[Senate Hearing 112-236]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 112-236

  EXAMINING THE LIFETIME COSTS OF SUPPORTING THE NEWEST GENERATION OF 
                                VETERANS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 27, 2011

                               __________

       Printed for the use of the Committee on Veterans' Affairs








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                     COMMITTEE ON VETERANS' AFFAIRS

                   Patty Murray, Washington, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Daniel K. Akaka, Hawaii              Johnny Isakson, Georgia
Bernard Sanders, (I) Vermont         Roger F. Wicker, Mississippi
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jim Webb, Virginia                   Scott P. Brown, Massachusetts
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
                       Kim Lipsky, Staff Director
                 Lupe Wissel, Republican Staff Director










                            C O N T E N T S

                              ----------                              

                             July 27, 2011
                                SENATORS

                                                                   Page
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......     1
Brown, Hon. Scott P., U.S. Senator from Massachusetts............     3
Tester, Hon. Jon, U.S. Senator from Montana......................     4
Johanns, Hon. Mike, U.S. Senator from Nebraska...................     4
Begich, Hon. Mark, U.S. Senator from Alaska......................     5
Isakson, Hon. Johnny, U.S. Senator from Georgia..................    55
Boozman, Hon. John, U.S. Senator from Arkansas...................    57

                               WITNESSES

Rieckhoff, Paul, Executive Director, Iraq and Afghanistan 
  Veterans of America............................................     7
    Prepared statement...........................................     9
    Posthearing questions submitted by Hon. Mark Begich..........    12
Hosek, James, Senior Economist, RAND Corporation.................    12
    Prepared statement...........................................    14
Nicely, Crystal, Caregiver and spouse of OEF veteran.............    18
    Prepared statement...........................................    20
St. James, Lorelei, Director, Physical Infrastructure Issues, 
  United States Government Accountability Office.................    22
    Prepared statement...........................................    23
    Posthearing questions submitted by Hon. Patty Murray.........    27
    Response to request arising during the hearing by Hon. Patty 
      Murray.....................................................    59
Golding, Heidi L.W., Principal Analyst for Military and Veterans' 
  Compensation, Congressional Budget Office......................    27
    Prepared statement...........................................    29
    Posthearing questions submitted by Hon. Patty Murray.........    49

                                APPENDIX

Wersel, Vivianne Cisneros, Au.D., Chair, Government Relations 
  Committee, Gold Star Wives; prepared statement.................    67
Sullivan, Paul, Executive Director, Veterans for Common Sense; 
  letter.........................................................    72
Whitehouse, Sheldon; prepared statement..........................    77

 
  EXAMINING THE LIFETIME COSTS OF SUPPORTING THE NEWEST GENERATION OF 
                                VETERANS

                              ----------                              


                        WEDNESDAY, JULY 27, 2011

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:04 a.m., in 
room 562, Dirksen Senate Office Building, Hon. Patty Murray, 
Chairman of the Committee, presiding.
    Present: Senators Murray, Tester, Begich, Isakson, Johanns, 
Brown of Massachusetts, and Boozman.

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

    Chairman Murray. Good morning, and welcome to today's 
hearing where we are going to examine the lifetime costs of 
supporting our newest generation of veterans.
    As we all know, when our Nation goes to war, it is not just 
the costs of fighting that war that must be accounted for. We 
must include the cost of caring for our veterans and families 
long after the fighting is over. And that is particularly true 
today, at a time when we have more than half a million Iraq and 
Afghanistan veterans in the VA health care system. That is an 
over 100 percent increase since 2008.
    This presents a big challenge, and one that we have no 
choice but to step up to meet if we are going to avoid many of 
the same mistakes we saw with the Vietnam generation. But it is 
more than just the sheer number of new veterans that will be 
coming home that poses a challenge for the VA. It is also the 
extent of the wounds, both visible and invisible, and the 
resources it will take to provide our veterans with quality 
care.
    Through the wonders of modern medicine, servicemembers who 
would have been lost in previous conflicts are coming home to 
live productive and fulfilling lives. But they will need a 
lifetime of care from the VA.
    Today, we will hear from the Congressional Budget Office, 
the Government Accountability Office, the RAND Corporation, and 
Iraq and Afghanistan Veterans of America in an effort to help 
us quantify and understand these costs and to ensure that we 
can meet the future needs of our veterans and their families.
    And today we are so fortunate to be joined by one of those 
brave family members, Crystal Nicely, who is not only a wife 
but also a caregiver to her husband, Marine Corporal Todd 
Nicely. Todd was seriously injured by an IED in the southern 
Helmand Province of Afghanistan. Since that time, he has come 
home to fight every day, focus on his recovery, and I even 
heard yesterday that he is already starting to drive again, and 
I want to take a moment to say thank you so much for your 
service to our country. You have shown bravery not only as a 
Marine in Afghanistan, but also through the courage you have 
displayed during your road to recovery.
    I invited Crystal here today because I think it is 
incredibly important that we hear her perspective. The costs we 
have incurred for the wars in Iraq and Afghanistan--and will 
continue to incur for a very long time--extend far beyond 
dollars and cents.
    When I first met Crystal last month while touring Bethesda 
Naval Base, her story illustrated that. Crystal is here today 
to talk about the human cost, and that cost is not limited 
exclusively to the servicemembers and veterans who fought and 
are fighting our wars, but it is also felt by the families of 
these heroes who work tirelessly to support their loved ones 
through deployments and rehabilitation day in and day out. 
Many, like Crystal, have given up their own jobs to become full 
time caregivers and advocates for their loved ones.
    Last month, while testifying before the Senate 
Appropriations Subcommittee on Defense, Chairman of the Joint 
Chiefs of Staff, Admiral Mullen, told me that ``without the 
family members we would be nowhere in these wars.'' I could not 
agree more; and after you hear Crystal's story, that will be 
even more clear.
    As the Members of this Committee know, over the course of 
the last few hearings we have examined how the veterans of 
today's conflicts are faced with unique challenges that VA and 
DOD are often falling short of meeting.
    We have explored mental health care gaps that need to be 
filled, cutting-edge prosthetics that must be maintained, a 
wave of new and more complex benefit claims that are taking too 
long to complete, the need to fulfill the promise of the Post-
9/11 GI Bill, and the need to support veterans who are winding 
up out-of-work and on the streets.
    All of these unmet challenges come with costs. Some costs 
we will be able to calculate. Some will not be fully known for 
decades.
    But today's hearing will be a reminder that in order to 
meet these costs we must safeguard the direct investments we 
make in veterans care and benefits. We must get the most value 
out of every dollar we spend, and we must start planning today 
at a time when critical long-term budget decisions are being 
made.
    As we all know, there is no question that we need to make 
smart decisions to tighten our belts and reduce our Nation's 
debt and deficit. But no matter what fiscal crisis we face, no 
matter how divided we may be over approaches to cutting our 
debt and deficit, no matter how heated the rhetoric in 
Washington D.C. gets, we must remember that we cannot balance 
our budget at the expense of the health care and benefits our 
veterans have earned.
    Their sacrifices have been too great. They have done 
everything that has been asked of them. They have been 
separated from their families through repeat deployments. They 
have sacrificed life and limb in combat. They have done all of 
this selflessly and with honor. And the commitment we have to 
them is non-negotiable, not just today but far into the future.
    So, thank you all of our witnesses for being here today and 
our Committee Members. I will now turn to Senator Brown for his 
opening statement.

               STATEMENT OF HON. SCOTT P. BROWN, 
                U.S. SENATOR FROM MASSACHUSETTS

    Senator Brown of Massachusetts. Thank you, Madam Chair, for 
holding this important hearing. I want to recognize Corporal 
Nicely and his wife Crystal for taking time and obviously, 
Crystal, for you to be here and for your devoted service to our 
country and the Corp.
    As you know, today we are here also to discuss the 
resources the VA will need in the future to care for current 
generations of wounded warriors and, as the Chairwoman noted, 
out of the total of 2.3 million servicemembers who have been 
deployed, 45,000 have been wounded in action; and as we look to 
the future and beyond for the next 10 years, it is important to 
understand where we have been and what we have learned because, 
as over the last 10 years, we have seen a large increase in the 
VA's medical care accounts. And since 2001, the VA medical care 
budget has grown by $27 billion or 130 percent.
    Last October, the Congressional Budget Office published an 
analysis on this topic, and their analysis indicates that, you 
know, we have some very real challenges coming up; and we all 
agree that we must provide the funding needed to support this 
generation of wounded warriors and continue caring for those 
who have previously borne the visible and hidden scars of war.
    And as you know, this morning we will hear from Crystal, 
the wife of a wounded warrior, and her husband Todd who was 
severely injured in March 2010 when he stepped on IED while on 
patrol in Afghanistan that left him as a quadruple amputee.
    He has been able to move on with his life somewhat and yet 
he ran into and, I believe, continues to run into bureaucratic 
hassles and delays in trying to complete the integrated 
disability evaluation system, a process that was supposed to 
alleviate these types of problems. And if a prompt 
determination cannot be made for someone who has lost all four 
limbs, what hope is there for the others who have lesser wounds 
or invisible wounds.
    Members of the RAND Corporation will talk about the gaps in 
access to mental health services at the VA, in particular the 
long wait times for appointments.
    I am disappointed, however, that the VA, our friends at the 
VA, will not be here to offer their testimony. I am sure we 
will follow up with them, Madam Chair, with your leadership.
    There are a few problems. These are just a few problems 
that we have and they continue to persist. As we have all 
learned as Members of the Committee and have all noted these 
throughout our time here.
    So, we have to look at the costs for caring for injured 
troops, and we should keep in mind that money cannot be the 
only solution to the problems that they face. If that were the 
case, Corporal Nicely would have breezed through the IDES 
process, and Loyd Sawyer would have gotten an appointment at 
the VA without any delay.
    With our country's current financial crisis, we need to 
reassess every dollar that we spend to make sure that it is 
being used effectively to deliver the services and benefits 
that our wounded warriors and veterans need in order to give 
them an opportunity to live healthier and more productive 
lives.
    So, thank you, Madam Chair. I look forward to hearing the 
testimony.
    Chairman Murray. Thank you very much, Senator Brown.
    Senator Tester.

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

    Senator Tester. Well, thank you, Madam Chairman. I want to 
thank you for convening this hearing.
    I want to welcome all the witnesses. I very much appreciate 
you all being here. I am going to single out Paul Rieckhoff. 
Thank you very much for being here, but more importantly thank 
you for your advocacy for the veterans. I very much appreciate 
it. You have been a bulldog.
    Crystal Nicely, thank you very, very much for being here. 
We always say when a soldier goes to war, their spouse goes 
with them and their family goes with them too. We appreciate 
you being here to tell your story. It is going to be a great 
perspective to hear.
    The welfare of the young men and women who defend this 
country is always at the forefront of our minds and the 
question whether to send them into harm's way to begin with is 
something that can never be taken lightly. In doing so, we have 
to prepare ourselves for the human and the monetary costs of 
these decisions.
    It is not just about providing the troops armaments and the 
equipment that they need and the tools they have to be 
successful in their missions, it is about ensuring that we are 
fully capable of caring for them and their families when they 
return home.
    To quote the VFW commander, ``The day this Nation cannot 
afford to take care of her veterans is the day this Nation 
should quit creating them.''
    A very true statement. Something we should keep in mind as 
our veterans come home in need of care with injuries both seen 
and unseen.
    I very much look forward to this hearing and I appreciate, 
Madam Chair, you convening these folks.
    Chairman Murray. Thank you very much.
    Senator Johanns.

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

    Senator Johanns. Madam Chair, let me also express my 
appreciation, and thank you for having this hearing.
    To the members of the panel, thanks for being here and 
thanks to your commitments.
    Let me, if I might, just associate myself with comments 
that have been made both by the Chair and by the Ranking 
Member. I believe they are hitting the nail on the head.
    In my view of the world, part of the cost of war is caring 
for our veterans. There will be a point at which the uniform is 
set aside and they come home and need to find a place if you 
will. If they have medical needs, then we need to find a way to 
address those needs.
    One of the things that is also enormously perplexing to me 
is the inability to transition so many veterans into the 
workforce. I appreciate the economic times are difficult and 
challenging. We all know that, but it is so disheartening when 
I talk to veterans and I go around the room and try to figure 
out where they are out in their life and how they are 
transitioning into the workforce.
    So many of them say, well, I have not been able to find a 
steady job. And the remarkable thing for me is that is in a 
State where our unemployment is actually quite low, 4.1 
percent.
    So, if I might just cue something for those who are going 
to testify today and maybe, Paul, I will point to you 
specifically. I am especially interested to hear testimony 
about the challenges our veterans are experiencing in 
transitioning from military life into a civilian job. It just 
seems to me we can do a better job here.
    I know that Hiring A Hero Act includes several provisions 
to address these issues. That is good. I applaud any efforts 
that have been made that might make this situation a little bit 
better, but I am especially interested in where we are not 
meeting the issues of training and in some cases rehabilitation 
so veterans can be prepared to enter the workforce.
    With that, to all of you who advocate for veterans to those 
who have served and those families who have been such an 
important part of that service, I do want you to know how much 
I appreciate your commitment to our country.
    Thank you, Madam Chair.
    Chairman Murray. Thank you.
    Senator Begich.

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

    Senator Begich. Thank you very much, Senator Murray, for 
putting this forum together today, and I want to thank the 
witnesses for being here. I will not be able to stay. I have to 
chair an Oceans, Fisheries, and Coast Guard Subcommittee 
hearing in about 12 minutes.
    But I want to at least let you know, first, I received all 
of your written testimony. I appreciate that. I have some 
questions that I will submit for the record.
    I will tell you, in my short time here in the Senate as a 
Member of this Committee, I have heard the incredible testimony 
from our brave warriors and families over the last two and a 
half years, and I want to be clear that examining the lifetime 
costs in supporting this new generation of veterans does not 
mean that we will not be there for you. You answered the call 
of duty. You have been there for our country, and we will be 
there for you.
    The costs that veterans and the families have suffered as 
the consequences associated with the scars of war, both 
financially and emotionally, place burdens that can last a 
lifetime.
    With Alaska having the highest number of veterans per 
capita of any State in this country, I have seen these impacts 
firsthand, and I will tell you what I tell every time I see a 
veteran when I am at home, ``Thank you, thank you, thank you 
for the service and the sacrifice, not only as an individual 
but also as a family. And we promise to continue to fight every 
day to do what we can to make sure that those services are 
there.''
    One of the issues that I will submit for the record for you 
all hopefully to answer is the question that I know I face, 
like Senator Tester, and Senator Johanns with rural veterans, 
veterans that have an extremely difficult time accessing health 
care.
    More and more veterans are choosing to live in rural 
communities. In my State, 80 percent of the rural communities 
cannot be accessed by road. So, it is very difficult for them 
to access the health care they need. It may be physical or 
mental services that they may need.
    I think I would be interested in your comments, if you have 
them, that you can put on the record again or I will submit as 
I am for the record a written question about how do we figure 
out the access points to ensure that the quality care no matter 
where you live as a veteran, it does not matter if you live in 
a small village in Alaska of 50 people or a large urban city, 
how we make sure we get the health care they need, they are 
owed in a timely basis.
    So, I would be anxious for your comments. I know it is a 
question that we have a piece of legislation we are talking 
about, the Alaska Heroes Card, to create some access points 
again for roadless areas that are just impossible for our 
veterans to get the quality service they need. So, I would be 
interested in your comments on that.
    Again, Madam Chair, thank you for holding this important 
hearing because, as we engage in wars, it is a two-parts cost. 
One is the action of the war and the actions after. And 
sometimes, and I can tell you as a new Member here, my personal 
opinion is when we engaged in the wars of Iraq and Afghanistan, 
not a lot of people thought about the next cost.
    And so, I am glad this hearing is here. It is a commitment 
we have to make, and it is owed to the veterans and the 
families of veterans. So, thank you again for all of you being 
here. And again, thank you, Madam Chair.
    Chairman Murray. Thank you very much.
    So at this time we will now turn to our witnesses. We will 
first hear from Mr. Paul Rieckhoff, the Executive Director and 
founder of Iraq and Afghanistan Veterans of America.
    Next we will hear from Dr. James Hosek, a senior economist 
from the RAND Corporation. We will then hear from Mrs. Crystal 
Nicely who, as I mentioned in my opening statement, is a 
caregiver and spouse of an Operation Enduring Freedom veteran.
    Following her testimony, we will hear from Mrs. Lorelei St. 
James, the Director of Physical Infrastructure for the 
Government Accountability Office; and closing out our panel 
this morning will be Mrs. Heidi Golding, who will be testifying 
on behalf of the Congressional Budget Office. She is CBO's 
principal analyst for military and veterans' compensation in 
the National Security Division.
    So thank you again to all of you for being here this 
morning for this important hearing.
    Mr. Rieckhoff, we will begin with you.

