becoming homeless. 
Likewise, many homeless veterans with minor children have been unable 
to avail themselves of VA's excellent programs because they have had no 
support for their children. It is clear this measure will provide more 
comprehensive services, to include child care services to this 
vulnerable population.
 s. 1310--a bill to authorize major medical facility projects for the 
  department of veterans affairs for fiscal year 2010, and for other 
                               purposes.
    This bill would authorize three major medical facility projects (in 
Livermore, Walla Walla and Louisville) and 15 capital leases (in 
Alabama, California, Florida, Georgia, Kansas, North Carolina, 
Pennsylvania, South Carolina and Texas). It would authorize 
appropriations of almost $1.2 billion for FY 2010 to carry out these 
projects. The bill would renew in FY 2010 previous Congressional 
authorization for construction of VA major medical projects in Denver 
and Bay Pines, with authorized appropriations to carry out these 
purposes.
    DAV resolution no. 237 supports the enhancement of medical services 
through modernization of VA health care infrastructure. This resolution 
urges VA to request adequate funding and Congress to provide such 
funding to address the Department's internally identified needs based 
on the conclusions of the Capital Asset Realignment for Enhanced 
Services (CARES) initiative. Equally important, our members believe 
Congress should carefully monitor any intended changes in VA 
infrastructure that could jeopardize VA's ability to meet veterans' 
needs for specialized VA medical care and rehabilitative services, or 
be the cause of diminution of VA's established graduate medical and 
other health professions education and biomedical research programs, 
consequential to deployment of any new facilities model of health care 
delivery.
    Similarly, the IB for FY 2010 included a recommendation regarding 
infrastructure and urged Congress to ensure adequate funding for VA's 
capital budget so that VA may properly invest in its physical assets to 
protect their value and to ensure that it can continue to provide 
health care in safe and functional facilities long into the future. 
Accordingly, we are concerned with some of the health care leasing 
projects identified in this bill as ``Health Care Centers.'' This new 
infrastructure concept is one about which we have written in the IB and 
expressed caution. In some cases, these Health Care Centers may be 
appropriate and beneficial. However, we believe there is the potential 
for unintended consequences through altering VA's future infrastructure 
and the possibility of disrupting its academic and research missions. 
Some of these leased health care centers are going to be activated 
where VA today operates major government-owned medical facilities, 
including the Loma Linda and Montgomery projects.
    Therefore, prior to Congressional authorization of these particular 
requested projects for leased Health Care Centers, we ask the Committee 
to use due diligence to reassure the veterans community that these new 
facilities will not become the cause of the diminution of VA's other 
critical missions in training health manpower and conducting important 
biomedical research.
    VA's intention to begin moving away from permanent government 
ownership of its health care facilities into a new phase in which VA 
could be a temporary leaseholder in privately owned buildings raises 
many questions about VA's future infrastructure and the implications on 
its missions other than health care delivery. We do not believe that VA 
has adequately evaluated how those other key missions would be affected 
by this new direction in infrastructure. A former VA Secretary reported 
to the Committee that, in respect to the Health Care Center leasing 
concept, no existing VA health facilities would be closed and no VA 
employees would lose their jobs. Before the Committee reports this 
legislation, we ask that you validate those assurances with the 
proponents of this bill, and to reassure the veterans community that 
VA's academic and scientific missions will be sustainable within these 
new arrangements.
           s. 1427--department of veterans affairs hospital 
                    quality report card act of 2009
    This bill would establish and implement a Hospital Quality Report 
Card Initiative to report on health care quality in VA medical centers. 
The purpose of the bill is to ensure that information on the quality 
and performance of VA hospitals is readily available and accessible to 
veteran patients and in identifying opportunities for quality 
improvement and cost containment. This measure would require the 
Secretary to make reports of the quality of each VA medical center 
available to the public and submit them to the House and Senate 
Veterans' Committees at least semiannually.
    The established ``hospital report card'' would cover a variety of 
activities of hospital care occurring in the medical centers of the 
Department, including effectiveness; safety; timeliness; efficiency; 
patient satisfaction; satisfaction of VA health professionals; equity 
of care provided to various patient populations including--female, 
disabled, geriatric, rural, homeless, mentally ill, and racial and 
ethnic populations. Additionally, VA would be required to provide 
information on staffing levels of health professionals; rates of 
certain types of infections; hospital sanctions and violations; and the 
availability of emergency rooms, intensive care units, and specialty 
services. We believe validation of the delivery of high quality care to 
service-disabled veterans is important and concur that veterans under 
VA care have the same rights as private sector patients to access and 
review the quality and safety data related to the care they receive 
while hospitalized. Therefore, we support this bill.
    We do note, however, that the purposes of this bill do not cover 
the majority of overall patient care workload in VA health care, namely 
primary (outpatient) care and extended care services provided in VA's 
nursing home care units and its various contracted programs.
       s. 1429--servicemembers mental health care commission act
    This bill would establish a 12-member Commission on veterans and 
members of the Armed Forces with Post Traumatic Stress Disorder (PTSD), 
Traumatic Brain Injury (TBI), or other mental health disorders, to 
enhance the capacity of mental health care providers to assist such 
veterans and members, to ensure such veterans are not discriminated 
against, and for other purposes.
    The Commission would monitor and oversee the treatment of active 
duty members and veterans for mental health problems caused by military 
service, and would be required to conduct a thorough study of long-term 
adverse consequences of mental illnesses caused by military service. It 
would set rules for appointment for Commission members with 
specifications, and would empower the Commission to review programs, 
obtain reports, travel and secure necessary information to function, 
and would require the Commission to submit reports to the VA the 
Department of Defense (DOD) and Congress. Also, the bill would 
authorize appropriations of $1 million in FY 2010 to support the work 
of the Commission. The Commission would be rescinded when the two 
Secretaries concerned agreed to do so. We note that the bill would not 
authorize appointment of any staff to carry out the Commission's 
purposes.
    While we appreciate the intended purposes of this new Commission, 
we ask the Committee to consider altering the scope of the bill to 
better account for the current situation in VA mental health services, 
and to consider our recommendations for an enhanced means of achieving 
better oversight and accountability in that program. We defer 
commentary on whether the Commission envisioned in this bill should 
also be responsible for monitoring mental health within DOD.
    We recognize the unprecedented efforts made by VA over the past 
several years to improve the consistency, timeliness, and effectiveness 
of mental health care programs for disabled veterans. We are especially 
pleased that VA has committed through its national Mental Health 
Strategic Plan (MHSP) to reform VA mental health programs, moving from 
the traditional treatment of symptoms to embrace recovery potential in 
every veteran under VA care.
    We also appreciate the will of Congress in continuing to insist 
that VA dedicate sufficient resources in pursuit of comprehensive 
mental health services to meet the needs of veterans. One key part of 
improving mental health services and increasing access to those 
specialized services is through sufficient staffing levels. In that 
regard, DAV supports the intent of this measure, but we remain 
concerned that the intended goal of the bill will be unfulfilled unless 
Congress also requires VA to adopt and enforce mechanisms to assure its 
policies at the top are reflected as results in the field. As written, 
we are concerned that the bill may not surface the kind of information 
Congress needs to conduct proper oversight of VA's results and status 
in achieving mental health reforms.
    The development of the MHSP and the new Uniformed Mental Health 
Services (UMHS) policy (detailed in VHA Handbook 1160.01, dated 
September 11, 2008) provide an impressive and ambitious roadmap for 
VHA's transformation of its mental health services. However, we have 
expressed continued concern about oversight of the implementation phase 
of these initiatives. The VA MHSP was developed before the impact of 
Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) was evident, 
and we believe a pressing need is emerging for Congress to ramp up the 
monitoring of VA's strategies, policies, and operating plans being 
implemented to deliver on the promise of the current strategic plan. We 
believe VHA must also conduct accurate annual needs and gap assessments 
to take into account the changing needs of the veteran population, 
including the newest generation of combat veterans.
    In response to the 2003 New Freedom Commission's call for action, 
VA developed a national strategic plan for mental health services which 
was finalized in November 2004. In showing sensitivity to VA's 
commitment to reform, Congress allocated new funds to enhance mental 
health services and required VA to spend these funds in pursuit of that 
reform. Despite these efforts, in May 2007 the VA Inspector General 
again criticized the consistency and adequacy of mental health services 
throughout the system.