   STATEMENT OF PAUL RIECKHOFF, EXECUTIVE DIRECTOR, IRAQ AND 
                AFGHANISTAN VETERANS OF AMERICA

    Mr. Rieckhoff. Thank you, Madam Chair, Members of the 
Committee. On behalf of IAVA, Iraq and Afghanistan Veterans of 
America, and over 200,000 of our members and supporters, many 
of whom are here today, thank you for inviting us to testify on 
the long-term costs of war for our generation of veterans.
    I served in Iraq from 2003 to 2004 as a platoon leader with 
the Third Infantry Division. When my unit returned and I came 
home from war, we returned to a country confused by and a bit 
uncomfortable with its warriors. People wanted to help. They 
just did not know how. So bringing to light the true costs of 
these wars is part of the reason we formed the IAVA in a 
cramped studio apartment back in 2004.
    This hearing comes at a critical time. Right now our Nation 
teeters on the edge of default and servicemembers and veterans 
are left concerned and a bit scared.
    IAVA members from across the country have contacted us in 
the past few days. They still do not know if they will get 
disability, retirement, GI Bill checks that day so rightfully 
earned, or even their base pay. They have enough to deal with 
already, and they deserve the answers to these questions. It is 
up to Congress and the President to get us these answers.
    But we are here today to examine the lifetime costs of this 
new generation of vets, and I will start with the bottom line 
up front, something I learned to do in the Army. It is going to 
be expensive and it is going to be complex, but history shows 
us that it will be less expensive and less complex if we invest 
as a Nation in our veterans now.
    Doing so also has the added bonus of cultivating a new 
generation of leaders, future teachers, doctors, CEOs, and 
maybe even a few Members of Congress. They will lead our Nation 
the only way they know how, from the front.
    The current condition of new veterans' readjustment into 
civilian society is not pretty. Officially, 13.3 percent are 
unemployed as of this past June, more than 4 percentage points 
higher than the national average.
    We see numbers in our membership closer to 20 percent. In 
Indiana, it is 24 percent. In Michigan, it is nearly 30 
percent. Nationwide that means approximately 260,000 people in 
real numbers are out of work. That is about the same size as 
the entire Marine Corps.
    It does get worse. The military and veterans communities 
also are facing a suicide epidemic. In 2010 alone, there were 
468 suicides throughout the military. It is estimated between 
2005 and 2009 one servicemember committed suicide every 36 
hours, and more committed suicide in 2010 than died in combat.
    These numbers, while bleak, are really just the tip of the 
iceberg. The legacy of these wars will be the cumulative impact 
of the multiple deployments year after year, a burden of many 
carried by few. And as these wars wind down, the military will 
likely downsize just as it has done in all postwar periods.
    A new surge of veterans is already returning to local 
communities nationwide and cost will be a word thrown around a 
lot. Investment, though, probably will not be and it should be 
because these are not just costs; they are investments.
    This Committee and the public sector in general have done 
many good things for new veterans returning home. The best 
example, of course, was the Post-9/11 GI Bill, which has 
provided close to 500,000 returning servicemembers with 
educational opportunities they otherwise they would not have 
dreamed of, and the exciting and urgently needed Hire Heroes 
Act, which the Members of this Committee are certainly familiar 
with, proves that you have not rested on your laurels.
    This bill can and should be the first jobs bill passed by 
this Congress. But legislation and government can only do so 
much. The private sector must do its part too. Companies that 
commit to hiring veterans will find it is not charity. It is a 
smart investment. It is good for their bottom line.
    Veterans are entrepreneurial by nature; and although they 
represent less than 1 percent of Americans, 9 percent of 
American firms are veteran owned. Many have specific skills 
that relate directly to the civilian trades: logistics, 
operations, communications, medicine and engineering.
    If folks really want to support the troops, they should 
hire them. Something companies and organizations have already 
realized. For example, IAVA has been proud to partner with 
companies like Google, JCPenney's, CBRE, Schwab, and the 
Chamber of Commerce in efforts to turn the tide on veteran 
employment.
    These are not just government problems or business problems 
or nonprofit problems; they are American problems. Take the 
experience of specialist Nick Colgin.
    While serving in Afghanistan with the 82nd Airborne 
Division as a medic, Colgin proved himself over and over again. 
He saved the life of a French soldier that was shot in the head 
and was ultimately awarded a Bronze Star for his actions over 
the course of his deployment. He also suffered a Traumatic 
Brain Injury due to an RPG attack.
    He was honorably discharged 2 months after he left the war. 
Unable to find a job anywhere in the medical field, he was 
looking to work as a first responder, which was the equivalent 
of what he did overseas, but employers said he lacked the 
proper certificates.
    While waiting many months for the VA to process his 
disability claim, he was forced to collect unemployment checks 
to make ends meet. But Colgin turned things around. The VA 
eventually did process his disability claim. He got the right 
paperwork to be a first responder; and after using some of the 
GI Bill benefits, he will begin his senior year at the 
University of Wisconsin Stevens Point this fall.
    Not all new veterans have the happy ending of a Nick 
Colgin, though sometimes we must all remember as we plan for 
the future. Long-term it is estimated the cost of these wars 
will be between $600 billion and $1 trillion.
    Those are imposing numbers to be sure especially in this 
time of economic recession and spiraling debt. Those numbers 
will only increase with time if we slash veterans programs in 
the shortsighted rush.
    The costs are clear and they are tremendous but so are the 
sacrifices that our men and women have made for our Nation and 
so is the potential for return.
    Before I deployed to Iraq, I worked on Wall Street. If I 
were analyzing the potential return on this investment, I would 
say my generation gets a strong buy rating. Investing in the 
innovation generation is like buying shares of Apple in 1980. I 
am here to tell you to put your money where your mouth is. 
Please invest in this generation. We are worth it. We will 
deliver, and we will not let America down. We never have, and 
we never will.
    Thank you for your time, and I look forward to your 
questions.
    [The prepared statement of Mr. Rieckhoff follows:]
 Prepared Statement of Paul Rieckhoff, Executive Director and Founder, 
                Iraq and Afghanistan Veterans of America
    Chairman Murray, Ranking Member Burr, and Members of the Committee, 
on behalf of Iraq and Afghanistan Veterans of America's over 200,000 
Member Veterans and supporters, thank you for inviting us to testify on 
the long-term costs of war for our new generation of vets.
    My name is Paul Rieckhoff and I am the Executive Director and 
Founder of IAVA. I served in Iraq from 2003 to 2004, as an infantry 
platoon leader in the U.S. Army National Guard. When my unit and I 
returned home from war, we returned to a country confused by and 
uncomfortable with its warriors. People wanted to help, they just 
didn't know how. Bringing to light the true costs of these wars is part 
of the reason we formed IAVA in my cramped New York studio apartment in 
2004.
    We are here to ``Examine the Lifetime Costs of a New Generation of 
Vets.'' I'll start with the bottom line up front, something I learned 
in the Army--it's going to be expensive. And it's going to be complex. 
But history shows us that it will be less expensive and less complex if 
we as a nation invest in our veterans now. Investing in these brave men 
and women now has the added bonus of cultivating a new generation of 
battle-born leaders, future teachers, doctors, business leaders and 
maybe even a few Members of Congress, that will lead our Nation the 
only way they know how--from the front. The alternative--missing 
critical investments, shortchanging their benefits and services--will 
cost our country terribly.
    The current condition of new vets' readjustment into civilian 
society isn't pretty. Officially, thirteen-point-three (13.3) percent 
are unemployed as of this past June, more than 4 percentage points 
higher than the national average. We see numbers in our membership 
closer to 20%. In Minnesota the number is 22.9%. In Indiana, 23.6%. And 
in Michigan, it's 29.4%. So nationwide, that means approximately 
260,000 people in real numbers are out of work--about the same size of 
the entire Marine Corps. To use a military term, that is un-sat.
    Not only are younger veterans at a greater risk of homelessness 
than the general population, but even when compared to the older 
veteran population, their risk is higher. Over 11,000 homeless vets 
officially listed as homeless in 2009 were between the ages of 18 and 
30. That's a full Army Division.
    It gets worse. The military and veteran community is also facing a 
suicide epidemic. In 2010 alone, there were 468 suicides throughout the 
military. It's estimated that between 2005 and 2009, 1 servicemember 
committed suicide every 36 hours. And more committed suicide in 2010 
than died in combat. But that's just part of the mental health problem, 
because once individuals separate from the military, it's impossible to 
track them unless they enroll in the VA--something only 51 percent of 
separated OIF and OEF veterans have done.
    And these numbers, while bleak, are really just the tip of the 
iceberg. The legacy of these wars will be cumulative impacts of the 
multiple deployments, year after year; a burden of many carried by few. 
Personal issues that are delayed for the needs of a unit can be put off 
temporarily, for another deployment, but they can't be put off forever. 
As these wars wind down, the military will likely downsize, just as it 
has done in all postwar periods. As a result, this new surge of 
veterans is already returning to local communities nationwide. Those 
initial months back home are key to the transition process; veterans 
will either return home to a job opportunity or an unemployment check, 
either have their own roof over their head or move from shelter to 
shelter, and either feel included in the community they fought for or 
feel isolated from it. And our Nation will either repeat the mistakes 
of the way we treated veterans after Vietnam, or it will turn the page. 
The public, private, and nonprofit sectors must work together to ensure 
it's the positive return our servicemembers experience--and not the 
slap in the face of patchwork or non-existent real support.
    This Committee, and the public sector in general, have done many 
good things for new veterans returning home. The best example, of 
course, was the Post-9/11 G.I. Bill in 2008, which has provided close 
to 500,000 returning servicemembers with educational opportunities they 
otherwise wouldn't have dreamed of. In 2009, advance funding for VA 
healthcare was passed into law. In 2010, the Caregivers Bill joined it. 
And the exciting and urgently needed Hiring Heroes Act, which the 
Members of this Committee are certainly familiar with, proves that you 
haven't rested on your laurels this year. This bill can and should be 
the first jobs bill passed by this Congress.
    Creative thinking for these complex issues is being used off of 
Capitol Hill, too. Veterans' courts are a great example. Designed to 
try cases of non-violent offenses and to deal with the invisible wounds 
of war, over 59 courts have been established since 2008, spanning at 
least 24 states. As part of the sentencing process, veterans in these 
courts agree to appropriate treatment that can include mentoring 
sessions and counseling. And it works. Big time. Of the veterans 
enrolled in the first year of the original veterans' court in Buffalo, 
New York, roughly 90 percent successfully finished it and none have 
committed any more crimes.
    But legislation and government can only do so much. The private 
sector must do its part, too. Companies will need to play a huge role 
in the hiring of new vets. That can't happen in a meaningful way until 
civilian employers better understand how military service and skill-
sets translate into the civilian sector--something 60 percent of human 
resource managers said was a challenge. The civilian and military 
divide is very much alive, and it's a shame. Companies that commit to 
hiring veterans will find it's not charity. It's a smart investment. 
Vets are entrepreneurial by nature; although they represent less than 1 
percent of Americans, 9 percent of American firms are veteran-owned. 
And yet the unemployment numbers for Iraq and Afghanistan veterans 
continue to rise. If folks really want to support troops, they should 
hire them--something some companies and organizations have already 
realized. For example, IAVA has been proud to partner with leaders like 
Google, J.C. Penney, CBRE, Schwab and the Chamber of Commerce, in 
efforts to turn the tide on vet unemployment.
    Jobs are the horse that drives this cart of solutions. The U.S. 
Government invested hundreds of thousands, if not millions, of dollars 
and training in these men and women for war. Many have specific skills 
that relate directly to civilian trades, such as logistics and 
operations, communications, medicine, and engineering. And they have 
worked in teams with a mission-focused approach, and in dynamic, high-
stakes environments that require flexibility and adaptation. They are 
entrepreneurial. They are innovative. And they are tough. As a society 
with an all-volunteer force, and one trying to invigorate our economy, 
we have an obligation (and an opportunity) to seek out these incredibly 
valuable civic assets, and engage and empower them in our domestic 
workforce. They've had our back overseas. When times were tough, they 
delivered for America. And they can do it again back home.
    These aren't just government problems, or business problems, or 
nonprofit problems. They are American problems. Take the experience of 
Army Specialist Nick Colgin. While serving in Afghanistan with the 82nd 
Airborne Division as a combat medic, Colgin proved himself over and 
over again. He saved the life of a French soldier that was shot in the 
head. His quick decisionmaking also led to 42 locals being rescued from 
a flooding river, and he was ultimately awarded the Bronze Star for his 
actions over the course of his deployment. He also suffered a Traumatic 
Brain Injury due to an RPG-attack on his convoy.
    Colgin was discharged honorably from the Army two months after he 
returned from war. He was unable to find a job anywhere in the medical 
field. He was looking to work as a first responder in Wyoming, which 
was the equivalent of what he did overseas, but employers said he 
lacked the proper credentials and certificates. While waiting for many 
months for the VA to process his disability claim, he was forced to 
collect unemployment to make ends meet. He readily admits to having 
serious readjustment issues, something brought on by a sense of 
isolation, a lack of daily purpose like he found in the military, and a 
lack of structural support for new vets in his community.
    But Colgin got things turned around. While the private sector 
failed him, the public sector did eventually process his disability 
claim (but after he waited for six months). He also got linked up with 
nonprofits like ours and the Wounded Warrior Project, where, on a 
fishing trip, he came face-to-face with veterans ``like him'' for the 
first time. This had a very positive effect on him, he said, as he 
realized that it was OK that the war had changed him. He eventually got 
the right paperwork to be a first responder, after using some of his 
New G.I. Bill benefits, and will begin his senior year at the 
University of Wisconsin-Stevens Point in the fall. Not all new veterans 
have the happy ending of a Nick Colgin, though. It's important to 
remember that those numbers I referenced earlier are living, breathing 
people just like Nick, or anyone at this testimony, with hopes and 
dreams and ambitions of their own. And every single one will have a 
cost. But every single one is worth it.
    Folks, we are at a crossroads in terms of veterans care. We can 
turn to history for some guidance on what to do and what not to do. 
World War II veterans returned to a nation fully engaged and invested 
in the war effort. Ticker-tape parades occurred across the country to 
celebrate the vets' victories in Europe and the Pacific. VA loans for 
homes and farms were made available at low interest rates. 
Approximately 50 percent of the ``Greatest Generation'' of veterans 
used their educational benefits provided by the original G.I. Bill. All 
of this played a huge role in the economic prosperity of the post-World 
War II years.
    Compare that, then, to Vietnam. Instead of returning to parades 
celebrating their sacrifices, they came home one by one in the middle 
of the night, all too often hiding their uniforms and crew cuts. The 
struggles to transition back home didn't end there. Long after the end 
of that war, in the 1980s, Vietnam vets earned about 15 percent less 
than their civilian counterparts. And even as late as 1991, they made 
up 49 percent of the veteran inmate population. While factors like 
these did lead to the formation of some wonderful nonprofit 
organizations, like our friends at Vietnam Veterans of America, the 
overall contrast of their experience with that of the World War II 
generation couldn't be more evident. They deserved better. And they've 
fought to ensure guys like me have gotten it. But we still have a long 
way to go.
    Which brings us to today, when a new group of 2.3 million combat-
tested veterans return home from their own battles abroad. American 
society has finally learned to separate politics from the warrior. 
There's a ``sea of goodwill'' for the returning vet, which is a great 
thing. But now comes a harder task--tapping into that sea, channeling 
it, directing it into supporting the troops in a meaningful, lasting 
way. Into more than just yellow ribbons and care packages.
    Long term, it's estimated that it'll cost between $600 billion and 
$1 trillion to care for them alone. Those are imposing numbers, to be 
sure, especially in this time of an economic recession and spiraling 
debt. But those numbers will only increase with time if we slash 
veteran program funding in a shortsighted rush.
    But of course paying the bills is only a part of the solution. In 
2010, the U.S. Government spent $57.5 billion on veterans' benefits. 
The government programs that used that money can only ask the following 
question: was that money spent as efficiently and deliberately as 
possible? As these vets learned trying to rebuild villages and cities 
in Iraq in Afghanistan, money itself is a weapons system. But it's a 
precision weapon, not an area weapon, and we'd all be wise to remember 
that as we go forward.
    The Department of Defense has recently explored various 
``resiliency models'' for its servicemembers and families, most notably 
the Army's Comprehensive Soldier Fitness program. The stated goal of 
this program is to ``master the skills necessary to achieve balance in 
their lives and build resilience in order to thrive in an era of high 
operational tempo and persistent conflict.'' This is a great example of 
the military's can-do spirit and something that can be--and should be--
applied to their lives after they leave the military. But the right 
tools and training need to be available for that to happen. It's a 
tough world out there right now, for everyone, vets and civilians 
alike. But this country will bounce back, just like it always has in 
times of difficulty. And it will be the military veterans that lead the 
way. The stage is set for the Next Greatest Generation--the Innovation 
Generation--if, during this formative time in their lives, the proper 
resources are provided for them to reach their full potential. 
Investing in Iraq and Afghanistan veterans now saves us money in the 
future and plants the seeds for continued national prosperity. We are 
at the crossroads. Now, where do we go? Will we make the easy turn and 
slash veteran program funding, or the hard turn, and invest in the 
future?
    The costs are clear. And they are tremendous. But so is the 
sacrifice these men and women have made for our Nation. And so is the 
potential for return. Before I deployed to Iraq, I worked on Wall 
Street for a bit. And if were analyzing the potential for return on 
this investment, my generation of veterans would get a ``strong buy'' 
rating. Investing in the Innovation Generation is like buying shares of 
Apple stock in 1980.
    In some ways, the battles on the homefront will be more challenging 
than those fought in Iraq and Afghanistan. If there were an easy way to 
reincorporate the 1 percent into the other 99 percent, someone would've 
done it by now. But that doesn't make it impossible. We're up to the 
challenge, America has done it before. But it's going to take everyone, 
from Capitol Hill to Wall Street to Main Street, to make it happen.
    The upside is huge. And the time is now. And we are the closest 
thing you'll ever have to a sure thing in this town. On behalf of our 
generation of veterans around the world, I am here to tell you to put 
your money on the table. We are worth it. We will deliver. We won't let 
America down. We never have and we never will.
    Just watch.