    To address these concerns VA has been provided with targeted mental 
health funds in more recent years' appropriations to augment mental 
health staffing across the system. This funding was intended to address 
widely-recognized gaps in the access and availability of mental health 
and substance-use disorder services that existed prior to the 
development of the MHSP, to address the unique and increased needs of 
veterans who served in OIF/OEF and to create a comprehensive mental 
health and substance-use disorders system of care within VHA that is 
focused on recovery--a hallmark goal of the New Freedom Commission. In 
addition, VHA developed its UMHS policy so that veterans nationwide can 
be assured of having access to the full range of high quality mental 
health and substance-use disorder services in all VA facilities and at 
the time that they are most needed. Timely, early intervention services 
can improve veterans' quality of life, prevent chronic illness, promote 
recovery, and minimize the long-term disabling effects of undetected 
and untreated mental health problems. These funds have been dispersed 
as part of special initiatives, with a clear mandate that they would be 
used to augment current mental health staffing, not merely replace 
older positions as they become vacant.
    While the specialized mental health augmentation funding has 
significantly improved mental health services across VHA, a recent gap 
analysis conducted by VHA, resulting in the UMHS plan, underscores how 
much still needs to be done to assure equity of access for all 
veterans. Furthermore we understand that this analysis (one that VA has 
not released to the Congress or the veterans service organization 
community) does not fully take into account many important factors such 
as the cost and effort required to provide newer evidence-based 
treatments for priority conditions such as PTSD.
    We believe the solution to this pressing problem would need two 
major components: an attentive oversight process, and an empowered 
organizational structure to inform that oversight responsibility.
    The oversight process we envision in mental health would be a 
constructive one that is helpful to VA facilities, rather than 
punitive. It should be data-driven and transparent, and should include 
local evaluations and site visits to factor in local circumstances and 
needs. Such a process could assure that ongoing progress is made in 
achieving the goal of the VA MHSP and UMHS package to provide easily 
accessible and comprehensive mental health services equitably across 
the Nation.
    Mr. Chairman, the second component necessary to make the first one 
meaningful would be putting in place an empowered VA organizational 
structure to assure that this oversight process is robust, timely and 
utilizes the best clinical and research knowledge available. Such a 
structure would require VHA to collect and report detailed data, at the 
national, network and medical center levels, on the net increase over 
time in the actual capacity to provide comprehensive, evidence-based 
mental health services. Using data available in current VA data 
systems, such as VA's payroll and accounting systems, supplemented by 
local, audited reports where necessary, could provide information down 
to the medical center level on at least the following for the period FY 
2004 to the present fiscal year:

     The number of full-time and part-time equivalents of 
psychiatrists and psychologists;
     The number of mental health nursing staff;
     The number of social workers assigned to mental health 
programs;
     The number of other direct care mental health staff (e.g. 
counselors, outreach workers);
     The number of administrative and support staff assigned to 
mental health programs;
     As a basis for comparison, the total number of direct care 
and administrative full-time employee equivalents (FTEE) for all 
programs, mental health and others; and
     The number of unfilled vacancies for mental health 
positions that have been approved, and the average length of time 
vacancies remain unfilled.

    In addition, we believe VA should be required to establish a web-
based clinical inventory instrument to gather information from the 
field about existing mental health programs (i.e., PTSD, substance-use 
disorder, etc.) in each VA facility including hours of operation, case 
loads and panel sizes, staffing levels and current capacity to provide 
evidence-based treatments as specified in published VA/DOD Evidence-
Based Practice Guidelines.
    VA should also develop an accurate demand model for mental health 
and substance-use disorder services, including veteran users with 
chronic mental health conditions and projections for the needs of OIF/
OEF veterans. This model development should be created parallel to the 
VA mental health strategic planning process. This model should include 
estimated staffing standards and optimal panel sizes for VA to provide 
timely access to services while maintaining sufficient appointment time 
allotment.
    Assuming the creation of these resource tools, Congress should also 
require VA to establish an independent body such as suggested in this 
legislation, or, more preferable, a ``VA Committee on Veterans with 
Psychological and Mental Health Needs,'' with appropriate resources, to 
analyze these data and information, supplement its data with periodic 
site visits to medical centers, and empower the Committee to make 
independent recommendations to the Secretary of Veterans Affairs and 
the Congress on actions necessary to bridge gaps in mental health 
services, or to further improve those services.
    Membership of the Committee should be made up from VA mental health 
practitioners, veteran users of the services and their advocates, 
including veterans service organizations and other organizations 
concerned about veterans and VA mental health programs. The site visit 
teams should include mental health experts drawn from both within and 
outside of VA. These experts should consult with local VA officials and 
seek consensual, practical recommendations for improving mental health 
care at each site. This independent body should synthesize the data 
from each of the sites visited and make recommendations on policy, 
resources and process changes necessary to meet the goals of the MHSP.
    In addition to these changes, VA should be directed to conduct 
specialized studies, under the auspices of its Health Services Research 
and Development Program and/or by the specialized mental health centers 
such as the Mental Illness Education, Research and Clinical Centers 
(MIRECCs) in several sites, the Seriously Mentally Ill Treatment, 
Research Education and Clinical Center (SMITREC) in Ann Arbor; and the 
Northeast Program Evaluation Center in West Haven, among others, on 
equity of access across the system; barriers to comprehensive substance 
use disorders rehabilitation and treatment; early intervention services 
for harmful/hazardous substance use; couples and family counseling; and 
programs to overcome stigma that inhibits veterans, particularly newer 
veterans, from seeking timely care for psychological and mental health 
concerns. As an additional validation, we believe that the Government 
Accountability Office (GAO) should be directed to conduct a follow-on 
study of VA's mental health programs to assess the progress of the 
MHSP, the UMHS, and to provide its independent estimate of the FTEE 
necessary for VA to carry out the above-noted initiatives.
    Congress should also require GAO to conduct a separate study on the 
need for modifications to the current VERA system to incentivize its 
fully meeting the mental health needs of all enrolled veterans.
    While DAV supports the basic intent behind S. 1429, we ask the 
Committee to consider a broader scope of oversight of VA's mental 
health program than envisioned by the bill. We believe the ideas 
expressed above--ideas that we have gleaned from a number of mental 
health and research professionals in and out of VA, and from the 
literature, are necessary to fully ensure VA is moving its mental 
health policy and program infrastructure in a proper direction. Also, 
we urge the Committee, which would be the major recipient of this new 
approach to reporting true VA mental health capacity, to continue its 
strong oversight to assure VA's mental health programs and the reforms 
it is attempting meet all their promise, not only for those coming back 
from war now, but for those already here.
                        s. 1444--combat ptsd act
    This bill seeks to clarify the meaning of ``combat with the enemy'' 
for purposes of service connection of disabilities by adding that the 
term includes service on active duty in a ``theater of combat 
operations during a period of war, or in combat against a hostile force 
during a period of hostilities.''
    The definition of what constitutes combat with the enemy is 
critical to all veterans injured in a combat theatre of operations, 
whether the issue is service connection of PTSD or other conditions 
resulting from combat. The current high standards required by the VA 
internal operating procedures for verifying veterans who ``engaged in 
combat with the enemy'' are impossible for many veterans to satisfy, 
whether from current or past wars. There are many reasons for this and 
possible scenarios include: unrecorded traumatic events taking place on 
the battlefield as operations expand and contract; unrecorded temporary 
detachments of servicemembers from one unit to another while in a 
combat theater of operations; field treatment for injuries that become 
problematic later but not in the circumstances and conditions of combat 
when servicemembers are compelled to return to duty by commitment to 
fellow servicemembers and country-and-poor recordkeeping.
    A practical example of the problems associated with the current 
burden of proof required to determine who ``engaged in combat with the 
enemy'' can be found with the U.S. Marine Corps' Lioness Program in 
Iraq. Despite a DOD policy banning women from direct ground combat, 
Marine commanders have been using women as an essential part of their 
ground operations in Iraq since 2003. These soldiers who accompany male 
troops on patrols to conduct house-to-house searches are known as Team 
Lioness, and have proved to be invaluable. Their presence not only 
helps calm women and children, but Team Lioness troops are also able to 
conduct searches of women and children without violating cultural 
strictures. Against official policy, and at that time without the 
training given to their male counterparts, and with a firm commitment 
to serve as needed, these dedicated young women have often been drawn 
onto the front lines in some of the most violent counterinsurgency 
battles in Iraq.
    The Combat Action Badge (CAB) was approved, according to the US 
Army's Web site (www.army.mil/symbols/combatbadges) on May 2, 2005, by 
the U.S. Army Chief of Staff to provide special recognition to soldiers 
who personally engage, or are engaged by the enemy. The CAB may be 
awarded by a commander regardless of the branch of Service or MOS. 
Assignment to a Combat Arms unit or a unit organized to conduct close 
or offensive combat operations, or performing offensive combat 
operations is not required to qualify for the CAB. However, it is not 
intended to award all soldiers who serve in a combat zone or imminent 
danger area. It may be awarded to any soldier performing assigned 
duties in an area where hostile fire pay or imminent danger pay is 
authorized. The soldier must be personally present and actively 
engaging or being engaged by the enemy, and performing satisfactorily 
in accordance with the prescribed rules of engagement. Some Lioness 
veterans were awarded the CAB, but others were not.
    The VA's current internal instruction (M21 Manual) requires proof 
by official military records that can be viewed as exceeding the law 
since the law does not require this level of documentation. To provide 
better assistance to veterans of military conflicts, VA should rely on 
the proper application of current legislation.
    As the Committee considers this bill, we ask that you designate the 
``theatre of operations'' as the combat zone. Using Iraq as an example, 
that country would be so designated as a combat zone and personnel 
assigned there, or who transit through Iraq as part of their duties, 
are considered to have engaged in combat for VA benefits purposes. 
Logistical staging and resupply points such as those found in Kuwait 
and Qatar have not been the scene of combat operations and thus 
personnel assigned to these areas would not be considered to have 
engaged in combat for benefits purposes. With such a designation, 
veterans must still provide satisfactory lay evidence consistent with 
their service.
    The last area of our testimony deals with the title of the bill 
itself. The current title ``Combat PTSD Act'' does focus on this 
important condition, yet the legislative language addresses the 
relationship between combat with the enemy and service-connected 
disabilities of all types. We ask for the Committee's consideration to 
rename this legislation to reflect its full intent of clarifying the 
very definition of combat with the enemy. We are pleased to support 
this measure, in accordance with DAV Resolution No. 013, which calls 
for the presumption of exposure to stressors for veterans who served in 
a war zone and who suffer from PTSD. This measure moves to clarify this 
important issue.
     s. 1547--zero tolerance for veterans homelessness act of 2009
    S. 1547 seeks to amend title 38, United States Code, and the United 
States Housing Act of 1937 to enhance and expand the assistance 
provided by the VA and the Department of Housing and Urban Development 
(HUD) to homeless veterans and veterans at risk of homelessness. 
Enactment of this bill would create a five-year, $50 million per year 
``homelessness prevention'' program and VA would directly carry out the 
prevention functions through their homeless veteran program 
coordinators by paying rent and mortgages, resolving credit problems, 
paying relocation costs, job assistance, and referrals to other 
agencies.
    The bill would expand the purposes of the comprehensive service 
program for homeless veterans by prohibiting the VA from denying 
participation by organizations that receive money from other sources 
than VA if the entity demonstrates a private nonprofit organization 
will provide oversight and site control of the project. Also, it would 
require a study of the existing per diem program to determine if there 
is a better way for VA to support non-governmental organizations 
providing homeless assistance to veterans. Funding would be increased 
from the existing $150 million annually, to $200 million in FY 2010, 
and ``such sums as may be necessary'' for 2011-2014.
    If enacted, the HUD-VASH (Veterans Affairs Supportive Housing 
Vouchers) program would increase the number of housing vouchers in 
annual increments of 10,000, up to 60,000 through the year 2013, and 
for the years thereafter. In regard to the HUD-VASH program, the bill 
would specify requirements on public housing agencies and for VA case 
management to ensure veterans in receipt of these vouchers also receive 
proper care and follow up, as well as supportive services.
    The position of Special Assistant for Veterans Services at HUD 
would be established, with specific qualifications outlined for 
appointment and the duties of the position. It would create a homeless 
veterans management information system for collection of data on 
veterans using homeless assistance programs of the VA and HUD, with 
required reporting. Finally, the bill would require VA to submit a 
comprehensive plan to end homelessness among veterans to Congress 
within one year of enactment, including details on rural homeless 
veterans.
    VA Secretary Shinseki has publicly stated that eliminating 
homelessness among veterans in the next five years is one of the 
Department's highest priorities and we concur that this is a worthy 
goal. We support this measure S. 1547, in accordance with DAV 
Resolution No. 249, which was reaffirmed at our most recent National 
Convention in Denver, Colorado. This resolution calls on Congress to 
provide sufficient funding for VA mental health, substance-use 
disorder, vision and dental care services, and effective outreach so 
that VA might better meet the needs of homeless veterans. Additionally, 
the FY 2010 IB also calls on both Congress and VA to step up programs 
to stem, and to ultimately eliminate, homelessness in the veteran 
population.
         s. 1518--caring for camp lejeune veterans act of 2009
    Section 2 of this bill would furnish hospital care, medical 
services, and nursing home care to veterans who were stationed at Camp 
Lejeune, North Carolina during a period, determined by the Secretary in 
conjunction with the Agency for Toxic Substances and Disease Registry, 
in which the water at Camp Lejeune was contaminated by volatile organic 
compounds, including known human carcinogens, notwithstanding that 
there is insufficient evidence to conclude such illness is attributable 
to such contamination.
    Section 3 of this measure would create a new section 1786 under 
subchapter VIII of title 38, United States Code. Specifically, this 
bill would require a family member of the above-described veteran who 
resided at Camp Lejeune during the same period, or who was in utero 
during such period, to be eligible for the same hospital care, medical 
services and nursing home care furnished by the Secretary for any 
condition, or any disability that is associated with such condition. 
The Secretary shall prescribe regulations that specify which conditions 
and disabilities are associated with said exposure.
    The DAV has two resolutions related to this bill: Resolution No. 
252, urges congressional oversight and Federal vigilance to provide for 
research, health care and improved surveillance of disabling conditions 
resulting from military toxic and environmental hazards exposure, and 
Resolution No. 211, calls for supporting legislation to provide for 
service connection for disabling conditions resulting from toxic and 
environmental exposures. Accordingly, we support section 2 of this 
measure; however, we recommend any medical care provided to dependents 
under section 3 of this bill should be provided under the Civilian 
Health and Medical Program of VA (CHAMPVA) service.
           s. 1607--wounded veteran job security act of 2009
    This bill would provide for certain rights and benefits for persons 
who are absent from positions of employment to receive medical 
treatment for service-connected 
disabilities.
    DAV Resolution No. 239 seeks to protect veterans from employment 
discrimination when seeking health care for service-connected 
conditions; therefore, we support passage and enactment of this bill to 
better protect the jobs of our disabled veterans while they seek 
treatment for their wounds incurred during military service. Many of 
this Nation's young men and women have answered the call to service in 
the Armed Forces and Congress, through the Uniformed Services 
Employment and Reemployment Rights Act (USERRA), provides protection 
from employment discrimination for persons to perform military duty. 
During the current conflict and others, employers have released their 
employees to perform military duty and many sustained service-connected 
disabilities as a result of their honorable service. Currently, USERRA 
mandates employers to make reasonable accommodations regarding these 
disabilities; however, employers are not specifically required by law 
to allow veterans with service-connected disabilities to be absent from 
the workplace to receive treatment for these disabilities. This 
important legislation seeks to correct this inequity by extending legal 
protections when such distinguished employees seek medical treatment 
for their service-connected conditions.

    Mr. Chairman, this concludes my testimony and I will be pleased to 
consider any questions by you or other Members of the Committee.
                                 ______
                                 
                                 
                                 
                                 ______
                                 
                                 
                                 
          Prepared Statement of Paralyzed Veterans of America
    Chairman Akaka, Ranking Member Burr, and Members of the Committee, 
Paralyzed Veterans of America (PVA) would like to thank you for the 
opportunity to present our views on the pending legislation for the 
Department of Veterans Affairs (VA) before the Committee today. These 
important bills will go a long way toward improving the lives of 
veterans and their families.
          s. 977, the ``prisoner of war benefit act of 2009''
    PVA supports S. 977, the ``Prisoner of War Benefit Act of 2009.'' 