    Thank you for your time. I look forward to your questions.
                                 ______
                                 
Posthearing Questions Submitted by Hon. Mark Begich to Paul Rieckhoff, 
   Executive Director and Founder, Iraq and Afghanistan Veterans of 
                                America
    Question 1. In examining the long-term costs we cannot forget the 
rural veterans. You may know that I introduced an Alaska Hero's Card 
which would offer Alaska veterans services in their most rural 
communities. I recently visited the Sunshine Clinic in Talkeetna, 
Alaska, over a hundred miles from Anchorage. They told me they are 
getting a lot of new rural vets. These young vets are more and more 
coming back and settling into rural areas.
     Do you have any suggestions or do you know of plans 
regarding how the VA is going to take care of so many vets that live 
far away from a VA facility?

    [Responses were not received within the Committee's 
timeframe for publication.]

    Chairman Murray. Thank you very much, Mr. Rieckhoff.
    Dr. James Hosek.

          STATEMENT OF JAMES HOSEK, SENIOR ECONOMIST, 
                        RAND CORPORATION

    Mr. Hosek. Thank you. I would like to thank Chairwoman 
Murray, Ranking Member Burr, and the Committee for the 
opportunity to testify.
    During the nearly 10 years since 9/11 more than 2.2 million 
active and reserve members have been deployed. Hallmarks of the 
era are the growing public recognition of the stresses borne by 
servicemembers and their families, and the invisible wounds 
that can haunt servicemembers who deployed.
    In my written testimony, I have given an overview of RAND's 
of studies on deployment, and this morning I hope to highlight 
selected findings.
    These touch on the following topics: The importance of 
total months on deployment in understanding the effects of 
deployments, the prevalence of PTSD and major depression among 
those who have deployed, the barriers to care they face, the 
importance of providing evidence-based care, and unemployment.
    In our research we found that extended length of deployment 
can have family and societal impacts ranging from the financial 
and emotional stress of increased divorce rates, academic and 
emotional consequences for children, to burdens of reduced 
reenlistment within the Armed Services. Here are some 
specifics.
    Exposure to combat trauma is the single best predictor of 
PTSD, major depression, and Traumatic Brain Injury, and the 
chance of exposure increases with months deployed.
    High months of deployments put negative pressure on Army 
and Marine Corps reenlistment that they countered with bonuses. 
This meant that personnel with high months of deployment who 
otherwise would have left were kept in service and were at risk 
of further deployment and exposure to combat trauma.
    We found that military divorces increase with total months 
of deployment. Deployment probably causes additional divorces 
among veterans but this has not been studied.
    More months of deployment were associated with more 
behavioral and emotional problems for children. For instance, 
30 percent of the children had elevated symptoms of anxiety, 
twice the rate found in other studies. We do not know if 
children's problems abate when the servicemember leaves the 
military and becomes a veteran.
    We found that almost one in five returning servicemembers 
has symptoms of PTSD or major depression, problems that may 
affect veterans for years to come.
    In our survey, 18.4 percent of all returning servicemembers 
in the spring of 2008 met criteria for either PTSD or major 
depression. Applying this percentage to the 2.2 million 
servicemembers who had deployed by last September implies that 
405,000 met criteria for PTSD or depression. We do not know the 
lifetime prevalence of these problems as some will develop 
later and others may diminish.
    Servicemembers and veterans in our studies reported 
barriers to care. Efforts are underway to reduce these barriers 
but more research may be needed on why veterans do not seek 
care and what might induce them to do so.
    We found that about half of those with probable PTSD or 
depression had not sought care in the prior year. Their reasons 
include concerns about confidentiality, potential negative 
career repercussions if care was sought, long wait times, and 
the side effects of medications.
    Other barriers were the diverse, seemingly disorganized and 
incomplete sources of information about where to seek care, 
what services were available, who was eligible and how to 
apply.
    Further, much of the care provided was not evidence-based 
care. Evidence-based care is care that statistical analysis has 
shown to be effective. Of those who had PTSD or depression and 
sought treatment, just over half received minimally adequate 
treatment, and the number who received evidence-based care 
would be even smaller.
    In our cost analysis, we found that delivering high-
quality, evidence-based care to all veterans who have PTSD or 
major depression would save money on net for society and 
improve the outcomes for those treated.
    Finally, veterans' transitions from the military to 
nonmilitary life often involve finding a job or going to 
school. As many realize, steps to assist in job search or in 
obtaining educational benefits can make the transition 
smoother.
    RAND studied unemployment among returning reservists. We 
found that many chose not to return to their pre-activation 
jobs but instead drew unemployment compensation for ex-
servicemembers. Although aimed at helping reservists who did 
not have a job, these benefits were also helping reservists to 
search for better positions.
    Also, we have identified difficulties in the early 
implementation of the Post-911 GI Bill. This research may help 
the VA and institutions of higher education focus their efforts 
to make these benefits more accessible and easier to use. It 
would be helpful to have research taking an integrated view of 
the job search, education, and health care of servicemembers 
who are transitioning from the military, particularly those 
with behavioral health conditions. Studies in this area, 
including RAND studies, have not taken an integrated view.
    Thank you once again for the opportunity to address the 
Committee. I hope that RAND's work on these subjects can be 
helpful to the Committee in fulfilling its important mission of 
serving our Nation's veterans.
    [The prepared statement of Mr. Hosek follows:]
       Prepared Statement of James Hosek,\1\ The RAND Corporation
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    \1\ The opinions and conclusions expressed in this testimony are 
the author's alone and should not be interpreted as representing those 
of RAND or any of the sponsors of its research. This product is part of 
the RAND Corporation testimony series. RAND testimonies record 
testimony presented by RAND associates to Federal, state, or local 
legislative committees; government-appointed commissions and panels; 
and private review and oversight bodies. The RAND Corporation is a 
nonprofit research organization providing objective analysis and 
effective solutions that address the challenges facing the public and 
private sectors around the world. RAND's publications do not 
necessarily reflect the opinions of its research clients and sponsors.
---------------------------------------------------------------------------
    insights from early rand research on deployment effects on u.s. 
                 servicemembers and their families \2\
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    \2\ This testimony is available for free download at http://
www.rand.org/pubs/testimonies/CT367/.
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                           publication ct-367
    I would like to thank the Committee for the opportunity to testify. 
As the Committee has requested, I will address my comments to findings 
from the recent RAND publication, How is Deployment to Iraq and 
Afghanistan Affecting U.S. Servicemembers and Their Families? I will 
also touch on more recent research that builds on and extends these 
findings.
    September 11, 2011, will mark ten years since the terrorist attacks 
that precipitated the war on terrorism and the military operations in 
Iraq and Afghanistan that continue today. During these ten years more 
than 2.2 million servicemembers from the active and reserve components 
have deployed for hostile duty. Each war has unique features, and the 
unique features of the current operations have included the absence of 
massed forces and a recognizable front line, the use of opportunistic 
small arms attacks and improvised explosive devices, and the religious 
and cultural currents that have led to shifting alliances and raised 
concern about the nature of the peace when it comes. But apart from 
these battlefield and diplomatic realities, another unique feature has 
been the public recognition of the stresses borne by servicemembers and 
their families in wartime and, equally important, the recognition of 
invisible wounds that can haunt our servicemembers who have deployed 
and that can follow them after they leave the military. Let me review 
some of what we know from our early studies on deployment and its 
effects.
    We found that experiencing a deployment affects a servicemember's 
willingness to reenlist. Interestingly, if deployment is not too 
extensive, deployment increases reenlistment over what it would have 
been in the absence of deployment. But extensive deployment causes 
reenlistment to decrease. In Iraq and Afghanistan, soldiers and marines 
have borne the majority of ground combat. Soldier tours have typically 
been 12 months (but some have been 15 to 18 months or longer) and 
marine tours have been 7 months, and many servicemembers have had more 
than one tour. We found that total months of deployment was a key 
variable in understanding the relationship between deployment and 
reenlistment. For soldiers, deployment of 11 or fewer months in the 36 
months preceding their reenlistment decision had a positive effect on 
reenlistment, but 12 or more months had a negative effect--and 18 or 
months had a still more negative effect. By 2006, two-thirds of those 
facing a reenlistment decision had 12 or more months of deployment. The 
high percentage of troops with long months of deployment coupled with 
the negative effect on reenlistment of long months of deployment put 
serious downward pressure on overall reenlistment. This was perilous as 
a drop in reenlistment would jeopardize the Army's ability to maintain 
its battlefield strength and would accelerate the deployment cycle, 
creating a vicious circle. Fortunately, the Army was able to stabilize 
its reenlistment rate by the extensive use of reenlistment bonuses. The 
same basic story held for the Marine Corps. Earlier RAND research on 
deployment also found that deployment, if not too long, led to higher 
reenlistment, while lengthy deployment decreased this positive effect 
and could make it negative. This pattern held across the services.
    Deployment brings a variety of stressors. As early as 2003, a 
survey of soldiers and marines serving in Iraq found that 89 percent of 
soldiers and 95 percent of marines reported having been attacked or 
ambushed. Deployed troops have had to face snipers, suicide bombers, 
improvised explosive devices (IEDs), and they have seen their fellow 
soldiers and friends killed or shattered by blasts, and may have had to 
kill enemy fighters, handle human remains, and may have inadvertently 
killed or injured civilians. Average temperatures in Iraq are over 120 
degrees in July and August and below freezing in January. Sandstorms 
pelt personnel and equipment with fine grit, and camel spiders are a 
lurking danger of sleeping in the open. Extensive research shows that 
stress in moderation can actually improve performance, but extreme 
stress can hurt performance, leading to mistakes and bad decisions and 
possibly to failed missions and unnecessary casualties. A person under 
constant excessive stress may screen out peripheral stimuli and lose 
the ability to process information and analyze complicated situations. 
However, research also shows that training and other moderators can 
reduce the negative effects of stress. Training, for example, can 
decrease the likelihood that a given stressor will actually cause an 
elevated level of stress, and it can increase the likelihood that a 
stressed person can nevertheless perform effectively.
    Having well trained, experienced personnel available to deploy 
helps to maintain the fighting effectiveness of deploying units, yet at 
the same time the personnel who re-deploy are subject to further 
combat-related stressors as well as separation from family and friends. 
RAND's Invisible Wounds of War study found that in the of spring 2008, 
18.4 percent of all returning servicemembers currently met criteria for 
either Post Traumatic Stress Disorder (PTSD) or major depression. This 
may be compared with a more recent RAND study, A Needs Assessment of 
New York State Veterans, that found 22 percent of the sample (Iraq and 
Afghanistan veterans who had separated from the military and were 
eligible for VA care) met criteria for probable PTSD or major 
depression. The Invisible Wounds of War study also found that 19.5 
percent reported experiencing a probable Traumatic Brain Injury (TBI) 
during deployment. For all these conditions, exposure to combat trauma 
was the single best predictor even after controlling for the number of 
months deployed and time since deployment return. It is reasonable to 
expect that the chance of exposure to combat trauma increases with the 
number of months deployed. Since 2003, a number of studies have been 
done to examine the extent of PTSD and depression among returning 
troops. Percentages of returning servicemembers with PTSD, depression, 
or the percent reporting that they experienced a TBI may vary depending 
on the study population as well as the method and timing of the 
assessment. However, studies of similar populations and methodologies 
consistently show that the rate of post-deployment mental health 
problems among returning servicemembers is about 15-20 percent at any 
given point in time. For the sake of illustration, if one wanted to 
understand the size and scope of the problem at a given point in time, 
applying the estimate of 18.4 percent to 2.2 million deployed 
servicemembers implies that about 405,000 Iraq and Afghanistan veterans 
meet criteria for with PTSD or depression. The number who may have 
experienced a probable TBI during deployment would be roughly similar, 
and there is significant overlap between those who experience PTSD, 
depression, and a probable TBI. It is important to note that these 
figures represent a snapshot of the size of the problem at a given 
point in time. We do not know yet the life-time prevalence of these 
problems among returning veterans, as some will develop problems later 
and others may recover.
    In our 2008 study, about half of the returned servicemembers with 
probable PTSD or depression had not sought care for a mental health 
problem in the prior year, and only 43 percent of those with probable 
TBI during deployment reported that they had been clinically evaluated. 
The chief reasons for not seeking care were related to access and 
organizational and cultural factors, including concerns about 
confidentiality and potential negative career repercussions that they 
may experience if they sought care. Access barriers included long wait 
times for appointments, particularly in facilities resourced primarily 
to meet the demands of older, more chronically ill veterans. The long 
wait times in part reflected the limited availability of providers. 
While significant efforts have been implemented to increase the supply 
of mental health providers, access barriers remain a concern for 
veterans. The more recent study on New York veterans' needs also 
pointed to the diverse and seemingly disorganized and incomplete 
sources of information about where to seek care, what services were 
available, who was eligible and how to apply, and to concerns about the 
side effects of medications. From the VA's perspective, perhaps the key 
lesson here is to increase awareness of the benefits of mental health 
treatment, as well as to continue to improve the application process 
and the capacity to deliver care.
    Studies consistently show that evidence-based treatment for PTSD 
and major depression is more effective than non-evidence based care. 
Our work documented a number of therapies that have been shown 
effective in treating these conditions, including cognitive behavioral 
therapy. However, of those who had PTSD or depression and also sought 
treatment, only slightly over half received minimally adequate 
treatment, and the number who received high-quality care would be even 
smaller. Thus, in addition to improving access and increasing the 
number of providers it is important that the providers be trained and 
supported to provide evidence-based care. In a cost-analysis, the 
Invisible Wounds of War study found that delivering high quality, 
evidence-based care to all veterans who have PTSD or major depression 
on net would save money for society and improve outcomes for those 
treated.
    The importance of providing healthcare to our servicemembers and 
veterans is without question, but the cost of doing so is not 
inconsequential. A challenge is how to organize the healthcare delivery 
system in an efficient way. This is partly a VA responsibility, but the 
healthcare system extends beyond the VA, bearing on both VA and non-VA 
providers, with the goal being to provide access to high quality care 
for veterans. Many, but by no means all, veterans may have health 
insurance through their employers and obtain healthcare through private 
providers. Structuring incentives so that veterans take full advantage 
of their other coverage and working with provider groups to promote 
evidence-based treatment will reduce the strain on the VA system and 
likewise help to hold down VA cost growth. At the same time, it will 
promote quality care for all veterans, whether or not they live near a 
VA facility. Similar points are discussed in recent RAND research on 
TRICARE Reserve Select.
    The extensive use of the reserve components in Iraq and Afghanistan 
has demonstrated the prowess of reserve forces and substantiated the 
role of the reserves as one that is both strategic and operational. It 
has also raised questions about reserve earnings and family support. 
Both survey data and editorials have suggested that reservists who had 
deployed took a cut in earnings. A loss in earnings was thought to be 
unfair for reservists and could lead some reservists to leave the 
military earlier than planned and cause potential enlistees not to join 
the reserves. RAND approached this question by using actual pay records 
and precise definitions of earnings. The pay data came from privacy-
protected individual-level military pay files and Social Security 
earnings records. The analysis found that most reservists--upwards of 
83 percent--actually earned more when they were deployed than they did 
at their civilian job. It is true that on average a reservist's 
civilian earnings decreased, but deployed earnings were roughly two 
dollars for each lost dollar of civilian earnings. The average 
reservist deployed for nine months or longer in a year gained over 
$19,000 on net. These findings helped to allay concerns about 
reservists' earnings losses.
    Another concern has been whether reservists returning from 
deployment would be able to transition back to their previous job, and 
more generally, whether their job security and career prospects within 
a firm were safely protected by the Uniformed Services Employment and 
Reemployment Rights Act (USERRA). The complementary side of this is 
whether employers are adversely affected by the more frequent use of 
reservist employees. RAND has a project underway on the latter topic 
with the objective of determining the implications of worker 
protections under USERRA for employers with different characteristics, 
and if needed, recommending possible changes to USERRA, potential 
improvements to DOD and service policies and practices governing 
reserve activation and utilization, and ways to modify Employer Support 
to the Guard and Reserve (ESGR)'s to provide better support to 
employers.
    From the perspective of the returning reservist, RAND studied the 
75 percent increase in enrollment in Unemployment Compensation for Ex-
Servicemembers (UCX) that occurred during 2002 to 2004. Part of the 
increase occurred simply because more reservists were being activated 
than in previous years. Also, significant numbers of reservists chose 
not to return to their pre-activation jobs. At the risk of speculating 
why that was so, it could be that many returning reservists were 
seeking new job or career opportunities, and UCX benefits, though 
initially aimed at helping reservists who did not have a job, were also 
helping reservists search for better positions.
    Further research on earnings is underway at RAND for the 11th 
Quadrennial Review of Military Compensation. This research focuses on 
the employment and earnings of wounded warriors and asks two questions: 
did they experience an earnings loss in the years following their 
injury relative to their expected earnings, and did disability 
compensation payments offset the loss? The analysis, which will be 
published this fall, takes into account the severity of the injury, and 
again is based on military pay and Social Security earnings records, 
and factors in the effects of their injury on their spouse's earnings.
    Other recent RAND research has looked into the Post-9/11 GI Bill. 
This legislation increases the generosity of the GI benefit and, like 
the GI Bill of World War II, holds the promise of allowing veterans to 
pursue and complete higher education. By identifying difficulties in 
the early implementation of the Post-9/11 GI Bill, this research may 
help the VA and institutions of higher education focus their efforts to 
make these benefits more accessible and easier to use.
    In 2007, RAND research on the needs and support of reserve families 
found that most reserve families (62 percent) reported coping ``well'' 
or ``very well'' with deployment. Deployment brought challenges to the 
family yet also had positive aspects. The mention of problems related 
to deployment varied by type of respondent. Reservists frequently cited 
disruption to employment or education as problems. Reservist spouses 
cited personal and emotional problems, household responsibilities, and 
children's issues. Reserve experts cited financial, legal, and 
healthcare issues. On the positive side, reservists mentioned financial 
gain while reservist spouses mentioned family closeness; patriotism, 
pride, and civic duty; and independence, confidence, and resilience. 
The resources the families relied upon during deployment included 
TRICARE, family support organizations, and extended families. 
Deployment affected the reservists' intentions to stay in the military. 
About 30 percent had an increased desire to stay, 40 percent had no 
change, and 30 percent had a decreased desire to stay. RAND continues 
to study reserve component families and ways to improve reintegration 
support.
    The study of reserve family needs and support, like the studies 
above, pointed to the importance of understanding family readiness for 
the full cycle of deployment and family resilience in the face of the 
challenges and uncertainties it would bring. RAND has now has begun 
longitudinal studies of family resilience and coping in each of the 
services. This series, called the Deployment Life Study, will be a 
landmark analysis that will follow a cohort of military families, from 
all service components, across a full deployment cycle. These studies 
are in an early phase and expect to have results over the next several 
years.
    The deployment of a servicemember parent affects children on the 
homefront. In 2008-2009, RAND surveyed parent caregivers, usually the 
mother, and their children ages 11 to 17 who had applied to Operation 
Purple Camp, a summer camp for children of servicemembers. We found 
that the children in the study experienced behavioral and emotional 
difficulties at rates above the national average. This finding was 
apparent in the first survey and remained much the same in the follow-
up surveys at 6 and 11 months.