This legislation would provide certain improved benefits for veterans 
who are former prisoners of war. It would repeal the currently required 
thirty day minimum period of internment for presumption of service 
connection for certain diseases for purposes of the payment of 
veterans' disability compensation. PVA also welcomes the inclusion of 
Type 2 diabetes as one of the listed diseases. This bill would also 
make former POWs inflicted with disease, determined by the Secretary of 
Veterans Affairs, to have ``positive association with the experience of 
being a prisoner of war'' eligible to receive disability compensation, 
and would establish procedures, including the recommendations from the 
Advisory Committee on Former Prisoners of War that such presumption be 
established for a non-listed disease.
 s. 1109, the ``providing real outreach for veterans act of 2009'' or 
                                  the 
                            ``pro-vets act''
    This legislation requires the VA and the Department of Defense 
(DOD) to enter into an agreement for the purpose of transferring 
information pertinent to the servicemembers' military service for 
improving the communication of veterans' benefits that servicemember 
has earned. PVA supports this effort to improve the current methods in 
which veterans learn about benefits. Often a veteran learns of 
available benefits during social conversations with other veterans, 
through a state employment office, reading a veterans service 
organizations newsletter, or communicating on line with other veterans. 
Of the thousands of military personnel leaving the service each year 
(320,000 in 2007 according to DOL testimony) there is not one uniform, 
standard, detailed message that these men and women receive. Currently 
the services offer the Transition Assistance Program (TAP) and the 
Disabled Transition Assistance Program (DTAP) to servicemembers leaving 
the military. In 2007 DOD and DOL were encouraged to work toward a goal 
of 85% of transitioning servicemember participation in TAP or DTAP 
workshops. In 2007 and 2008 the DOL Advisory Committee on Veteran's 
Employment, Training and Employer Outreach (ACVETEO) visited several 
TAP workshops in various parts of the country. They found that the best 
technical tools were not available to the facilitators to prepare 
separating servicemembers for the 21st Century. In particular, the use 
of computers was not observed in any classrooms thus denying 
servicemembers the opportunity to see real time how to use the internet 
in their job search or review other benefits they have earned. The 
Committee members also discovered that the TAP program would vary in 
length from one day, to two and a half days. Another challenge was that 
often the servicemember received this information in the last two or 
three weeks preceding their discharge.
    Improving the TAP and DTAP presentations explaining medical 
assistance offered by the VA, veterans benefits, career opportunities 
with the Federal Government, or other employment information can be 
achieved with the combined effort of DOL and DOD. This legislation 
proposes requirements from DOD and VA that could require many years to 
implement and involve potential IT problems and unexpected costs. PVA 
would like to see more effort placed on the delivery of veterans' 
benefits information before the servicemember leaves the military. If a 
veteran is aware of a benefit, they can then inquire if they qualify.
                                s. 1118
    PVA supports the intent and concept of S. 1118, that increases DIC 
to fifty-five percent of the one hundred percent rate under Title 38, 
Section 1114 (j) for survivors. However, we are disappointed that the 
legislation does not support higher rates for survivors of veterans who 
were rated for special monthly compensation under Section 1114 (k) 
through (s). PVA believes that the survivors of severely disabled 
veterans should be compensated at a higher rate commensurate with the 
level of disability.
    For example, the spouse of a veteran who was rated under Section 
1114 (r)(1) has made sacrifices and provided significant care for the 
veteran while he or she was alive due to the severity of the service-
connected conditions. Consequently, we recommend amending the bill to 
provide for a rate of fifty-five percent of the rates from (k) through 
(s) provided the veteran was so entitled at the time of death.
                                s. 1155
    PVA supports S. 1155, a bill that would establish a position of 
Director of Physician Assistant Services. This legislation is 
consistent with a recommendation included in the FY 2010 edition of The 
Independent Budget.
    The Department of Veterans Affairs is the largest single Federal 
employer of physician assistants (PA), with approximately 1,800 full-
time PA positions, and has utilized PAs since 1969 when the profession 
started. However, once Congress enacted Public Law 106-419, the 
``Veterans Benefits and Health Care Improvement Act of 2000,'' which 
directed that the Under Secretary for Health to appoint a PA advisor, 
the Veterans Health Administration (VHA) only assigned the PA position 
as a part-time, field-based employee. Finally, in April 2008, VHA made 
the position a full-time employee, but the position is still field-
based and often does not receive travel funding until late in the 
second quarter each year, resulting in missed opportunities to attend 
VHA meetings. It is time to establish a real, permanent staff PA at the 
VA to oversee these critical care providers.
   s. 1204, the ``chiropractic care available to all veterans act of 
                                 2009''
    PVA supports the provisions of S. 1204, the ``Chiropractic Care 
Available to All Veterans Act of 2009.'' Chiropractic care has become a 
widely accepted and used medical treatment. It is a treatment covered 
by TRICARE, and it is only appropriate that it should be provided at VA 
facilities. But it is also important for the Committee to recognize 
that by providing this treatment benefit to veterans, it will entail a 
new type of care which is currently not considered in funding. When new 
treatments are authorized at VA facilities, they must be considered 
when determining VA appropriations to prevent those becoming unfunded 
mandates.
   s. 1237, the ``homeless women veterans and homeless veterans with 
                         children act of 2009''
    PVA fully supports S. 1237, the ``Homeless Women Veterans and 
Homeless Veterans with Children Act of 2009'' and appreciates Senator 
Murray expanding this program to include male veterans with minor 
children and correcting the oversight that only provided for support to 
women with minor children.
    In addition, this legislation will provide targeted assistance to 
homeless women veterans and those with children, who face particular 
dangers and challenges on the street. PVA offers our assistance to the 
Secretary of Labor and the Assistant Secretary for Veterans' Employment 
and Training to support and promote this program when enacted.
     s. 1302, the ``veterans health care improvement act of 2009''
    Regarding S. 1302, the ``Veterans Health Care Improvement Act of 
2009'', PVA recommends caution in proceeding with this legislation. 
While the findings presented in the legislation are valid, it may be 
detrimental to veterans if pay-for-performance measures are too quickly 
introduced without an assessment of the impact of such measures. While 
PVA fully supports accountability and the need to provide the highest 
quality services to veterans and we recognize that a pay-for-
performance model does offer a promising approach to improve the 
outcome of services, it may have the opposite effect of negatively 
impacting veterans if implemented too quickly without adequate 
understanding on the part of service providers. PVA would ask that the 
Committee evaluate the impact before implementing such legislation.
      s. 1394, the ``veterans entitlement to service act of 2009''
    PVA supports S. 1394, the ``Veterans Entitlement to Service Act of 
2009.'' This legislation would direct the Secretary of Veterans Affairs 
(VA) to acknowledge the receipt of any claim for medical services, 
disability compensation, or pension under laws administered by the 
Secretary, or other communication relating to such services, 
compensation, pension, within 30 days after its receipt. PVA believes 
the VA must keep the servicemember informed and up-to-date with timely 
communication during the compensation and pension process.
 s. 1427, the ``department of veterans affairs hospital quality report 
                                 card 
                             act of 2009''
    Although PVA has no objection to the requirements for a Hospital 
Quality Report Card Initiative outlined in this legislation, we remain 
concerned that this wealth of information will go unused. As we 
testified in May 2007, collecting this information and assessing it 
without acting on any findings from that information would serve no 
real purpose. While the public might be more and better informed, we 
would hope that the congressional committees will use the information 
published in these reports each year to affect positive change within 
the VA. However, we must emphasize that additional resources will need 
to be provided to allow the VA to properly compile this information as 
we believe that this could be a major undertaking.
   s. 1429, the ``servicemembers mental health care commission act''
    PVA strongly supports S. 1429, the ``Servicemembers Mental Health 
Care Commission Act.'' As the wars in Afghanistan and Iraq continue, 
more and more veterans of the War on Terrorism are in need of mental 
health care. As the language of the legislation indicates, the rates of 
Post Traumatic Stress Disorder (PTSD) and depression are greatest among 
women veterans and members of the Reserves. While the Armed Forces are 
working hard to help those who remain on active duty, veterans who have 
left the service face particular challenges as they leave the military 
support groups critical to coping with the horrors of war.
    Establishing a commission to oversee monitoring and treatment of 
veterans with PTSD, Traumatic Brain Injury and other mental health 
disorders caused by service and to study the long-term adverse 
consequences of these conditions is critical to determining treatments 
that may be most effective. And while PVA welcomes the requirement for 
annual reports to Congress, it will be unfortunate if this reporting 
remains simply an exercise and does not lead to Congressional action on 
recommendations. Too often Congress has the information to make 
changes, but is unable to enact legislation that truly impacts those 
who need care. As the wars in Afghanistan and Iraq continue, we ask 
that this legislation do more than just identify what we already 
believe, but be the first step in treating this serious effect of war.
                    s. 1444, the ``combat ptsd act''
    PVA supports S. 1444, the ``Combat PTSD Act.'' This bill clarifies 
and defines the meaning of ``combat with the enemy'' for purposes of 
proof of service connection for veterans' disability compensation for 
service on active duty outlines as: (1) in a theater of combat 
operations during a period of war; or (2) in combat against a hostile 
force during a period of hostilities. This clarification will help to 
reduce confusion and ease the burden of proof when trying to prove a 
combat stressor when they file a claim for compensation for PTSD.
 s. 1467, the ``lance corporal josef lopez fairness for servicemembers 
                    harmed by vaccines act of 2009''
    PVA supports S. 1467, the ``Lance Corporal Josef Lopez Fairness for 
Servicemembers Harmed by Vaccines Act of 2009.'' This legislation would 
prohibit the Secretary of Veterans Affairs from excluding from coverage 
under the traumatic injury provisions with respect to the 
Servicemembers' Group Life Insurance program a veteran suffering a 
qualifying loss resulting from an adverse reaction to a vaccination 
administered by the Department of Defense (DOD). PVA believes every 
servicemember that is affected by traumatic loss or injury should be 
entitled to the traumatic injury benefits under SGLI.
s. 1483, the ``max j. beilke department of veterans affairs outpatient 
                                clinic''
    PVA has no position on this bill. It deals specifically with naming 
issues and these should be considered by the local community with input 
from veterans organizations within that community.
     s. 1518, the ``caring for camp lejeune veterans act of 2009''
    PVA supports S. 1518, the ``Caring for Camp Lejeune Veterans Act of 
2009.'' The intent of this legislation is to provide hospital care, 
medical services, and nursing home care to veterans and family members 
who were stationed at Camp Lejeune, NC, while the water was 
contaminated by volatile organic compounds, including known human 
carcinogens and probable human carcinogens, for any illness, to include 
a child who was in utero at the time. These servicemembers and their 
families have been suffering for decades and should be entitled to care 
and compensation.
  s. 1531, the ``department of veterans affairs reorganization act of 
                                 2009''
    PVA supports S. 1531, the ``Department of Veterans Affairs 
Reorganization Act of 2009,'' which will establish the position of 
Assistant Secretary for Acquisition, Logistics, and Construction. In 
2008 the Secretary of Veterans Affairs, James B. Peake, reorganized the 
functions of acquisition, logistics, major construction and real 
property programs into the Office of Acquisition, Logistics, and 
Construction (OALC). The creation of this position will improve 
management oversight and performance of these critical programs.
 s. 1547, the ``zero tolerance for veterans homelessness act of 2009''
    PVA supports S. 1547, the ``Zero Tolerance for Veterans 
Homelessness Act of 2009.'' PVA has always been a strong supporter of 
helping homeless veterans. While VA estimates nearly 131,000 veterans 
are homeless on any given night, and that approximately 200,000 
veterans experience homelessness in a year, these numbers are lower 
than have been reported in the past and the Committee should be 
cautious of these numbers. But regardless of what the actual numbers 
are, this is clearly a massive problem that the VA, veterans service 
organizations, homeless providers, and similarly interested parties, 
have all tried to help overcome. This is a tragedy that continues to 
plague our Nation. PVA believes that this legislation may help to 
reduce these unfortunate numbers. We particularly appreciate that the 
legislation aims to address those veterans at risk of becoming homeless 
and not just those veterans who have already lost there homes.
          s. 1556, the ``veteran voting support act of 2009''
    PVA supports S. 1556, the ``Veteran Voting Support Act of 2009.'' 
PVA advocates for the rights of veterans, persons with disabilities, 
and all Americans, which enable them to participate in the election 
process. Making the voting process accessible and available for 
paralyzed veterans has been a priority for our organization.
    PVA supports the requirement of the VA to provide information 
relating to requesting an absentee ballot and making absentee ballots 
available upon request. PVA also supports the provision of the bill 
that would permit nonpartisan organizations to provide voter 
registration information at facilities of the VA.
       s. 1607, the ``wounded veteran job security act of 2009''
    S. 1607, the ``Wounded Veteran Job Security Act of 2009'' would 
amend Title 38, to provide for certain rights and benefits for persons 
who are absent from employment in order to receive medical treatment 
for service-connected disabilities. PVA supports this legislation to 
protect the employment of a veteran that has a disability, disease, or 
other medical condition that was a result from their service to the 
Nation. The legislation must also include treatment for medical 
conditions related to, or a result of that disability, disease, or 
medical condition. The veteran living with a spinal cord injury or 
disease, as a result of their service, may contract a urinary tract 
infection, a bladder infection, decubitus ulcer or other medical 
condition that may require treatment and time at home recuperating for 
several days or weeks. This new medical condition may be directly 
related to that veteran's spinal cord injury or disease, although it is 
not predisposed in the veteran's medical history. Veterans should not 
be at risk of losing their jobs when they seek medical care due to 
their service for this Nation.
          s. 1668, the ``national guard education equity act''
    PVA fully supports S. 1668, the ``National Guard Education Equity 
Act.'' Soldiers operating under Title 32 provisions perform in the 
exact same manner as Active Duty soldiers and airmen when called to 
active duty for homeland security, disasters or other missions in 
support of the United States. In addition, members of the Active Guard 
Reserve perform duties in the same capacity as active duty soldiers and 
deserve the same benefits and considerations as their active duty 
brothers and sisters.
                                s. 1752
    PVA supports S. 1752, a bill to direct the Secretary of Veterans 
Affairs to provide wartime disability compensation of 10 percent or 
more for certain veterans with Parkinson's disease. In addition to 
direct compensation, PVA would like to propose that VA should exhaust 
all available scientific research methods to provide any finding of 
long-term effects of the disease.
 s. 1753, the ``disabled veterans caregiver housing assistance act of 
                                 2009''
    PVA supports the intent of S. 1753, the ``Disabled Veterans 
Caregiver Housing Assistance Act of 2009,'' that would increase 
assistance for disabled veterans who are temporarily residing in 
housing owned by a family member. However, this legislation is 
problematic to veterans in need of transitional housing who may have 
the intent of purchasing a home and using adaptive housing assistance 
at a later date. The Temporary Residing Assistance (TRA) grant is 
subtracted from the overall maximum benefit of $60,000 from Specially 
Adapted Housing (SAH) grant. For example: If a disabled veteran 
receives a TRA grant of $12,000, he/she would have only $44,000 
available under the SAH grant, rather than $60,000, to adapt or build a 
permanent residence in the future. This legislation is not conducive as 
a benefit to disabled veterans who have temporary and ultimately 
permanent adaptive housing needs.
    GAO reported (GAO-09-637R) on June 15, 2009 to Members of Congress 
that VA has processed nine TRA grants since it's creation on June 15, 
2006 through a period ending February 28, 2009. During the same period, 
VA processed 2,431 SAH and SHA grants. This is a substantial difference 
in the number of applications for each program.
    PVA recommends SAH and TRA become two separate grants due to having 
different objectives. This would exclude TRA deducting from the maximum 
benefit of SAH and substantially increasing the favorability of the TRA 
grant and its applicants. This will give a reason for veterans to use 
TRA and still allow them to adapt their own residence in the future. 
Additionally, this is something our severely disabled veterans 
desperately need and would provide a substantial difference in their 
quality of life and have less of a financial hardship on the veteran 
and their family.
          s. 1779, the ``health care for veterans exposed to 
                     chemical hazards act of 2009''
    PVA fully supports S. 1779, the ``Health Care for Veterans Exposed 
to Chemical Hazards Act of 2009'' to provide health care for veterans 
exposed to chemical hazards through their service. Military service 
often involved exposure to hazardous materials, whether fuels, 
insecticides or other chemicals regularly used during military 
operations. In addition, during deployments to areas with less 
stringent environmental regulation, the possibility of exposure to 
industrial or agricultural chemicals increases dramatically.
    As with the previously discussed ``Caring for Camp Lejeune Veterans 
Act of 2009,'' it is difficult to know what veterans may be exposed to 
during their service. By creating a registry of former members of the 
Armed Forces, VA can better track and identify those who may have been 
exposed to hazards allowing for rapid examinations and counseling. Only 
by knowing who may have been affected and providing prompt care can 
America provide the care that is due to our veterans.

    This concludes PVA's my testimony and we would be happy to answer 
any questions the Committee may have.