     Anxiety was a specific problem. Anxiety is characterized 
by feeling frightened or having difficulty sleeping, for example. 30 
percent of the children in the study sample had elevated symptoms of 
anxiety, which is twice the rate found in other child studies. In 
contrast, the children in the study were similar to the national 
average in peer and family functioning, academic engagement, and risk 
behaviors.
     Older teens experienced more difficulties such as having 
to take on more household responsibilities, take care of siblings, and 
missing school activities, and had trouble getting to know their 
deploying parent again and adjusting to the parent fitting back into 
the household routine.
     Girls reported more difficulties during the parent's 
reintegration into the family, including worrying about the parent's 
next deployment, dealing with the parent's mood changes, and worrying 
about how parents were getting along.
     Children in families where the non-deployed parent is 
coping with emotional health issues tended to experience more 
difficulties.
     Also, just as longer total months of deployment were found 
to have a negative effect on reenlistment, they were associated with 
more problems for children. This held true across the services and in 
both active and reserve components.

    Overall, the results suggest that because children with a deployed 
parent are experiencing more emotional and behavioral difficulties, 
they may need more assistance in addressing their needs. Further, it 
might be useful to target the assistance. Perhaps families can be 
screened for emotional problems during routine healthcare visits. Also, 
support might be targeted on families facing more cumulative months of 
deployment, with the support being provided across the deployment cycle 
and not just at the start or end.
    Finally, related to the findings on the children of deployed 
parents and on family effects more generally, RAND has recently done 
research on the effect of deployment on military divorce. We find that 
the probability of divorce increases as total months of deployment 
increases.

    Thank you once again for the opportunity to address the Committee.

    Chairman Murray. Thank you very much, Dr. Hosek.
    Now, I will now turn to Mrs. Crystal Nicely.

          STATEMENT OF CRYSTAL NICELY, CAREGIVER AND 
                     SPOUSE OF OEF VETERAN

    Ms. Nicely. The morning, Chairman Murray and Members of the 
Committee. Thank you for inviting me to share me and my husband 
Todd's experiences with you today.
    My hope, through my testimony today, that those looking in 
will understand my frustration and heartache.
    Ever since my husband was injured, I have assumed a higher 
responsibility to care for him and support him as we transition 
into a new life.
    My husband lost his arms and his legs while serving his 
country in Afghanistan. During a combat patrol through the 
village of Lakari, which is in the southern Helmand Province, 
Todd was hit by an IED.
    It has been a long journey since that day in early 2010, 
and you would think that it would be quite easy for someone to 
lose hope and motivation after such a catastrophic injury. But 
my husband has been a fighter since day one.
    In recovery he displayed the same irresistible warrior 
spirit for which the Marines are so beloved, first, fighting 
off infection and disease, and then working aggressively with 
his physical medicine and rehabilitation. He continues fighting 
through progression in prosthetic training and also fighting 
for me and our future together.
    The community of wounded warriors at Walter Reed is 
diverse, and each Marine has their own particular needs. Many 
of them are fortunate enough to be accompanied by their loved 
ones. For most of the family members, we were thrown into this 
new role unexpectedly and unprepared. We have discovered that 
we could never have prepared ourselves for what we face on a 
day-to-day basis while caring for our loved ones.
    Many of us left our lives back home and assumed a new role 
at Walter Reed. Life here is not a picnic. There is not much my 
husband can do without me or someone assisting. Without his 
prosthetics Todd is unable to perform many of the very basic 
activities of daily living that people take for granted.
    We attempt to function independently, but the reality of 
his injuries requires that I or someone be at his side 
continuously. This is our new norm. For me, I am not only my 
husband's caregiver, nonmedical attendant, appointment 
scheduler, cook, driver, and groomer, but I am also his loving 
wife faced with my own stresses and frustrations.
    To be clear, this is not an issue of being overwhelmed with 
caring for my husband, but what is upsetting is the lack of 
support, compassion, and benefits for these individuals. It 
needs to be just a little bit easier.
    For the family members, we must go through a very tedious 
process to serve as a nonmedical attendant, especially at a 
time when we must oversee all other parts of our households and 
our lives, that I have to continually re-apply to keep serving 
as a nonmedical attendant, feels as though I am being judged on 
my loving care for Todd.
    Helping him through his treatment is what I want to do but 
I need the system to work with me to do that. It is almost 
disheartening to think that they believe someone else, no 
matter how willing they can be, can care for my husband more 
than I can.
    As caregivers, we leave our jobs and schools and there are 
those who have children to look after as well. We leave all of 
this to inherit another full-time job. I rely on compensation 
that is provided to nonmedical attendants to assist maintaining 
my household.
    With Todd's injuries, the bills do not stop coming and, in 
fact, it has gotten more expensive. We are grateful for what 
assistance we do get from the Marine Corps, but had we not been 
greeted by a host of people who wanted to assist, we would have 
been lost in the recovery process.
    Although my husband is one of only four surviving quadruple 
amputees, his struggles and hardships are very similar to many 
wounded warriors.
    The process in transitioning out of the military has been 
particularly difficult. Todd has been a part of an integrated 
disability evaluation system, which I understand is supposed to 
be faster--a more efficient way to complete evaluations and 
transition out of the military service.
    That has not been our experience. At one point, a simple 
summary of my husband's injuries sat on someone's desk for 
almost 70 days waiting for approval. I thank Chairman Murray 
for helping get the issue resolved but it should not take me 
talking to a U.S. Senator to help my husband. More importantly, 
what about all the other wounded Marines who have not had the 
chance to ask for that kind of help.
    Coordination of care for Todd has also been a problem. 
There seems to be so many coordinators that they are actually 
not all on the same page at this time doing opposite things. 
Though she was trying to help, I rarely saw my Federal recovery 
coordinator who seemed to have too many people she was 
responsible for.
    This lack of communication has also extended to benefits 
and programs. I have received very little information on how to 
participate or enroll in what is offered by the VA.
    For the benefits we know about, we are faced with problems 
in actually receiving them. For instance, periodically the 
stipends stop which makes things very difficult. I do not know 
why this occurs, and it is especially difficult to get a clear 
definite answer. But we need help.
    Chairman Murray, I appreciate all that is currently being 
done to assist future wounded warriors and their families. As 
for me I will never be able to fully express my appreciation 
for what assistance we do get and for what is available to us 
now because every little bit counts.
    I hope my testimony today has been helpful to you as you 
continue working to resolve these issues. Thank you very much, 
and I am happy to answer any questions you have.
    [The prepared statement of Ms. Nicely follows:]
          Prepared Statement of Crystal Nicely, Caregiver and 
                        Spouse of an OEF Veteran
    Good Afternoon. Chairman Murray, Ranking Member Burr, Members of 
the Committee, Thank you for inviting me to share my and my husband 
Todd's experiences with you today.
    I hope, through my testimony today, that those looking in will feel 
my frustration and heartache. Ever since my husband was injured I have 
assumed a higher responsibility to care for him and support him as we 
transition into a new life. I'm sharing my personal experiences and 
feelings which I hope will be useful to you in creating a better system 
of support for wounded warriors and their families. My husband lost his 
arms and legs while serving his country in Afghanistan. During a combat 
patrol through the village of Lakari, which is in the southern Helmand 
Province, Todd was hit by an IED.
    It has been a long journey since that day in early 2010. Under 
normal circumstances, one would think that it would be quite easy for 
someone to lose hope and motivation after such a catastrophic injury. 
But my husband has been a fighter since day one. In recovery he 
displayed the same irresistible warrior spirit for which the Marines 
are so beloved. First fighting off infection and disease, then working 
aggressively with his physical medicine and rehabilitation, through 
progression in prosthetic training, and also fighting for me and our 
future together.
    Although my husband is one of only three surviving quadruple 
amputees in the Marine Corps, his struggles and hardships are very 
similar to other Wounded Warriors, regardless of their injuries. I am 
here today, not only on behalf of my husband, but also the countless 
other wounded Marines and their caregivers.
                      coordination and transition
    The process of transitioning out of the military has been 
particularly difficult. Todd has been part of the Integrated Disability 
Evaluation System (IDES), which I understand is supposed to be a 
faster, more efficient way to complete the evaluations and transition 
servicemembers. That has not been our experience. At one point, a very 
simple narrative summary of my husband's injuries sat on someone's desk 
for almost 70 days waiting for a very simple approval. I thank Chairman 
Murray for her help in getting that resolved, but it should not take my 
talking with a United States Senator to make that happen. More 
importantly, what about all the other wounded Marines who have not had 
the chance to ask for that kind of help?
    Coordination of care for Todd has also been a problem. There seem 
to be so many coordinators that they are actually not all on the same 
page and sometimes doing things opposite of each other. Though she was 
trying to help, I rarely got to see our Federal Recovery Coordinator, 
who seemed to have too many people she was responsible for. The lack of 
communication also extended to benefits and programs. While I'm 
optimistic for the new VA caregiver program, I have gotten hardly any 
information on how to participate. There has been a similar lack of 
information about a variety of VA and other benefits.
    For the benefits we know about, we are also faced with problems in 
actually receiving them. Periodically the stipends stop, which makes 
things very difficult. I do not know why this occurs, especially as it 
is difficult to get a clear and definitive answer, but we need help.
                            caregiver needs
    The community of wounded Marines at Walter Reed is diverse, and 
each has their own particular needs. Many of them are fortunate to be 
accompanied by their loved ones. For most of the family members, we 
were thrown into this new role unexpectedly and unprepared, but we have 
taken it in stride with determination and hope of the future. What we 
have discovered is that we could never have prepared ourselves for what 
we face on a day to day basis while taking care of our loved ones.
    For me, I am not only my husband's caregiver, non-medical attendant 
(NMA), appointment scheduler, cook, driver, and groomer, but I am also 
his loving wife faced with my own stresses and frustrations. To be 
clear, this is not an issue of being overwhelmed with caring for my 
husband for there is no other place on earth I want be other than by 
his side. I am sure that many of the other caregivers would agree. What 
is upsetting is the lack of support, compassion, and benefits for these 
individuals. It needs to be just a little bit easier. Many of us, left 
our lives back at home, and assumed a new role and life at Walter Reed, 
as many caregivers have done across the country. Simply put, life here 
isn't a picnic. It is a bittersweet struggle of coping with new 
identities and new norms, whatever those may be.
    I first wish to address the most difficult and disheartening issue 
that continues to be a problem and barrier at Walter Reed. There is not 
much these days my husband can do without me or someone at his side. We 
attempt to function independently, but the reality of his injuries 
requires that I be close to his side, and even if I am away for only 
short periods someone must be there. This is part of our new normal. 
Without his prosthetics Todd is unable to perform many of the very 
basic Activities of Daily Living (ADL) that are taken for granted by so 
many.
    The process to serve as an NMA is tedious, particularly at a time 
when we must oversee all the other parts of our household and our 
lives. I am not enlisted so it is frustrating when I'm expected to 
carry on as if I were, when the circumstances I have now are so much 
bigger than that. This is an additional and unnecessary burden for the 
spouses and family members.
    This continual process of reapplying to be an NMA feels as though I 
am being assessed on my love and care for Todd, or my value to him and 
his condition. But helping him through his treatment is what I want to 
do. How could I ever ask someone else to step away from their lives to 
come do what we so proudly do, loving and caring for our husbands. It's 
almost disheartening to think that someone no matter how willing they 
may be can care for my husband more than I can. It hurts just to 
consider having someone else there instead of me sharing and growing in 
this experience with my husband. A lot of us come from jobs or school, 
and there are those that have children to look after as well. 
Personally, I was attending school before this. Now I have to consider 
the very expensive life that lies ahead for my husband and me. However, 
none of these factors would change my decision or take me away from my 
involvement in helping Todd's recovery. I believe it is helpful when we 
can be there learning together to learn these new life skills so, in 
the near future, I can step away without worry knowing that he can 
perform everyday activities safely and, eventually, without someone 
else there.
    Many of us caregivers are unable to work, there just are not enough 
hours in the day, and in my case, leaving my husband's side is just not 
an option. Thus, I do rely on the compensation that comes with being an 
NMA to assist with maintaining my household and saving for our future. 
With Todd's injury the bills did not stop coming and, to be honest, 
things have become more expensive. We are grateful for what assistance 
we do get from the Marine Corps, but had we not been guided by our case 
managers, other volunteers like the Semper Fi Fund, and other families 
of wounded warriors, we would have been lost in this recovery process.
                        warrior transition units
    Frequent rotation of section leaders in the warrior transition 
units is another problem area. When the new leaders take over, they 
know less about what is required than the spouses. This is no fault of 
their own, for most of these individuals that are sent here to support 
the wounded come from military occupational specialties that are 
unrelated to what there are about to be asked to do. So it is a 
learning process, but by the time they understand, it is time for new 
section leaders to take over, again without the requisite skillsets, 
and the challenges continue. I have to seek out other sources and 
individuals to assist me. Additionally, in these situations, trust is a 
key part of an effective relationship, but the continual turnover 
hinders the development of that trust.
                               conclusion
    It should not take a newspaper article or appearing at a Senate 
hearing to address these problems, but I am glad to have the 
opportunity to express this to you and seek your help. I want to take a 
moment to express my appreciation for what is being done now to aid in 
future assistance of the wounded and their families. I know that issues 
are being worked toward and I will never be able to fully express my 
appreciation for what assistance we do get and for what is available to 
us now, for every little bit counts. I hope my testimony today has been 
helpful to you as you continue working to address these issues. Thank 
you very much and I would be happy to answer any questions you have.