                                 ______
                                 
                                 
                                 
                                 ______
                                 
 Prepared Statement of Richard Weidman, Executive Director for Policy 
          and Government Affairs, Vietnam Veterans of America
    Chairman Akaka, Ranking Member Burr, and other Members of this 
distinguished and important Committee, Vietnam Veterans of America 
(VVA) appreciates the opportunity to offer our statement for the record 
concerning several bills affecting veterans that are up for your 
consideration. Please know that VVA appreciates the efforts of this 
Committee for the work you are doing on behalf of our Nation's veterans 
and their families.
    Mr. Chairman, as you have indicated that you are most interested in 
VVA's views on S. 1237 and S. 1547, we'll commence with these, and then 
follow with the other bills in the order in which they were introduced.
    s. 1237, the homeless women veterans and homeless veterans with 
                          children act of 2009
    Enactment of this legislation would expand the grant program for 
homeless veterans with special needs to include male veterans who are 
homeless with minor dependents, and to establish a grant program for 
reintegration of homeless veterans, both male and female, with 
children.
    Vietnam Veterans of America (VVA) has a long history of promoting 
equal access to care, treatment, and benefits for all veterans. With 
the increasing number of new, and younger, veterans who find themselves 
without a home and with dependent children, it is essential that the 
agencies of government and the non-governmental entities funded to 
assist these men and women be given the mandate and the funding 
necessary to assist these veterans--before their homelessness becomes 
chronic. Job training and job skills enhancement and placement services 
can lead to employment possibilities that will otherwise likely escape 
these veterans. Providing funding for the care of their children, too, 
is a vital facet of this effort.
    While VVA supports enactment of this legislation, we caution, 
though, that for many of these veterans, job counseling, training, and 
assistance need to be coupled with appropriate mental health and 
substance abuse services and housing. The VA needs to be held 
accountable for the tens millions of dollars that were supposed to go 
toward hiring new mental health clinicians. Were the clinicians 
actually hired? Have they been they properly trained and supervised? 
Are they following the recognized best practices protocols? We urge 
that the Congress do much more stringent oversight of the VA for how 
they actually use the funds they get. With this in mind, VVA urges that 
Congress take a holistic approach to the persistent issue of 
homelessness among veterans.
   s. 1547, the zero tolerance for veterans homelessness act of 2009
    This bill, with its almost utopian title, would enhance and expand 
the assistance provided by the Departments of Veterans Affairs and 
Housing and Urban Development to veterans who are homeless and veterans 
at risk of homelessness. President Obama recently stated that ending 
homelessness among veterans in five years will take a serious infusion 
of resources, coordination of services, and overhaul of the way we 
treat our vets after their service. While VVA supports enactment of 
this legislation, we would like to offer our comments on how this 
legislation can be strengthened to achieve the goal established by the 
President.
    We might quibble with the numbers of homeless veterans estimated by 
the VA: It seems that the census of homeless veterans dipped from more 
than 200,000 to 153,000, and then in short order to 131,000, while at 
the same time there appears to be an increase in the number of homeless 
women veterans and homeless veterans, male and female, who served in 
Afghanistan and Iraq. The ``numbers game'' seems to have more to do 
with how one defines homeless than with any change in the number of 
veterans affected by this situation. (Incidentally, VVA argues that a 
veteran who has no permanent domicile is homeless. That is not the 
litmus test used by the VA.) However, the persistent problem of 
homelessness among veterans is all too real, and VVA applauds Congress 
for recognizing this fact and seeking 
solutions.
    Certainly, the VA ought to be able to identify veterans receiving 
healthcare through VA medical facilities or disability compensation who 
are homeless or who are in danger of becoming homeless. We question, 
however, if this represents ``all'' of the target population. We would 
posit that the VA needs to formulate a strategic program of outreaching 
to veterans who otherwise do not utilize VA services, or receive 
monthly compensation from the Veterans Benefits Administration, the 
VBA.
    The VA has legal authority as mandated by Public Law 110-389, the 
Veterans' Benefits Improvement Act of 2008, Section 532 to advertise in 
national media, and an ethical obligation to reach out to all veterans 
and their families to inform them of the benefits to which they are 
entitled. While populating kiosks in VA medical centers and regional 
offices with booklets and pamphlets is fine, these do little good if 
they do not get into the hands of the very poor who do not use the 
system, the ``middle class'' who use private physicians and who may be 
living from paycheck to paycheck, and some who, so many reasons, either 
choose to or are forced to dissociate from society. To reach these 
folks, the VA has had no real strategic outreach plan. In fact, VA 
outreach to those who do not use VA facilities is negligible at best, 
and has been for a long, long time. A strategic plan, aided perhaps by 
the Ad Council with input from veterans service organizations and 
military unit associations, needs first to be well thought out, and 
then implemented. How much such an outreach effort will cost will be 
dependant in part on the media (TV and radio, billboards, electronic 
media) that are used. Part of such an outreach effort ought to include 
a ``help line'' modeled after the VA's suicide hotline.
    We would offer, too, that a plan that targets the homeless, or 
those at risk of incipient homelessness, ought to be part of this 
larger, more inclusive outreach strategy that informs veterans of the 
benefits and services they have earned by virtue of their military 
service, and that informs veterans of any health conditions or health 
care risks that might derive from their time, and place, in service.
    Sec. 3: That said, we caution that there will need to be a very 
close and collaborative interaction between those tasked by the 
Secretary of Veterans Affairs with identifying and assisting veterans 
who are homeless or at imminent risk of becoming homeless and their 
counterparts at HUD.
    Sec. 4: In testimony provided by VVA in April 2008, we recommended 
that Congress go above the authorizing level for the Homeless Grant and 
Per Diem program and fund the program at $200 million and not the $150 
million authorized. We are gratified that this funding increase is 
stipulated herein.
    We would hope, however, that no consideration be given to provide 
per diem payments to entities that house veterans but offer no 
services. ``Three hots and a cot'' is little more than a very temporary 
palliative. Should this occur, it would open the door to funding 
``empty-shell shelters'' in every city, municipality, or county in the 
country, and would defeat the purpose of this bill.
    We would offer that a consolidation of the VA's Homeless Grant and 
Per Diem (HGPD) projects be included in this bill. This is a per diem 
issue for all existing programs that received a second grant for 
expansion of an existing original program. In the past, some successful 
VA HGPD residential programs identified a need for increased bed space 
because of the number of veterans requesting admission. These programs 
asked for additional beds under a ``Per Diem Only'' (PDO) grant process 
and were awarded the ability to increase their overall program beds. 
But because the original grant and the PDO grant were awarded at 
different times, they have separate project numbers, which leads to an 
accounting nightmare as everything related to the program has to be 
divided by percentages and every veteran who changes beds has to be 
tracked by not one but two project numbers. This does not make much 
sense to us. There should be a provision by which a modification of the 
original grant can accomplish the same purpose without adding ``busy 
work'' that actually does not increase accountability.
    Sec. 5: Perhaps the key area in this section is the promise of case 
management services, without which far too many veterans who are 
homeless will inevitably drift back into homelessness even after they 
are afforded rental housing. Caring, informed case management is 
particularly critical in assisting those homeless veterans who have 
mental health and/or substance abuse issues. Yet herein is a conundrum: 
Many veterans do not meet the criteria for HUD-VASH because they 
require case management. They also do not meet the criteria for Mental 
Health Intensive Case Management (MHICM) included in this legislation. 
These compromised veterans are left without recourse to fend for 
themselves. Therefore, we would urge inclusion in this bill for case 
management services for those individuals who would otherwise be 
ineligible for HUD-VASH.
    Sec. 6: The appointment of a Special Assistant for Veterans Affairs 
in the Office of the Secretary of Housing and Urban Development simply 
makes sense. HUD needs an individual who has the ear of the Secretary 
and who can coordinate all programs and activities at HUD relating to 
veterans. This position needs to be high enough within the HUD 
hierarchy to be taken seriously.
    Sec. 7: Establishing a method for the collection and aggregation of 
data on homeless veterans participating in VA and HUD programs also 
makes sense.
    Sec. 8: Researching and writing and devising a ``comprehensive plan 
to end homelessness among veterans'' sounds fine. It is likely, 
however, to result in yet another tome that does little more than 
gather dust. What may make more sense, of course, is to focus on 
preventing homelessness in the first place. But program managers within 
HUD and the VA, along with key leaders working in non-governmental 
organizations that provide assistance to homeless veterans, perhaps 
need to form working groups on different facets of the homeless veteran 
issue, conclude what programs work and need enhancement and what 
programs ought to be consigned to the dust bin of history, and make 
recommendations to their respective Secretaries. The watch word of any 
such plan should be KISS (Keep It Simple, Soldier). Just because it is 
simple does not mean it is easy.
    Whether we want to acknowledge this or not, our Nation is likely 
always to have some veterans who drift through life, without roots, 
many of them battling the demons of their wartime experiences. However, 
we can and must do a far better job than we are currently doing.
            s. 977, the prisoner of war benefits act of 2009
    This bill would provide certain improved benefits for veterans who 
are former prisoners of war. It would repeal the minimum period of 
internment for presumption of service connection for certain diseases. 
It would make ex-POWs afflicted with diseases determined by the 
Secretary of Veterans Affairs to have ``positive association with the 
experience of being a prisoner of war'' eligible to receive disability 
compensation.
    As long as any determination by the Secretary, as stipulated in the 
bill's language, is made based on sound medical and scientific 
information and analyses, VVA supports enactment of this bill, as there 
are so few former POWs left that the cost of the bill should be 
minimal, and therefore any ``pay-go'' implications not particularly 
onerous.
 s. 1109, providing real outreach for veterans act or pro-vets act of 
                                  2009
    Should this bill be enacted, it would direct the Secretary of 
Veterans Affairs to enter into an agreement with the Secretary of 
Defense for the transfer of data to the VA to provide members of the 
Armed Forces as well as veterans with individualized information 
concerning veterans' benefits for which each member and veteran may be 
eligible. It would require the VA Secretary, after receiving such data, 
to: 1) compile a list of all benefits for which each member or veteran 
may be eligible; 2) notify the member or veteran (or their legal 
representative) of such benefits; and 3) provide a second notification 
if the member or veteran does not apply for a listed benefit within 60 
days. It would provide for annual notifications thereafter. And it 
would require additional notifications based on changed circumstances, 
although it would allow each member or veteran the option to decline 
further notifications.
    There are many difficulties in this proposed legislation, not the 
least of which is cost. The sheer effort to comply with the provisions 
of S. 1109 would bloat an already bloated central bureaucracy.
    Yes, the VA as well as DOD needs to do a far better job of 
informing troops and veterans of their rights and benefits. But there 
are far better ways of accomplishing this. The VA could start with a 
much better search engine on their web site, as well as other 
enhancements to make their web site more user friendly. Many veterans, 
particularly the newest generation of veterans, get their info on the 
Internet. Why not provide veterans with a card listing key VA telephone 
numbers and web addresses? Why not incorporate information about 
benefits in an overall outreach strategy to be developed by the VA, one 
that would use billboards as well as public service announcements?
    While this bill is very well meaning, taken alone it is not the 
answer.
                                s. 1118
    S. 1118 would provide for an increase in the amount of monthly 
dependency and indemnity compensation (DIC) payable to surviving 
spouses by the Department of Veterans Affairs. One provision of this 
bill would reduce eligibility to receive DIC from age 57 to age 55, 
after which remarriage shall not terminate such compensation.
    VVA endorses enactment of this legislation. Even as the fighting in 
Afghanistan and Iraq are adding surviving spouses almost daily, the 
majority of surviving spouses are women who are nearing retirement age, 
or have been retired for some time if they ever worked outside the 
home. Many of these women devoted themselves to caring for their spouse 
who may have been profoundly disabled as a result of his service in the 
military; many of these spouses did not have the opportunity to build a 
career of their own. Enactment of S. 1118 would in effect recognize 
their service, and sacrifice, even though DIC payments alone are 
inadequate to support an adult in most parts of the country.
                                s. 1155
    S. 1155 would establish within the Veterans Health Administration 
(VHA) of the Department of Veterans Affairs (VA) the position of 
Director of Physician Assistant Services in the Office of the Under 
Secretary for Health.
    VVA endorses S. 1155 as we have endorsed its companion bill in the 
House, H.R. 1302. As we noted in testimony in the House, this bill 
seems to us a logical if somewhat belated effort to establish the 
position of Director of Physician Assistant Services under the Under 
Secretary of Veterans Affairs for Health. As stipulated in this bill, 
the director, who would be a qualified physician assistant, ``shall be 
responsible to and report directly to the Under Secretary for Health on 
all matters relating to the education and training, employment, 
appropriate utilization, and optimal participation of physician 
assistants within the programs and initiatives of the Administration.''
    The last three individuals to occupy the position of Under 
Secretary for Health have refused to accord Physician Assistants, most 
of whom are veterans, equal prestige and respect with Nurse 
Practitioners (most of whom are not veterans). The reasons are 
puzzling, and to say the aforementioned individuals and their 
functionaries have been less than honest in discussing this issue with 
Congress, veterans service organizations, and organized labor would be 
an understatement. It is shameful that this bill needs to be enacted to 
get the VHA to act decently, honestly, and as common sense would 
dictate, but this is the case.
  s. 1204, the chiropractic care available to all veterans act of 2009
    This bill would amend the Department of Veterans Affairs Health 
Care Programs Enhancement Act of 2001 to require the provision of 
chiropractic care and services to veterans at all VA medical centers.
    While VVA supports the enactment of this bill, we would suggest 
that this body consider looking into other alternative healthcare 
options that have shown varying degrees of effectiveness. These might 
include acupuncture. These might include as well such modern relaxation 
techniques as biofeedback, which has proven successful in treating 
fibromyalgia, hypertension and certain heart conditions, and even 
Traumatic Brain Injuries (TBI).
       s. 1302, the veterans health care improvement act of 2009
    This bill would provide for the introduction of pay-for-performance 
compensation mechanisms into contracts between the VA and community-
based outpatient clinics (CBOCs) operated by private contractors for 
the provision of healthcare services.
    VVA endorses S. 1302. It recognizes that, while the ``top 
priorities for CBOCs should be to provide quality health care and 
patient satisfaction for America's veterans,'' in some instances 
``current contracts for CBOCs may create an incentive for contractors 
to sign up as many veterans as possible, without ensuring timely access 
to high quality health care for such veterans.'' It also would set in 
place mechanisms to ``eliminate abuses in the provision of health care 
services by CBOCs under contracts that continue to utilize capitated-
basis compensation mechanisms for compensating contractors.'' It would 
also set in place mechanisms to ``ensure that veterans are not denied 
care or face undue delays in receiving care.''
  s. 1394, the veterans entitlement to service act or the vets act of 
                                  2009
    This legislation would direct the Secretary of Veterans Affairs to 
acknowledge the receipt of medical, disability, and pension claims and 
other communications submitted by claimants within 30 days of the 
receipt of the claim or other communication.
    If enactment of this legislation can increase the efficiency and 
accountability of VA personnel, we would endorse it. We fear, however, 
that it has the potential to create more flurries of action and/or 
mounds of additional paperwork without increasing efficiencies in the 
adjudication of claims.
     s. 1427, the department of veterans affairs hospital quality 
                        report card act of 2009
    This bill would establish and implement a Hospital Quality Report 
Card Initiative to report on health care quality in VA medical centers.
    VVA is in favor of much more disclosure of information by VA, 
especially as to resource allocation and quality measures. This report 
card has the potential to make every veteran and ombudsman.
    Further, if this initiative can inspire a competition among VA 
medical centers to be the best, to get the highest rating, this could 
be a good thing, but only if the VA is measuring the right things in 
the right way as to actually improve the quality of care.
     s. 1429, the servicemembers mental health care commission act
    This bill would establish a commission on veterans and members of 
the Armed Forces with Post Traumatic Stress Disorder (PTSD), Traumatic 
Brain Injury (TBI), or other mental health disorders, to enhance the 
capacity of mental health care providers to assist such veterans and 
members of the military, and to ensure that such veterans are not 
discriminated against.
    Another commission! Although there are myriad efforts by both 
public and private entities to deal with the epidemic of mental health 
woes that afflict men and women who have served in a combat zone, there 
is no single entity extant to ``oversee'' this. Our skepticism about 
this bill, however, is based on the yet-another-commission attempt to 
deal with a problem or an issue. After the scandal at Walter Reed Army 
Medical Center was exposed by the Washington Post two and a half years 
ago, of a sudden there were task forces and commissions appointed by 
the President and hearings by Congress to ask how such a thing could 
happen and how we could prevent it from happening again.