    Chairman Murray. Crystal, thank you so much for your 
courage in being here today and sharing your story. I really 
appreciate all you and your husband have done to help educate 
me about what you are going through and so many others are. So 
thank you for being here.
    Mrs. Lorelei St. James.

      STATEMENT OF LORELEI ST. JAMES, DIRECTOR, PHYSICAL 
INFRASTRUCTURE ISSUES, UNITED STATES GOVERNMENT ACCOUNTABILITY 
                             OFFICE

    Ms. St. James. Chairman Murray, Senator Brown, and Members 
of the Committee, I am pleased to be here today to talk about 
GAO's recent work on VA's approaches to estimating future 
capital and health care budgets.
    For the aging veteran population and for younger veterans 
returning from Afghanistan and Iraq, it is vital that VA 
effectively estimate the facilities and health care that 
veterans may need.
    Let me first talk about VA's capital planning process. VA 
has thousands of facilities to provide health care and other 
services to millions of veterans estimating the type and 
location of facilities and services is a complex process; and 
as we recently reported, VA over the course of several years 
has changed its approach to this planning.
    VA's current planning process is the Strategic Capital 
Investment Planning Process or SCIP. However, I cannot tell you 
if SCIP is an effective planning tool. It is too early to tell. 
But I can say that VA incorporated a number of leading 
practices into SCIP.
    For example, VA now considers capital investments across 
the organization using weighted criteria and expanded its 5-
year planning horizon to 10 years.
    Also prior to SCIP, VA's planning process appeared to be 
moving in the right direction. For example, VA reduced the 
number of hospitals and opened 82 community-based outpatient 
clinics, but it is not all good news.
    VA faces a daunting backlog of repairs, about $10 billion; 
and as we reported in January, 24 ongoing construction projects 
needed an additional $4.4 billion to complete.
    Moreover, the VA continues to face age-old challenges such 
as getting stakeholders to agree on needed changes, legal and 
budgetary limitations, and getting rid of excess or 
underutilized property.
    Let me now turn to VA's approach to developing its health 
care budget estimate. In January of this year, we reported that 
VA used the Enrollee Health Care Projection model and other 
methods to estimate its health care budget for fiscal years 
2011 and 2012.
    We found the model uses data reflecting the types of health 
care that veterans might need, the projected or potential 
costs, and the number of veterans who might enroll for health 
care.
    Overall, the model projects the resources to meet demand 
for over 60 health care services that account for about 83 
percent of the VA's health care cost estimate.
    The model's projections only provide a starting point for 
the budget. Throughout the budget process, the health care 
estimate is reviewed and weighed against other VA and OMB 
priorities; and in June we reported that VA's budget estimate 
using the model for 2012 and 2013 changed as it moved 
throughout the budget formulation process.
    In general, at the end of the process, VA's estimate or the 
President's request to Congress could be higher or lower than 
the model's estimate as VA and OMB weigh the estimate against 
other priorities or initiatives.
    Along the way VA has a voice in the process. For example, 
if the OMB estimate for nonrecurring maintenance is lower than 
the amount that the model projects, VA determines the impact on 
health care services and decides what action, if any, it will 
take up with OMB. VA could also propose a lower estimate for 
nonrecurring maintenance than the model projects based on other 
VA priorities.
    For example, compared to the models estimate, nonrecurring 
maintenance was $904 million lower for 2012 and $1.27 billion 
lower for 2013.
    But before that, one has to recognize that the model is 
based on imperfect data and assumptions that change. Also 
projections are made three to 4 years into the future and 
budgets are developed months in advance.
    In summary, VA uses sophisticated and complex methods to 
estimate its capital planning and health care budget. These 
methods do help to provide transparency into VA's methods; but 
the estimates they produce, like the processes and models 
themselves, are not perfect and all must compete for funding 
and sometimes unforeseen priorities.
    Thank you. I am happy to answer any of your questions.
    [The prepared statement of Ms. St. James follows:]
      Prepared Statement of Lorelei St. James, Director, Physical 
      Infrastructure Issues, U.S. Government Accountability Office
    Madam Chairman Murray, Ranking Member Burr, and Members of the 
Committee: I am pleased to be here today as you examine the lifetime 
costs of supporting the newest generation of veterans. The Department 
of Veterans Affairs (VA) operates one of the largest health care 
delivery systems in the Nation, providing care to a diverse population 
of veterans. VA operates about 150 hospitals, 130 nursing homes, and 
820 outpatient clinics through 21 regional health care networks called 
Veterans Integrated Service Networks. VA is responsible for providing 
health care services to various populations--including an aging veteran 
population and a growing number of younger veterans returning from the 
military operations in Afghanistan and Iraq. Budgeting for this vital 
health care mission is inherently complex. It is based on current 
assumptions and imperfect information, not only about program needs, 
but also on future economic and policy actions that may affect demand 
and the cost of providing these services. Adding to this complexity, VA 
has recognized over the years the need to plan and budget for facility 
modernization, and realign its real property portfolio to provide 
accessible, high-quality, and cost-effective access to its services.
    My statement today addresses VA's real property realignment efforts 
and VA's approach to developing budget estimates for health care. It is 
based on our prior real property realignment work, where we examined 
the extent to which VA's capital planning efforts resulted in changes 
to its real property portfolio, helped VA identify facility planning 
priorities, and reflected leading Federal practices for real property 
management.\1\ It is also based on our prior budget estimate work, 
where we examined how VA develops its health care budget estimate, 
addressed what VA identified as the key changes that were made to its 
budget estimate to develop the President's budget request for fiscal 
years 2012 and 2013, and explained how various sources of funding for 
VA health care and other factors informed the President's budget 
requests.\2\ To perform the work related to real property realignment 
efforts, we reviewed leading capital planning practices and data on 
VA's real property portfolio and future priorities. We also interviewed 
VA officials and veterans service organizations, and visited sites in 5 
of VA's 21 Veterans Integrated Service Networks. To perform the work 
related to budget estimates for health care, we reviewed VA documents 
on the methods, data, and assumptions used to develop VA's health care 
budget estimate that informed the President's two most recent budget 
requests for fiscal year 2011, 2012 and 2013.\3\ Our review of those 
most recent budget requests focused on the three appropriations 
accounts for VA health care services: Medical Services, Medical Support 
and Compliance, and Medical Facilities.\4\ We also interviewed VA 
officials responsible for developing this estimate and staff from the 
Office of Management and Budget (OMB). Our work was performed in 
accordance with generally accepted government auditing standards. More 
detailed information on our objectives, scope and methodology for this 
work can be found in the issued 
reports.
---------------------------------------------------------------------------
    \1\ See GAO, VA Real Property: Realignment Progressing, but Greater 
Transparency about Future Priorities Is Needed, GAO-11-197 (Washington, 
DC: Jan. 31, 2011).
    \2\ GAO, Veterans' Health Care Budget Estimate: Changes Were Made 
in Developing the President's Budget Request for Fiscal Years 2012 and 
2013, GAO-11-622 (Washington, DC: June 14, 2011); and GAO, Veterans' 
Health Care: VA Uses a Projection Model to Develop Most of Its Health 
Care Budget Estimate to Inform the President's Budget Request, GAO-11-
205 (Washington, DC: Jan. 31, 2011).
    \3\ The Veterans Health Care Budget Reform and Transparency Act of 
2009 provided that VA's annual appropriations for health care include 
advance appropriations that become available 1 fiscal year after the 
fiscal year for which the appropriations act was enacted. Pub. L. 111-
81, Sec. 3, 123 Stat. 2137, 2137-38 (2009), codified at 38 U.S.C. 
Sec. 117. The act provided for advance appropriations for the Medical 
Services, Medical Support and Compliance, and Medical Facilities 
appropriations accounts.
    \4\ The Medical Services account funds health care services 
provided to eligible veterans and beneficiaries in VA's medical 
centers, outpatient clinic facilities, contract hospitals, state homes, 
and outpatient programs on a fee basis. The Medical Support and 
Compliance account funds the management and administration of the VA 
health care system, including financial management, human resources, 
and logistics. The Medical Facilities account funds the operation and 
maintenance of the VA health care system's capital infrastructure, such 
as costs associated with nonrecurring maintenance, utilities, facility 
repair, laundry services, and groundskeeping.
---------------------------------------------------------------------------
                                summary
    Through its capital planning efforts, VA has taken steps to realign 
its real property portfolio from hospital based, inpatient care to 
outpatient care, but a substantial number of costly projects and other 
long-standing challenges remain. For example, VA reported in its 5-year 
capital plan for fiscal years 2010-2015 that it had a backlog of $9.4 
billion of facility repairs. The 5-year plan further identified an 
additional $4.4 billion in funding to complete 24 of the 69 ongoing 
major construction projects. We also found that VA, like other 
agencies, has faced underlying obstacles that have exacerbated its real 
property management challenges and can also impact its ability to fully 
realign its real property portfolio. We have previously reported that 
such challenges include competing stakeholder interests, legal and 
budgetary limitations, and capital planning processes that did not 
always adequately address such issues as excess and underutilized 
property. Furthermore, we found that VA's capital planning efforts 
generally reflected leading practices, but lacked transparency about 
the cost of future priorities that could better inform decisionmaking. 
VA concurred with our recommendation to improve the transparency of its 
budget submissions. We have not yet assessed the extent to which VA has 
implemented our recommendation in relation to the President's 2012 
budget.\5\
---------------------------------------------------------------------------
    \5\ VA's budgets for new construction exist in two accounts--Major 
Construction and Minor Construction--which are funded as separate line 
items within VA's appropriation. Major construction projects are those 
estimated to cost more than $10 million, while minor construction 
projects are those estimated to cost $10 million or less. See 38 U.S.C. 
Sec. 8104(a)(3)(A). Nonrecurring maintenance projects that may result 
in a change in space function or a renovation of existing 
infrastructure are funded through the VHA Medical Facilities budget 
account.
---------------------------------------------------------------------------
    VA uses what is known as the Enrollee Health Care Projection Model 
(EHCPM) to develop most of its health care budget estimate and uses 
other methods for the remainder. The EHCPM's estimates for these 
services are based on three basic components: projected enrollment in 
VA health care, projected use of VA's health care services, and 
projected costs of providing these services. The EHCPM makes a number 
of complex adjustments to the data to account for characteristics of VA 
health care and the veterans who access VA's health care services. For 
example, these adjustments take into account veterans' age, gender, 
geographic location, and reliance on VA health care services compared 
with other sources, such as health care services paid for by Medicare 
or private health insurers. VA officials identified changes made to its 
estimate of the resources needed to provide health care services to 
reflect policy decisions, savings from operational improvements, 
resource needs for initiatives, and other items. The President's 
request for appropriations for VA health care for fiscal years 2012 and 
2013 relied on anticipated funding from various sources, including new 
appropriations, collections, unobligated balances of multiyear 
appropriations, and reimbursements VA receives for services provided to 
other government entities.
      real property realignment efforts progressing, but greater 
              transparency needed about future priorities
    In January 2011, we reported that through its capital planning 
efforts, VA had taken steps to realign its real property portfolio from 
hospital based, inpatient care to outpatient care, but a substantial 
number of costly projects and other long-standing challenges also 
remain. Several of VA's most recent capital projects--such as community 
based outpatient clinics, rehabilitation centers for blind veterans, 
and a spinal cord injury center--were based on its Capital Asset 
Realignment for Enhanced Services (CARES) efforts and subsequent 
capital planning. VA officials and veterans service organizations we 
contacted agreed that these facilities have had a positive effect on 
veterans' access to services. However, VA had identified several high-
cost priorities such as facility repairs and projects that have not yet 
been funded. For example, VA reported in its 5-year capital plan for 
fiscal years 2010-2015 that it had a backlog of $9.4 billion of 
facility repairs. The 5-year plan further identified an additional $4.4 
billion in funding to complete 24 of the 69 ongoing major construction 
projects. Besides substantial funding priorities, we also found that 
VA, like other agencies, has faced underlying obstacles that have 
exacerbated its real property management challenges and can also impact 
its ability to fully realign its real property portfolio. We have 
previously reported that such challenges include competing stakeholder 
interests, legal and budgetary limitations, and capital planning 
processes that did not always adequately address such issues as excess 
and underutilized property.
    Furthermore, we found that VA's capital planning efforts generally 
reflected leading practices, but lacked transparency about the cost of 
future priorities that could better inform decisionmaking. For example, 
VA's 2010-2015 capital plan linked its investments with its strategic 
goals, assessed the agency's capital priorities, and evaluated various 
alternatives. Also, VA's new Strategic Capital Investment Planning 
(SCIP) process strengthened VA's capital planning efforts by extending 
the horizon of its 5-year plan to 10 years, and providing VA with a 
longer range picture of the agency's future real property priorities. 
VA officials told us that the SCIP process builds on its existing 
capital planning processes, addresses leading practices, and further 
strengthens VA's efforts in some areas. We have not fully assessed SCIP 
and it remains to be seen what impact SCIP will have on the results of 
VA's capital planning efforts. While these changes were positive steps, 
we found that VA's planning efforts lacked transparency regarding the 
magnitude of costs of the agency's future real property priorities, 
which may limit the ability of VA and Congress to make informed funding 
decisions among competing priorities. For instance, for potential 
future projects, VA's 2010-2015 capital plan only listed project name 
and contained no information on what these projects were estimated to 
cost or the priority VA had assigned to them beyond what was then the 
current budget year. Transparency about future requirements would 
benefit congressional decisionmakers by putting individual project 
decisions in a long-term, strategic context, and placing VA's fiscal 
situation within the context of the overall fiscal condition of the 
U.S. Government. It is important to note that providing future cost 
estimates to Congress for urgent, major capital programs is not without 
precedent in the Federal Government. Other Federal agencies, such as 
the Department of Defense, have provided more transparent estimates to 
Congress regarding the magnitude of its future capital priorities 
beyond immediate budget priorities.
    We concluded in our report that billions of dollars have already 
been appropriated to VA to realign and modernize its portfolio. 
Furthermore, VA had identified ongoing and future projects that could 
potentially require several additional billion dollars over the next 
few years to complete. Given the fiscal environment, VA and Congress 
would benefit from a more transparent view of potential projects and 
their estimated costs. Such a view would enable VA and Congress to 
better evaluate the full range of real property priorities over the 
next few years and, should fiscal constraints so dictate, identify 
which might take precedence over the others. In short, more 
transparency would allow for more informed decisionmaking among 
competing priorities, and the potential for improved service to 
veterans over the long term would likely be enhanced. To enhance 
transparency and allow for more informed decisionmaking related to VA's 
real property priorities, we recommended that the Secretary of Veterans 
Affairs provide the full results of VA's SCIP process and any 
subsequent capital planning efforts, including details on the estimated 
cost of all future projects, to Congress on a yearly basis. VA 
concurred with the recommendation. We have not yet assessed the extent 
to which VA has implemented our recommendation in relation to the 
President's 2012 budget.
 va uses a projection model to develop most of its health care budget 
 estimate and changes were made to the estimate for fiscal years 2012 
                                and 2013
    We reported in January 2011 that VA uses what is known as the 
Enrollee Health Care Projection Model (EHCPM) to develop most of its 
health care budget estimate and uses other methods for the remainder. 
Specifically, VA used the EHCPM to estimate the resources needed to 
meet expected demand for 61 health care services that accounted for 83 
percent of VA's health care budget estimate for fiscal year 2011.The 
EHCPM's estimates for these services are based on three basic 
components: projected enrollment in VA health care, projected use of 
VA's health care services, and projected costs of providing these 
services. To make these projections, the EHCPM uses data on the use and 
cost of these services that reflect data from VA, Medicare, and private 
health insurers. The EHCPM makes a number of complex adjustments to the 
data to account for characteristics of VA health care and the veterans 
who access VA's health care services. For example, these adjustments 
take into account veterans' age, gender, geographic location, and 
reliance on VA health care services compared with other sources, such 
as health care services paid for by Medicare or private health 
insurers. VA uses other methods to develop nearly all of the remaining 
portion of its budget estimate for long-term care and other services, 
as well as initiatives proposed by the Secretary of VA or the 
President. Long-term care and other services accounted for 16 percent 
and initiatives accounted for 1 percent of VA's health care budget 
estimate for fiscal year 2011.
    In June 2011, we reported on the President's budget request for 
fiscal years 2012 and 2013. We reported that VA officials had 
identified changes made to its estimate of the resources needed to 
provide health care services to reflect policy decisions, savings from 
operational improvements, resource needs for initiatives, and other 
items to help develop the President's budget request for fiscal years 
2012 and 2013. One of the changes that VA identified was in its 
estimates for non-recurring maintenance to repair health care 
facilities. Non-recurring maintenance funds are used for expansion, 
renovation, and infrastructure improvements that cost more than 
$25,000.\6\ VA's estimate for non-recurring maintenance was reduced by 
$904 million for fiscal year 2012 and $1.27 billion for fiscal year 
2013, due to a policy decision to fund other initiatives and hold down 
the overall budget request for VA health care. VA's estimates were 
further reduced by $1.2 billion for fiscal year 2012 and $1.3 billion 
for fiscal year 2013 due to expected savings from operational 
improvements, such as proposed changes to purchasing and contracting. 
Other changes had a mixed impact on VA's budget estimate, according to 
VA officials; some of these changes increased the overall budget 
estimate, while other changes decreased the overall estimate.
---------------------------------------------------------------------------
    \6\ In addition, expansion, renovation, and infrastructure 
improvements can be categorized as minor or major construction and 
funded by the respective appropriations accounts. The Minor 
Construction account funds projects estimated to cost as least $500,000 
but not more than $10 million, and the Major Construction account funds 
projects estimated to cost more than $10 million.
---------------------------------------------------------------------------
    The President's request for appropriations for VA health care for 
fiscal years 2012 and 2013 relied on anticipated funding from various 
sources. Specifically, of the $54.9 billion in total resources 
requested for fiscal year 2012, $50.9 billion was requested in new 
appropriations. This request assumes the availability of $4.0 billion 
from collections from veterans and private health insurers, unobligated 
balances of multiyear appropriations, and reimbursements VA receives 
for services provided to other government entities. Of the $56.7 
billion in total resources requested for fiscal year 2013, $52.5 
billion was requested in new appropriations, and $4.1 billion was 
anticipated from other funding sources. The President's request for 
fiscal year 2012 also included a request for about $953 million in 
contingency funding to provide additional resources should a recent 
economic downturn result in increased use of VA health care. 
Contingency funding was not included in the advance appropriations 
request for fiscal year 2013. As mentioned earlier, budgeting for VA 
health care is inherently complex because it is based on assumptions 
and imperfect information used to project the likely demand and cost of 
the health care services VA expects to provide. The iterative and 
multilevel review of the budget estimates can address some of these 
uncertainties as new information becomes available about program needs, 
Presidential policies, congressional actions, and future economic 
conditions. As a result, VA's estimates may change to better inform the 
President's budget request. The President's request for VA health care 
services for fiscal years 2012 and 2013 was based, in part, on 
reductions to VA's estimates of the resources required for certain 
activities and operational improvements. However, in 2006, we reported 
on a prior round of VA's planned management efficiency savings and 
found that VA lacked a methodology for its assumptions about savings 
estimates.\7\ If the estimated savings for fiscal years 2012 and 2013 
do not materialize and VA receives appropriations in the amount 
requested by the President, VA may have to make difficult tradeoffs to 
manage within the resources provided.
---------------------------------------------------------------------------
    \7\ GAO, Veterans Affairs: Limited Support for Reported Health Care 
Management Efficiency Savings, GAO-06-359R (Washington, DC: Feb. 1, 
2006).