    Well, after all the heat, there was very little light. The heralded 
case management initiative for the severely wounded has had some 
successes but is, from all that we can see, a washout. Many of the same 
problems remain. The case management system at Walter Reed Army Medical 
Center still does not work very well, and the so-called pilot project 
for the Medical Evaluation Boards/Physical Evaluation Boards (MEB/PEB) 
is not working very well at all.
    Will a commission enhance the treatment of servicemembers and 
veterans afflicted with PTSD or TBI or a host of other mental health 
issues? Not unless it is a permanent body, and answers directly to the 
White House, and has some actual power to help force positive change on 
this process.
 s. 1444, the compensation owed for mental health based on activities 
 in theater post-traumatic stress disorder act, or the combat ptsd act
    This bill attempts to ``clarify the meaning of `combat with the 
enemy' for purposes of service-connection of disabilities.''
    VVA can support this bill if its intent is that it be applied to 
veterans with a valid diagnosis of PTSD (i.e., in the manner called for 
as noted in the 2006 Institute of Medicine report at http://iom.CMS/
3793/32410.aspx), and if the intent is that any veteran who served ``in 
a theater of combat operations (as determined by the Secretary in 
consultation with the Secretary of Defense) during a period of war,'' 
or ``in combat against a hostile force during a period of hostilities'' 
be taken at their word that the event or incident which occurred in 
service gave rise to their disability.
    As VVA has stated repeatedly in prior Congressional testimony, an 
appropriate process already exists for VA PTSD claims processing as 
mandated by Congress back in 2000 under the Veterans Claims Assistance 
Act. However, it doesn't work because the VA fails time and time again 
to provide for the uniformity, consistency, and efficiency that are 
necessary to ensure that the claims process works in a timely fashion 
for all veteran claimants.
    The VA does not use the guidelines established by the IOM on the 
medical side, and does not use their own ``Best Practices Manual for 
Adjudication of PTSD Claims.'' The problem is not with the law; rather, 
it's with the implementation of the law by the VA that's the issue.
  s. 1467, the lance corporal josef lopez fairness for servicemembers 
                     harmed by vaccines act of 2009
    If passed, this bill would provide coverage under Traumatic 
Servicemembers' Group Life Insurance for adverse reactions to 
vaccinations administered by the Department of Defense.
    There can be no doubt that some members of the military who are 
given inoculations against certain diseases suffer adverse reactions. 
Some of these reactions are life-altering, even life-threatening. All 
such adverse reactions are covered under existing Traumatic 
Servicemembers' Group Life Insurance guidelines under DOD, but the 
Department of Veterans Affairs Insurance Center does not follow suit in 
all instances, as in the case of former Marine Lance Corporal Lopez.
    Enactment of this bill would in effect close a loophole that would 
benefit Mr. Lopez and his family and perhaps countless others. It has 
the unqualified support of VVA.
       s. 1518, the caring for camp lejeune veterans act of 2009
    The intent of this bill is to furnish hospital care, medical 
services, and nursing home care to veterans who were stationed at Camp 
Lejeune, North Carolina, while the water there was contaminated by 
volatile organic compounds, including known and probable human 
carcinogens. It would provide the same services to a family member of a 
veteran who resided at Camp Lejeune during a given period, as well as 
to a child who was in utero at the time.
    Passage of this legislation would provide a measure of justice to 
veterans and their families who, through no fault of their own, were 
harmed simply by being assigned to Camp Lejeune. It would be up to the 
Secretary of Veterans Affairs to prescribe the regulations that would 
specify which conditions are associated with exposure to the 
contaminants, and which disabilities are associated with such 
conditions. We hope that this bill receives swift passage.
 s. 1531, the department of veterans affairs reorganization act of 2009
    The purpose of this legislation is to establish within the VA the 
position of Assistant Secretary for Acquisition, Logistics, and 
Construction to provide policy direction and manage oversight with 
respect to acquisition and construction programs of VA facilities.
    Although we think the title of this bill is far too broad, we 
strongly support its purpose. It is key that the individual named to 
this position have a strong and unwavering commitment to small 
business, particularly veteran-owned and service-disabled veteran-owned 
small business. We all want accountability and the best ``bang for the 
buck'' in Federal procurement. The fallacy is that we can achieve this 
by giving the majority of business to big firms. Competition is what 
creates innovation and ultimately drives down the prices, thereby 
increasing value for dollar invested.
            s. 1556, the veteran voting support act of 2009
    This bill would require the Secretary of Veterans Affairs to permit 
facilities of the Department to be designated as voter registration 
agencies.
    Enactment of S. 1556 would avoid what had been a brewing 
controversy prior to the 2008 Presidential election when the previous 
administration at first refused to let VA facilities act as voter 
registration agencies. While we support the intent of this bill, we do 
not endorse the provision in the bill that would require the Secretary 
to provide a mail voter registration application form to each veteran 
who seeks to enroll or is enrolled in the VA healthcare system. We do 
agree that the VA can and should provide voter registration information 
and assistance, as well as absentee ballots to veterans residing in a 
community living center or domiciliary to ``the same degree of 
information and assistance with voter registration as is provided . . .
with regard to the completion of its own forms, unless the applicant 
refuses such assistance.''
    We agree as well with the provision that would instruct the 
Secretary to permit nonpartisan organizations along with state and 
local election officials to provide voter registration information and 
assistance at facilities of the VA healthcare system, subject to 
reasonable time, place, and manner restrictions, including limiting 
activities to regular business hours and requiring advance notice.
         s. 1607, the wounded veteran job security act of 2009
    The goal of this bill is to provide for certain rights and benefits 
for persons who are absent from positions of employment to receive 
medical treatment for service-connected disabilities.
    To fight the war on terror, officials at the Department of Defense 
have bled the Reserves and National Guard, which comprise almost 50 
percent of our military strength. Far too many Reservists and Guardsmen 
and--women have returned to find that they have lost their job, or have 
lost their seniority and other rights and benefits. This is wrong. This 
is un-American. It will make individuals think twice about enlisting or 
re-enlisting in the Guard or Reserves, to the detriment of the citizens 
in the states in which they are based.
    The intent of this bill is noble; passage of this bill is needed. 
It has the endorsement of VVA.
    In this same regard, VVA would note that a small minority of 
employers are helping to bear the cost of this war because it is their 
employees are being activated. There needs to be a system of tax breaks 
and re-training funds for these employers to make at least some effort 
of holding them harmless.
          s. 1668, the national guard education equality act.
    This bill provides for the inclusion of certain active duty service 
in the reserve components as qualifying service for the Post-9/11 
Educational Assistance Program.
    This bill attempts to cover members of the Army National Guard or 
Air Force National Guard who had ``full-time duty'' in response to a 
domestic emergency; as part of the Active Guard Reserve; as part of the 
Air Sovereignty Alert; as part of Operation Jumpstart; in response to 
Hurricane Katrina; as part of an airport security mission; or as part 
of a counterdrug activity. It is a bill VVA would support so long as 
those who served in these capacities meet the minimum amount of active-
duty service as any Guardsman or Reservist who was activated and sent 
to Iraq or 
Afghanistan.
 s. 1753, the disabled veteran caregiver housing assistance act of 2009
    This bill would increase assistance for disabled veterans who are 
temporarily residing in housing owned by a family member.
    Catastrophically disabled veterans need a significant amount of 
care. In many instances, their families will provide such care as best 
as they can. However, providing this care may entail not insubstantial 
reconstruction of a home. S. 1753 recognizes this, increasing the 
amount of financial assistance allowable and providing for future 
increases based on the residential cost-of-construction index for the 
preceding year.
    VVA supports passage of this bill.
   s. 1779, the health care for veterans exposed to chemical hazards 
                              act of 2009
    Last but not least, this bill would provide health care to veterans 
exposed in the line of duty to occupational and environmental chemical 
health hazards ``notwithstanding that there is insufficient medical 
evidence to conclude that [a veteran's health condition or disability] 
may be associated with such exposure.''
    This bill derives from National Guardsmen taken ill after being 
exposed to a chemical burn pit in Iraq. We fear that their exposure may 
be only the tip of the iceberg, to borrow a cliche. VVA believes that 
enactment of this bill is critical if a new generation of veterans is 
to be taken care of for respiratory and other health conditions that 
have an excellent possibility of having been caused by exposure to the 
toxic soup of burn pits in Iraq.

    Mr. Chairman, Vietnam Veterans of America sincerely appreciate the 
opportunity to provide our views on these bills, and we look forward to 
working with you and your distinguished colleagues to address the 
concerns of our Nation's veterans.
      

                                  