    Madam Chairman Murray, Ranking Member Burr, and Members of the 
Committee, this concludes my prepared remarks. I would be happy to 
answer any questions that you may have.
                                 ______
                                 
  Posthearing Questions Submitted by Hon. Patty Murray to Ms. Lorelei 
St. James, Director, Physical Infrastructure, Government Accountability 
                                 Office
    Question 1. Please provide more information on the true depth of 
VA's backlog in construction projects involving improvements needed to 
protect the privacy and safety of women veterans?

    Question 2. How will the lack of investment in keeping up with 
ongoing maintenance and repairs affect VA's utilization of limited 
resources and future proposals of its infrastructure portfolio?

    Question 3. Especially in the context of current fiscal issues, all 
aspects of VA operations must be assessed for their potential to 
operate most efficiently. With respect to VA's capital planning 
process, please provide an assessment of how underutilized property can 
be of best use.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Chairman Murray. Thank you very much, Ms. St. James.
    And we will turn to Ms. Heidi Golding.

    STATEMENT OF HEIDI L. W. GOLDING, PRINCIPAL ANALYST FOR 
   MILITARY AND VETERANS' COMPENSATION, CONGRESSIONAL BUDGET 
                             OFFICE

    Ms. Golding. Thank you. Madam Chairman, Senator Brown, and 
Members of the Committee, thank you for the opportunity to 
appear before you today to discuss the health care of our 
veterans returning from overseas contingencies operations in 
Iraq and Afghanistan, which I will refer to as OCO.
    I will address some of the medical conditions they have, 
their use of health care provided by the Veterans Health 
Administration, VHA, and that CBO's projections of future 
potential costs to treat them. All costs will be expressed in 
2011 dollars.
    About 2.3 million active and reserve personnel have 
deployed to overseas operations through March 2011. The medical 
conditions resulting from their participation affect the 
numbers of veterans who will require medical care in the 
future, including that provided by be VHA.
    In total, about 69,000 servicemembers have been evacuated 
from the combat theaters because of injuries and other medical 
conditions and diseases. Many more seek care in-theater or 
after returning home.
    Traumatic Brain Injury, TBI, and Post Traumatic Stress 
Disorder, PTSD, are conditions whose treatment could result in 
substantial future costs for VHA. However, the problems of TBI 
and PTSD, that is, the proportion of people with those 
conditions, whether diagnosed with them or not, is uncertain 
partly because the conditions can be challenging to identify.
    This makes resource planning for treatment of OCO veterans 
more difficult. Nonetheless, data helpful to resource planning 
does exist. For example, through March 2011 DOD had diagnosed a 
total of 35,000 TBI's among OCO servicemembers. About 90 
percent of those were classified as mild TBI's, which typically 
heal quickly within weeks or months with relatively little 
medical intervention.
    Both DOD and VHA have implemented programs to clinically 
screen for TBIs. VHA screening indicates that about 7 percent 
of its new OCO patients have TBI with ongoing symptoms.
    In addition, VHA as diagnosed about 27 percent of OCO 
patients with PTSD. That rate is relatively high compared to 
published studies of prevalence that generally range from about 
5 to 25 percent, but it is not surprising if veterans who have 
health problems are more likely than other veterans to seek 
care.
    The number of veterans who are eligible for VHA benefits 
and the extent to which they use those services will affect 
future VHA costs. About 1.3 million OCO veterans have become 
eligible for health care through VHA. Just over half of them 
have sought that care through March 2011. The number of OCO 
veterans who have ever used VHA has grown by about 100,000 per 
year since 2005.
    Roughly half of those, those who have used a VHA, began 
using it within about 12 months of separating from service. 
Their use is typically highest in the months immediately after 
they enroll in that system.
    VHA spent almost $1.9 billion or $4800 per OCO patient in 
2010, and a cumulative total of $6 billion to treat OCO 
veterans through 2010. Although OCO veterans were 7 percent of 
all veterans treated in 2010, they represented 4 percent of VHA 
spending.
    CBO has projected the resources that VHA would need between 
2011 and 2020 to treat all of OCO veterans who seek care. CBO 
examined two scenarios.
    Under scenario one, CBO assumes that the number of deployed 
servicemembers drops to 30,000 by 2013 and remains there 
through 2020. In addition, VHA's health care expenditures per 
OCO enrollee grow at about the same rates as the national 
averages.
    Under this scenario, VHA would treat 1.3 million OCO 
veterans at least once before the end of the decade. The annual 
cost for their care would nearly triple over the decade, rising 
from $1.9 billion in 2010 to roughly $5.5 billion in 2020 for a 
10-year total of $40 billion.
    The largest growth would be early in the projection period 
due to a large influx of new enrollees. Because OCO patients 
are less expensive to treat than the average VHA patients, OCO 
veterans would consume 8 percent of VHA's total spending in 
2020.
    For scenario two, CBO assumes that the number of 
servicemembers deployed drops to 60,000 in 2015 and remains 
there. In addition, CBO assumes VHA's expenditures per OCO in 
enrollee grow at an annual rate that is about 30 percent higher 
than in scenario one.
    Under scenario two, the cost to treat OCO veterans in 2020 
is more than 50 percent higher than in scenario one, $8.4 
billion. Costs over 10 years would total $55 billion. Almost 2/
3 of the cost difference is due to the faster growth in 
expenditures per enrollee.
    Thank you very much. I am happy to answer any questions.
    [The prepared statement of Ms. Golding follows:]
   Prepared Statement of Heidi L. W. Golding, Principal Analyst for 
    Military and Veterans' Compensation, Congressional Budget Office




                                    _____

   Posthearing Questions Submitted by Hon. Patty Murray to Ms. Heidi 
 Golding, Principal Analyst, National Security Division, Congressional 
                             Budget Office
    Question 1. Please provide more information regarding how 
addressing excess and duplication at VA will raise efficiency and 
maximize a return on resources without negatively impacting services?

    Question 2. Many of the deficit and debt reduction proposals 
included across the board spending cuts and caps. Please provide any 
information your agency has regarding what impact such a cap will have 
on VA's ability to provide health care for over 8.3 million veterans in 
the coming years?

    [Responses were not received within the Committee's 
timeframe for publication.]

    Chairman Murray. Thank you very much. Thank you again to 
all for your testimony today. It is really appreciated.
    Mrs. Nicely, I want to start with you. When I first met you 
up at Bethesda, I was really disconcerted when you told me that 
you had been waiting forever for your husband to finish his 
joint disability evaluation process. You had to wait almost 70 
days for approval of a simple narrative summary.
    Now, I went and checked. What I understand is that the 
summary only needed to state the obvious, that your husband was 
indeed missing two legs and two arms, and that essentially sat 
on somebody's desk for more than 2 months. That is just really 
unacceptable, and my apologies to you and your family on behalf 
of everyone for that.
    But I wanted you, as you shared with me, to talk to me a 
little bit about what you were going through for those 70 days 
while this country essentially bureaucratically put you on 
hold.
    Ms. Nicely. I think Todd's therapy is very important but he 
got to a point in his therapy where he was able to do more 
stuff more independently which did not require his therapist to 
be there I guess during the whole time.
    So, it is a requirement. I do not know if it is just Marine 
Corps procedure or whatever that they go into therapy; and if 
Todd was not being taught new things or it was just getting 
redundant, he was doing the same things over and over again, so 
he had pretty much accomplished much of what he has wanted to 
within that timeframe, which meant he was taking up more space 
that other people could have been utilizing the therapist.
    So, I guess why pay for his therapy or why if you could be 
paying it for somebody else. So, it was just a waste of time I 
guess.
    Chairman Murray. What were you spending your time doing?
    Ms. Nicely. Support. Taking Todd back and forth to therapy 
and just helping him with the daily living.
    Chairman Murray. You talked to me a little bit about 
coordinators of care, that they were coming through changing 
every 2 months and that you knew more than they did and they 
left and you were training the coordinators of care.
    Can you share with us a little bit about that?
    Ms. Nicely. I do not want to say that all of them are at 
fault due to the situation because of the way it is. But the 
way that the military side has the liaisons coming in and out 
is very frustrating because they are not MOS specific. They are 
not trained in the jobs to get done that are being asked of 
them.
    So, they come here without the knowledge of what they are 
expected to do and take the time while they are here to learn 
what they are doing, and by the time that they have adjusted 
and maybe have absorbed some of it, it is time for them to 
leave again, and new individuals come in who are not still not 
MOS specific.
    So, that does not help us with what they are here for is 
the frustration and helping them take the stress off of the 
families and able to do the things that are necessary.
    Instead me personally had to look for outside assistance 
from whether it was other family support or my case manager but 
was not assisted on the military side of things.
    That also does not aid, and for me in the beginning of the 
family process, it is really hard to open up to people and 
trust individuals. So, to be able to get a connection with 
somebody and have somebody there for that short period of time 
and then transition out and give us somebody else new is not 
allowing us to have that connection or allow us to want to open 
up to them because we are like, OK, if we come to you what are 
you going to do for me because I know more than you do.
    So, it is extremely frustrating. I know that they are 
working on it but it is still frustrating.
    Chairman Murray. You are a tremendous advocate for your 
husband, and I am extremely impressed what Todd is capable of 
doing, and I know that you are proud of that as well. I also 
know that he needs you at his side, and you are there every 
single minute doing that.
    You met many people through this process. What does 
somebody do that does not have a wife or a live-in caregiver?
    Ms. Nicely. That is hard because you do see it. In some 
cases the family support is maybe not there or maybe not there 
for the right reasons. I think because of the lack of, I do not 
want to say lack of knowledge but their ability to assist in a 
lot of ways and the lack of compassion when it comes to a lot 
of these guys, their next choice would be to reach out to 
somebody I do not know whether it is through the military side 
of things or through the hospital because the hospital staff is 
wonderful. I guess there is not really a way to say that.
    Chairman Murray. Maybe if you can share with this 
Committee, as you did with me, a little bit about what your day 
is like.
    Ms. Nicely. Well, here recently a lot easier than normal 
because Todd has strived to become very independent with his 
prosthetics. Without his prosthetics, I would be doing the work 
for two people every day. And with his prosthetics and because 
of his knowledge and what he has been able to absorb through 
his therapist and his daily work in putting into therapy, I 
basically just observe and watch and, if he needs assistance, 
then I assist him if he asks, of course.
    Chairman Murray. Thank you. And thank you for your courage 
in being here again too.
    Mr. Rieckhoff, our government's ability to fulfill the 
sacred responsibility has been called into question by the 
ongoing debt crisis that is in front of us today.
    If the debt limit is not raised, some have speculated that 
the government will not have enough money to provide veterans' 
benefits checks. As you can imagine, and I am sure you know 
this, this uncertainty has caused an incredible amount of 
anxiety among our veterans and, of course, their families. I 
understand that the IAVA was at The White House yesterday, and 
I wanted to ask you if you can describe what the impact of a 
default would be on veterans.
    Mr. Rieckhoff. We do not know, and that is what we hoped to 
find out at The White House yesterday. We came back with no 
real additional information for our members.
    So, I would ask you all what the impact will be. I think 
the bottom line for our members right now is they do not know 
what is going to happen August 1. They do not know what is 
going to happen September 1. They do not know if disability 
checks are coming. They do not know if paychecks are coming. 
They do not know if GI Bill checks are coming, and they are 
extremely concerned. They are scared.
    Some of these folks who are 100-percent disabled have 
gotten no additional information and we have been getting quite 
a few e-mails, tweets, Facebook posts. People are more and more 
concerned by the day. And I think they understand generally 
where the debate is. They do not understand the specifics of 
how it will impact them. No one has been able to project with 
any kind of certainty how they should plan for their next 60 
days.
    Chairman Murray. I assume there is a lot of frustration.
    Mr. Rieckhoff. Incredible frustration, just devastating 
disappointment. And it has become demoralizing. I mean, not 
even from folks just here Stateside but overseas. There is a 
guy on a checkpoint in Afghanistan right now who does not know 
for certain what is going to happen to him and his family in 30 
days.
    That is ridiculous and it is outrageous and our members are 
beyond upset, and so, I would ask this Committee if you can 
help us get certainty. We have e-mails standing by. I can send 
it out to them within an hour and let them know what is going 
on but we need clarity and guidance from you all in this town 
about what to tell them. We have not gotten it yet.
    Chairman Murray. Thank you. Thank you for much.
    Senator Brown.
    Senator Brown of Massachusetts. Thank you very much.
    Crystal, I was concerned a little bit. You mentioned in 
your initial testimony about you have to go and get recertified 
on a regular basis to be in your position as a home care?
    Ms. Nicely. Yes, sir.
    Senator Brown of Massachusetts. Can you tell me a little 
bit about that? Like what they have told you, what is the 
process, how long does it take, why have they told you that you 
need to do it?
    Ms. Nicely. In the beginning, from my understanding, it 
requires a doctor's approval. So, like a re-evaluation of the 
military servicemembers' health and how they are getting better 
on a day-to-day basis.
    So, the use of or the need of a medical attendant, I 
believe, is why they make us re-apply for it, and it takes 
quite a long time. In the beginning, I do not know, months 
almost. I know there was a waiting list for a nonmedical 
attendant assistants.
    From my understanding, they are working on it to improve 
that and it has improved speedwise, but going about how to get 
approved and the stipulations, and a better understanding of 
its is a need I would have to say.
    Senator Brown of Massachusetts. So, how long does your 
certification actually last?
    Ms. Nicely. I think the longest that you can request a 
nonmedical attendant is 6 months.
    Senator Brown of Massachusetts. So, how many times have you 
had to recertify?
    Ms. Nicely. I have only actually had to do it once for 
myself due to, I guess, the stipulations or the requirements of 
the law that due to I am transferred by record book to where my 
husband is that I no longer rate it. So, but I know certain 
from other family members and other individuals that have gone 
through it had to re-apply many times. I do not know if that is 
due to the process, the loss of paperwork, or----
    Senator Brown of Massachusetts. So, thank you for that. I 
am wondering how long has Todd been part of the IDES?
    Ms. Nicely. What do you mean by that?
    Senator Brown of Massachusetts. Well, he has been going 
through I know the expedited disability system.
    In listening to your testimony, you said it was very 
frustrating, and there were breakdowns. I have a sense that you 
did not want to blame anybody because you are thankful 
obviously for the things that you have.
    But on the other hand, you are upset at the fact that no 
one seems to be coming and saying, hey, listen, this is what 
you have, this is how you get it, and this is where you go, and 
this is, you know, how much you are going to get or the 
assistant. Has anyone ever done that and actually sat down and 
laid it all out to you on a piece of paper so you can actually 
almost have a flowchart?
    Ms. Nicely. Before Senator Murray spoke to us, nobody sat 
down and gave us a better understanding of how the med board 
process works, nor what was to be expected of it, except that 
it was going to take a very long time. That was what we were 
informed of.
    Senator Brown of Massachusetts. So how long was it from 
point ``A'' to Senator Murray getting involved?
    Ms. Nicely. It started, Todd's Med Board I would say 
January timeframe because they said that there was a 
possibility that it would take quite a long time. So, by the 
time Todd was ready, and therapy was completed and he was ready 
to leave the hospital that it should be completed.
    Senator Brown of Massachusetts. So you mentioned just a 
summary took 7 months, it was on somebody's desk you said.
    Ms. Nicely. 70 days.
    Senator Brown of Massachusetts. I am sorry. 70 days. Thank 
you. 70 days. Were you given any reason for that?
    Ms. Nicely. Officially that it was just sitting on 
someone's desk. I believe that is what we were informed of that 
it was just sitting and waiting.
    Senator Brown of Massachusetts. That is certainly not 
acceptable. Are you recognizing any additional hassles or 
problems of things moving along more expeditiously now?
    Ms. Nicely. Oh, yes. She, as in Senator Murray, really put, 
kick them in the butt and we have not had any issues since.
    Senator Brown of Massachusetts. That is great.
    It is interesting because, according to our original 
estimates, it is 42,000. Does it take a Senator to kick 
people's butts to get help for the other soldiers and family 
members that are having very similar problems?
    You have a husband who is obviously extremely injured. For 
him to have to go through this stuff and you as well, I just 
find once again, you know, we are getting back to the fact that 
the VA is not here. I would suggest, I am just sitting in as 
the Ranking Member today but with Senator Burr's consideration 
also that we find out like why.
    Chairman Murray. Senator Brown, I appreciate that. I will 
say that the military was responsible at this point, and 
Secretary Lynn is personally involved.
    Senator Brown of Massachusetts. Great. Thank you. My time 
is up and there are other Members. I will come back. Thank you.
    Chairman Murray. Thank you very much.
    Senator Tester.
    Senator Tester. Thank you, Madam Chair and thank you all 
for your testimony. Crystal, thank you especially.
    You talked about your gratitude for Chairwoman Murray, and 
we all are grateful for Chairwoman Murray but the fact is our 
gratitude goes the other way. We thank you for what you do. We 
thank you for the sacrifices that your husband and you have 
given this country. We cannot repay you. That is just the way 
it is. There is nothing we can do to repay what you sacrificed.
    And I think the VA is probably listening to this hearing, 
and I think the constructive criticism you have given is very 
positive. The questions about the IDES process, the section 
leader, the NMA recertification were already asked. I am not 
going to ask them again. I think you did a fine job.
    Obviously, there needs to be more education done. There 
needs to be some streamlining because, quite honestly, with the 
number of disabled vets that are out there, the action of a 
Senator, there is no way we can do it all. So, the VA has to 
step up in a bigger way, and I think they are hearing that 
message through C-SPAN or whatever means it might be today.
    Paul, I would like to echo your testimony. I think that the 
lifetime costs are huge but I think intervention in the 
beginning can save money and make quality-of-life better for 
our veterans.
    It seems like a lot of the problems stem from access. A lot 
of problems stem from education. It is particularly difficult 
in rural America. We have tried to do some things. We have 
tried to enhance mileage. We tried to get more clinics out 
there, tried to get telemedicine going. More employment 
counselors in rural America.
    The challenges are many. This is not a fair question, but I 
am going to ask it anyway. If you are going to look from my 
rural America perspective, the challenges that are out there, 
we have made some improvements.
    Is there more we need to be doing and what areas would you 
invest in if you were sitting in this chair?
    Mr. Rieckhoff. Yes, sir. There is a lot of room for 
improvement, and that is what we hear consistently from our 
members. One thing that I think is important for this Committee 
and for this entire town to really wrap their heads around is 
that right now only 52 percent of our generation of veterans 
are enrolled in VA health care. Only half.
    So we have got to think more creatively. The country thinks 
that the VA is a one-stop, the only solution, the silver bullet 
that is going to solve all the problems of this generation, and 
the VA I know is improving.
    Obviously, we are disappointed they are not here. They have 
a long way to go. But we have also got to think more 
creatively. And I think we have to have a sustained effort that 
invests in community-based nonprofits, that enrolls the private 
sector, that involves the faith-based community, the people who 
are in those rural communities, because the VA has not 
innovated as a nationwide model. It is still catching up from 
30 years ago in every way shape or form.
    So, what we have seen as successful is involving those 
communities, leveraging technology especially. That is how you 
can get to those folks where they have decent access to the 
Internet, but that does give you a tremendous opportunity for 
innovation and for impact. You are not going to be able to 
bring everybody 400 miles to the nearest facility.
    So, we have got to think creatively and find ways to invest 
in the community-based solutions that are working, you know, 
find those pilots and then take them to scale, because that is 
where we see in the field the most consistent entrepreneurial 
attitude.
    It is that community-based church group or VFW hall or 
folks who are at the point of attack who are trying to deal 
with those problems. We have not seen a lot of innovation that 
has really been encouraged and taken to scale outside of the 
VA.
    So, that is kind of I think a big bite of the apple that we 
as a Nation have to start to take on. The President has got to 
reframe it as well. He has to talk about more than the VA when 
we talk about veterans.
    Senator Tester. Thank you. I want to talk about local 
contracting. I guess initially it would be for Ms. St. James 
but whoever would like to answer this.
    It is a huge issue in my State. The inability for the VA to 
recruit and retain doctors and surgeons is a big, big, big 
issue. We have not had a full-time orthopedic surgeon in 
Montana for several months. The VA is trying to recruit one. 
They cannot get them.
    Now, we have got veterans who have to travel out of State, 
out-of-pocket care, quality-of-life goes down. There are 400 
veterans on a wait list now that is approaching 2 years for 
orthopedic surgeries. It is completely unacceptable, and I know 
Montana is not the only State in this boat.
    I do not think it is cost-effective to ship somebody miles 
and miles, hundreds of miles away from their home for surgery 
when it could be contracted locally in areas where we cannot 
get docs in the VA.
    Can you tell me if this makes sense to you, to locally 
contract if you cannot get a doctor that is a specialist? If it 
is not you, Mrs. St. James, somebody else can answer the 
question.
    But it appears to me that this could help solve any problem 
where we have need and we cannot fill the positions, it just 
seems to me that it would be a natural follow-on, to contract 
locally, take care of it so you do not have to travel halfway 
across the western United States and back again.
    Ms. St. James. I think that is more appropriate for someone 
else on the panel.
    Senator Tester. OK. Anyone else want to take a shot at it. 
If not, it is yours, Paul.
    Ms. Golding. All I can say on that, because I am not an 
expert on that aspect, is that I know there is some fee-based 
care in VHA. I do not know how they decide when it goes to fee-
based care or not.
    Senator Tester. Paul.
    Ms. Golding. I am shooting it back to you, Paul.
    Mr. Rieckhoff. Sir, when you are in the fight and you need 
ammo, you put your hand back and you want ammo, OK, these folks 
are out in the fight. You have heard from Mrs. Nicely. They 
need immediate care.
    Senator Tester. Right.
    Mr. Rieckhoff. And I think whether or not it is a contract 
is like DC talk to folks in the field.
    Senator Tester. Right.
    Mr. Rieckhoff. They want to know, who can I call right now 
that can help me.
    Senator Tester. Right.
    Mr. Rieckhoff. And I think whatever it takes to creatively 
deliver to that point of impact is what we need to come up 
with.
    Senator Tester. Right. That is my perspective too. I think 
that having people that need knee or hip replacement on a list 
for 2 years, it is not a good way to run a ship. I understand 
the problem with recruitment in rural America. It is in the 
private sector and in the public sector both. So, it is really 
important.
    My time has run out long past, and I thank you all for your 
testimony and appreciate your perspectives.
    Chairman Murray. Thank you very much.
    Senator Isakson.

               STATEMENT OF HON. JOHNNY ISAKSON, 
                   U.S. SENATOR FROM GEORGIA

    Senator Isakson. Well, I want to compliment Crystal on her 
courage and their bravery to be here, and I want to take the 
presumptive position of recommending to the Chairman and the 
Ranking Member that our testimony be mailed to every Member of 
the U.S. Senate as required reading because I think it is a 
story that needs to be told over and over.
    Sometimes, we get so busy doing things like we are doing 
right now, which is running around in circles, we do not really 
take into consideration those who are meeting tremendous 
challenges in life because of what they have to do.
    You are a real hero to me, and I hope the Chair will do 
that and make sure every Member of the Senate at least gets the 
opportunity to read what a true American hero and Crystal and 
her husband really are.
    Chairman Murray. I would hope that all of America hears it.
    Senator Isakson. Absolutely.
    Paul, I appreciate you being a very articulate spokesman on 
behalf of our Iraqi and Afghanistan veterans. They are going to 
need it over the years. There are a lot of them, and the 
challenges just like Crystal has described are greater.
    The advances we have had in health care are wonderful but 
it also means there are a lot of people surviving battlefield 
injuries that did not before that require a tremendous amount 
of help and support. So, I appreciate what you are doing.
    Crystal, on the nonmedical attendant, when you were 
answering Senator Brown, you said the VA provides one for up to 
6 months. I thought I heard you say.
    Ms. Nicely. I think it is actually military compensation 
because the VA does not pick you up until after the 
servicemember has retired. So, it is military compensation. It 
is up to 6 months. I think that is the requirement from my 
understanding.
    When I first initially applied for the nonmedical 
attendant, they did it for a year, and then I was informed that 
it could only be 6 months, and then I was informed before 
applying it again that I did not rate it because I was 
transferred with Todd by record book.
    Senator Isakson. So you are compensated by the VA as a 
nonmedical attendant during that period of time?
    Ms. Nicely. Not yet, no, sir.
    Senator Isakson. What I was trying to get at, Scott's 
question was right on point with me, why in the world you would 
have to continue to re-apply to the main nonmedical attendant 
over and over again.
    Ms. Nicely. It is frustrating, I guess, if the 
servicemember does need the assistance and the family is here 
to care or a friend or whatever the case may be. I do not know. 
I just know that they do require you to re-apply.
    Senator Isakson. Walter Reed is being closed in the next 30 
days, if I am not mistaken. Have you had any consultation with 
the new move to Bethesda? I guess Todd will be going to 
Bethesda. Is that right?
    Ms. Nicely. Actually, due to Senator Murray's kick in the 
butt----
    Senator Isakson. She is good at that by the way.
    Ms. Nicely. Yes, she is. We actually have a date on which 
he is going to retire. So, we actually will not have to do the 
move. But they are, they just recently had a town hall meeting 
for servicemembers to come to so that way they could explain 
the move and ask questions if need be.
    Senator Isakson. Thank you very much again, Crystal.
    Mrs. St. James, I know you are in the physical evaluation 
which means the bricks and mortar, that type of thing. Do you 
feel like the VA is making adequate plans in terms of that?
    And going to Senator Tester's statement about contract 
services, particularly in States like Montana and take South 
Georgia where we have 63 counties where we do not have a 
physician private or VA for that matter.
    Do you think the VA is making adequate plans to deal with 
what is going to be a higher volume of services because of the 
veterans of Iraq and Afghanistan in terms of the physical 
plant?
    Ms. St. James. We looked at their planning process both on 
the part of bricks and mortar, as you mentioned, as well as 
looking at their enrollee health care projection model.
    And on the physical infrastructure side, the new planning 
process that they have, which is called SCIP, we have not had 
time really to evaluate that, and to know whether or not it is 
taking into account what needs to be done.
    VA appears to take into account the overall plan of what 
needs to be done on the health care side for those services. 
But quite honestly, the SCIP process is new. We have not had 
time to evaluate it.
    I can only say that VA appears to have progressed from its 
earlier days of capital planning, but the SCIP process was just 
used to inform the 2012 budget.
    So, we do not know how effective it is going to be.
    Senator Isakson. Thank you.
    Thank you, Madam Chairman.
    Chairman Murray. Thank you.
    Senator Boozman.

                STATEMENT OF HON. JOHN BOOZMAN, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Madam Chair.
    And again, Crystal, we really do appreciate your testimony. 
You have done a good job. It has been very informative.
    You represent your family and your husband very, very well, 
and more importantly, I think all of the other families that 
are in the same situation. So, give yourself a pat on the back. 
Like I say, you have done very, very well and very helpful.
    Here so much comes from the top down, and it is so 
important and I just appreciate you, Madam Chair, having her 
here in the sense that, you know, we do not dwell from the 
bottom up meaning relating to the people that are actually out 
there fighting the battle, like you are doing, on a daily 
basis. It really is very helpful to hear.
    Paul, I think the comments you made about the faith-based 
communities or the faith-based interaction in the communities, 
not just the faith-based but just all of the, you know, the 
nonprofits, the charitable organizations are trying to do a 
good job.
    One of the problems that we have we see all of these 
deployments from our guard units, and they are going off with a 
regular unit and then coming back, you are still with your 
buddies and life goes on, but just all of a sudden you are 
thrown back and many times, myself representing a southern 
State, many times going back and I think that is probably true 
throughout the country, going back to small communities where 
there is not a lot of resources, you know, very limited with 
the VA, and then just the nature of the beast of how they are 
separated, it really is real important.
    So, we would like to work with you to strengthen, you know, 
your ideas on how we strengthen those relationships and 
encourage that to flourish.
    Could you comment about that for a second?
    Mr. Rieckhoff. Yes, sir. I think it is about wrapping the 
communities around these veterans when they come home. What is 
so unprecedented is the small percentage of people who are 
serving relative to the overall population. So, if we can find 
creative ways to galvanize around those veterans, it would be a 
worthy investment.
    I think what I see--in the local communities and in the 
rural areas especially--is a patchwork of services. If someone 
calls me from rural Montana and says my husband is suicidal, 
the services available to them are going to be dramatically 
different than Kansas or Florida or somewhere else.
    And so, our team has a really difficult time of being able 
to deliver or even connect them with reliable services because 
they are so fragmented. I really firmly believe there has not 
been a significant investment nationwide in community groups of 
all kinds.
    The comparison that we have started to draw on recently is 
that what veterans face right now is kind of like AIDS 25 or 30 
years ago when you did not have existing infrastructures.
    There is no massive philanthropic investment. There is no 
corporate investment. A lot of the nonprofits only started 
seven, 8 years ago. Some of them out of people's trunks. So, we 
are really in the earliest stages of creating an entire 
national network around a totally new set of issues, whether it 
is multiple amputations, or traumatic brain injury or women's 
issues.
    A lot of the stuff is new, and there is not a system in 
place nationwide to tackle it. So, I think we have really got 
to issue a national call over and over again on some of the 
issues that Senator Tester talked about earlier.
    The fact that we still do not have enough qualified mental 
health care workers is ridiculous. I have been coming here 
every year talking about this. If the President stood up 
tomorrow and said if you want to serve your country, be 
qualified as a mental health care worker, go work at the VA, go 
work at the DOD and we are going to pay you and we are going to 
support you and we are going to train you, that is a great way 
for people to serve their country, and I think they would step 
up.
    We have got to make those calls clear and we have to think 
more creatively than outside of the existing bureaucracies.
    Senator Boozman. Very good. I agree. We have to put that 
infrastructure in place and then another problem, and you might 
comment on this, Crystal, is the fact that we do have stuff in 
place now and yet families do not know about it. It is not 
readily accessible.
    If you can comment on that or ways that we can improve 
that. But I see that as something that we really need to get 
aggressive with.
    Ms. Nicely. Like many have said that the strides that have 
been made are amazing because many years ago you did not have 
what we have now.
    But I think that, as that being said, what should be 
focused on now is these things and the improvements that are 
going to be there for the future because the war is not going 
away and people are still going to be wounded.
    So, the accessibility to the things that the servicemembers 
are needing. In my husband's case, prosthetics are a big thing. 
So, if we did move to a small town or a small area, would we 
have to go further away from our home due they did not have the 
technology or the things needed to be able to assist him with 
what he does need to make life easier on a daily basis.
    So, those drives are amazing and great and improvement is 
always something to be proud about. But it is a problem that is 
not going away, and the improvements will always be needed.
    Senator Boozman. Good. Thank you, Crystal. Thank all of you 
for being here. We appreciate your testimony.
    Chairman Murray. Thank you very much.
    Mrs. St. James, I want to ask you while you are here, I 
recently heard some were disturbing complaints from a female 
veteran. She told me she had a great deal of difficulty in 
accessing appropriate safe care for herself. She had some exams 
from a doctor where he left the exam room open to a crowded 
hallway, had been harassed by male veterans while trying to get 
mental health care and other concerns.
    I am concerned about the lack of separate women-only 
inpatient mental health care units that we are hearing about as 
well. So, I am very concerned that the VA is not strategically 
planning for the increasing number of women veterans. Something 
Mr. Rieckhoff mentioned as one of the costs of this war.
    Can you share with this Committee how many of VA's 
backlogged construction projects involve improvements needed 
just to protect the privacy and safety of women veterans?
    Ms. St. James. I really do not have that specific 
information. I do know that there are initiatives that VA 
includes in its planning process but I do not know specifically 
if that is one.
    Chairman Murray. Is that something you can find out for us?
    Ms. St. James. We can certainly get back to you on that.
    Chairman Murray. I would really appreciate that.
Response to Request Arising During the Hearing by Hon. Patty Murray to 
   Lorelei St. James, Director, Physical Infrastructure Issues, U.S. 
                    Government Accountability Office
    Question 1. Can you share with this Committee how many of VA's 
backlogged construction projects involve improvements needed just to 
protect the privacy and safety of women veterans?
    Response. GAO's current work on Department of Veterans' Affairs 
(VA) facilities and health care issues does not directly include a 
total number of projects that involve improvements to protect the 
privacy and safety of women veterans. We asked VA to provide a more 
specific total, but the agency was unable to provide an answer by the 
Committee's August 17, 2011, deadline. We will forward that information 
to the Committee as soon as it is available from VA. While we do not 
know the number of backlogged construction projects that relate to the 
privacy and safety of women veterans, our past work has identified that 
VA drafted a set of weighted criteria by which it plans to evaluate 
capital investment projects, one of which is to assess whether capital 
investments address selected key major initiatives and supporting 
initiatives identified in VA's strategic plan.\1\ VA's strategic plan 
outlines its major initiatives, including a goal to enhance veterans' 
access to health care.\2\ For example, the strategic plan calls for 
continued realignment of the VA health care delivery system because of 
a shift in demographics, specifically an increase in the number of 
women veterans.
---------------------------------------------------------------------------
    \1\ GAO, VA Real Property: Realignment Progressing, but Greater 
Transparency about Future Priorities Is Needed, GAO-11-197 (Washington, 
DC: January 31, 2011).
    \2\ Department of Veterans Affairs, VA Strategic Plan Refresh FY 
2011-2015, (Washington, DC: Undated).
---------------------------------------------------------------------------
    We have also found that VA identified a number of key challenges in 
providing health care services to women veterans. For example, in our 
report on services available to women veterans, officials at VA medical 
facilities told us that space constraints have raised issues affecting 
the provision of health care services to women veterans particularly 
related to ensuring their privacy and safety.\3\ According to VA 
officials, most VA medical centers have planned renovation, 
construction, or relocation projects as part of their efforts to expand 
services and implement comprehensive primary care for women veterans. 
In our recent report regarding sexual assaults and other safety 
incidents, VA medical facilities we visited used a variety of 
precautions intended to prevent sexual assaults and other safety 
incidents.\4\ However, we found some of these measures were deficient, 
compromising medical facilities' efforts to prevent such incidents. For 
example, medical facilities used physical security precautions, such as 
closed-circuit surveillance cameras, to actively monitor areas, and 
locks and alarms to secure key areas. However, at the five sites we 
visited, we found significant weaknesses in the implementation of these 
physical security precautions, including poor monitoring of 
surveillance cameras, alarm system malfunctions, and the failure of 
alarms to alert both VA police and clinical staff when triggered. 
Further, inadequate system configuration and testing procedures also 
contributed to these weaknesses. To address vulnerabilities in physical 
security precautions at VA medical facilities, we recommended that VA 
ensure that alarm systems are regularly tested and kept in working 
order and that coordination among stakeholders occurs for renovations 
to units and physical security features at VA medical facilities. VA 
concurred with our recommendations and provided an action plan to 
address them.
---------------------------------------------------------------------------
    \3\ GAO, VA Health Care: VA Has Taken Steps to Make Services 
Available to Women Veterans, but Needs to Revise Key Policies and 
Improve Oversight Processes, GAO-10-287 ( Washington, DC: March 31, 
2010).
    \4\ GAO, VA Health Care: Improvements Needed for Monitoring and 
Preventing Sexual Assaults and Other Safety Incidents, GAO-11-736T 
(Washington, DC: June 13, 2011).

    Chairman Murray. Ms. Golding, you testified that the 
medical costs for Iraq and Afghanistan veterans between 2011 
and 2020 could total between $40 billion and $55 billion. That 
number, of course, does not take into account the cost of 
paying for our previous generations of veterans that we are 
still responsible for.
    Ms. Golding. Correct.
    Chairman Murray. CBO did another report earlier this year 
on possible ways to reduce the deficit where they made a couple 
of recommendations about veterans programs.
    I do not support those specific proposals because they 
negatively impacted benefits, which I believe we should not be 
touching. But I do believe there are some ways that we can be 
more effective with taxpayer dollars but not diverting it from 
direct delivery of services and health care.
    I wanted to ask you this morning: do you believe there is 
enough excess and duplication that can be addressed to make VA 
more efficient without negatively impacting services?
    Ms. Golding. Just one or two points that I want to make on 
that, and the first is that we also had projections for the 
2011-2020 timeframe for VHA for all veterans; and the budget 
would grow, not the budget but the amount of the cost to treat 
those individuals would rise from the $48 billion in 2010 to, 
under the one scenario, $69 billion, and in the much higher 
scenario which includes higher medical inflation and so forth, 
I think it was $85 billion.
    So, in the lower case we are talking about an increase of 
about 45 percent over the next 10 years, which is a substantial 
increase in order to be able to provide the health care for all 
enrolled veterans.
    Now, we do not make policy recommendations, and we have not 
in that paper looked at options for cutting that growth. We 
have not looked at efficiencies.
    So, I cannot tell you about that specifically. I mean, you 
are aware of our budget options apparently. So, we do have a 
couple of options in that but it may also involve not just 
efficiencies but it may involve shifting some costs or some 
other things.
    Chairman Murray. If we just do efficiency and shifting 
costs, will we meet that projection that you just made?
    Ms. Golding. I cannot tell you unfortunately.
    Chairman Murray. Mr. Hosek, a 2008 RAND study concluded 
that there is a possible connection between having PTSD, TBI, 
and major depression and being homeless.
    Last month, Admiral Mullen expressed concern about 
repeating the mistakes we made after the Vietnam War and he 
said, we are generating a homeless generation, many more 
homeless female veteran; and if we are not careful, we are 
going to do the same thing we did last time, unquote.
    Can you walk me through the costs, both budgetary and 
human, of caring for veterans after they become homeless and of 
using care as a tool to prevent homelessness?
    Mr. Hosek. Unfortunately, I cannot give you estimates of 
the cost.
    Chairman Murray. Do you want to turn on your mike.
    Mr. Hosek. Thanks. Unfortunately, I cannot give you 
estimates of the cost. My concern, which I foreshadowed in my 
testimony, is that there may be a value in being more proactive 
in guiding people as they leave the service.
    Right now when servicemembers leave the service, they 
receive an outbrief. That outbrief covers, among other things, 
the benefits they are entitled to and advises them, of course, 
that they will have a post-deployment health assessment and a 
6-month follow-up of that if they are still in the service and 
then leave later on.
    But this information comes at them very fast; and even 
though it is provided, which is a good thing, I am afraid that 
many of them do not really absorb it at the time. And when they 
leave the military and go out and need care or need to learn 
about their VA benefits or need to learn about job search 
support, they really do not know where to turn.
    They have not necessarily absorbed or remembered what they 
were told, and our research indicates that there are not 
readily available cohesive, easily accessible sources of 
information.
    Now, people absorb information in two ways, when it is 
pushed at them or when they pull for it. And a lot of the 
discussion that we have received has to do with the push of 
information, that is, just making it available.
    But the fact that there are not readily available cohesive 
sources of information, something that Paul referred to, I 
think is important too.
    I mention in my testimony that one thing we really do not 
know much about are people who leave the service. We do not 
know about their joint seeking of educational benefits and 
further education or work and their health care. And we are 
particularly interested in, or particularly concerned about 
servicemembers----
    Chairman Murray. Are you looking at the cost of that? Is 
that something----
    Mr. Hosek. These are simply ideas I am responding to you 
for your questions. These are not, to my knowledge, studies we 
have underway at RAND. I realize the importance of this, and I 
wish I could give you a specific estimate.
    It is important, I think, to think about this sort of 
jointly occurring set of concerns that servicemembers have. If 
there happen to be roughly one in five, perhaps fewer, 
servicemembers who leave with major depressive disorder or Post 
Traumatic Stress Disorder and they also want to find a job or 
they want to seek health care, we are finding a lot of them are 
having trouble finding jobs.
    The lot of them are not seeking care. We have talked about 
the barriers to care. That has come up in several of the 
testimonies today, and I know in your hearing last week. All of 
those things come together.
    Trying to make things easier for veterans to provide that 
information, this is something that Paul's outfit is 
particularly concerned with but it is not only something that 
should be left to volunteer organizations.
    It is possible that more effective support could be 
provided by the services or by contractors, or simply by making 
more effective Web-based services available.
    For example, the Military OneSource source of information 
has been a big boon to servicemembers, providing them with 
information on many service-related resources for 
servicemembers and their families before, during, and after the 
deployment.
    Developments in that direction for veterans are likely to 
be helpful. As I mentioned in my testimony, veterans have 
reported difficulty knowing where services are offered, what 
kind of services are available, how to apply for them, who is 
eligible. Those are fundamental questions.
    The fact that half of those with probable PTSD or MDD had 
not seen a physician and had not been evaluated within the 
prior year or two to our survey was striking. These are 
individuals who arguably ought to be evaluated.
    There are certainly many veterans who leave, who can do 
well on their own. But for people with these probable 
symptoms--and sometimes individuals do not report their 
symptoms, so that is one of the reasons for the wide variance 
in estimates of PTSD and MDD--they should be incentivized and 
have the information to seek help.
    We clearly have in the VA system an issue of surge 
capability. The VA caseload largely consists of older veterans, 
and VA handles many individuals who need health care.
    The immediate growth of the new generation of veterans, as 
you have referred to it here in the hearing, is a challenge for 
them because they need to adapt their provider mix, and those 
are growth problems.
    To the extent that there are also providers available in 
the private sector, I will suggest, without the basis of 
research, that it is certainly worth thinking about trying to 
figure out how to make use of extant capacity in the private 
sector.
    Chairman Murray. And I appreciate that. One of the points 
of this hearing is the cost of war, just providing it in the 
private sector is not free. It is still a cost, and we have to 
keep focused on that.
    Senator Brown.
    Senator Brown of Massachusetts. Thank you.
    Crystal, I just want to go back to you, and I apologize. I 
had to go down to a HSGAC hearing, and I will have some 
questions. So, if you have answered this, I apologize.
    But during your time going through what you were going 
through, did you ever go to any outside agencies, outside the 
military, outside the VA to get some additional assistance?
    If so, could you kind of explain what you did and what that 
response was like?
    Ms. Nicely. Well, in the beginning, I really did not know 
of what was available. But due to my case manager, Jordan Hall, 
he gave us some information in regards to some foundations that 
could help; and when we sought those foundations, they were 
able to assist us like the Semper Fi Fund, Operation Homefront, 
and Soldiers' Angels. I mean there are so many that are great 
foundations, that help and assist. Yes.
    Senator Brown of Massachusetts. Great. Thank you.
    Mr. Rieckhoff, in your written testimony you state that 
long-term, it is estimated it will cost between $600 billion 
and $1 trillion to care for OEF/OIF veterans alone. I am 
interested in learning a little bit more about your estimate.
    Is this a study conducted by you folks or any other 
organization that would come up with those figures?
    Mr. Rieckhoff. I think this is actually to the doctor's 
earlier point. Estimates are all over the place, and in part 
because we do not have real good research on a lot of things.
    So, these are high-end, low-end estimates that come from a 
variety of places ranging from RAND to Harvard researchers to 
veterans' groups. I think two things we have to identify are 
accurate numbers for homelessness and suicide. VA just released 
their new numbers of 10,000 homeless veterans.
    Those numbers are really fuzzy. Places like New York do not 
even count veterans when they go out to count homeless people. 
So, we really do not know what the cost of that is going to be.
    On suicide specifically, we do not know how many veteran 
suicides there are. That is really troubling. We hear 
anecdotally about suicides from the community on a regular 
basis that are not counted. If you separate from the military 
and you are a veteran who doesn't use the VA, you do not get 
counted. And we cannot even begin to calculate those costs.
    So, I think it is important that we recognize that some of 
the best research that came from the RAND study back in 2008 is 
still the best research now. And that was privately funded.
    So, to answer your question, sir, is we do not know and I 
do not think anybody knows. And anybody who tells you they do 
know, let us see the research.
    Across this industry, as you guys try to think in the next 
couple of years about how to spend money and how to support 
different programs, we need much more research and we all have 
a hard time I think finding really good data.
    And I think the suicide is the best example. We have no 
idea how many veterans have committed suicide since 9/11. 
Nobody knows because there is nobody counting the veterans 
population. I think that is a major problem when we tried to 
forecast any kind of cost.
    Senator Brown of Massachusetts. Thank you.
    Dr. Hosek, did you notice at all a difference between 
active Army, active military versus Guard and Reserve in terms 
of getting the materials, because you indicated that when 
somebody leaves, they have an outbriefing obviously?
    I know being from Massachusetts that not only do we, as a 
Guard and Reservist, not only do you get an outbrief, you have 
to go through basically a total top to bottom exit interview. 
They give you the packet. They give you everything so when you 
are saying they do not have anywhere to go, quite frankly I 
would suggest that they look in the packet that they have been 
given as we do it in Massachusetts.
    What are your observations in that?
    Mr. Hosek. Well, to begin with a specific answer, I have 
not seen any research whatsoever comparing the outprocessing 
support for active versus Reserve. So, I am not sure what that 
difference would be.
    I agree with you that individuals actually receive 
briefings. They receive materials. They basically should have a 
starting point on where to go, and that is good. At the same 
time, the recently done RAND New York State Veterans Needs 
paper, as well as the earlier paper on invisible wounds, 
indicated that many of the respondents were not sure where to 
turn, what to seek.
    This could reflect differences among individuals in their 
capacity to remember and recall information or to process 
complicated information.
    So I think, as I said a minute or two ago, while I think 
that what is being done right now is probably very helpful, it 
is not totally effective. There is a question about how to 
continue to reach people after they leave the service and begin 
actively seeking some sort of support or assistance, health 
care, GI Bill benefits, what have you.
    Senator Brown of Massachusetts. Thank you.
    Ms. St. James, in your analysis of the VA's 5-year capital 
plan for 2004 to 2009, GAO noted VA's real property portfolio 
changed to with an increase in leases and leased spaces. This 
was VA's efforts to adjust their real property portfolio to 
match the agency's overall mission to move the delivery of care 
toward more outpatient facilities.
    Beyond CBOCs and Vet Centers, in what ways can the Veterans 
Health Administration expand their inventory of leased 
buildings, and also, is there any effort to have these 
buildings within already government on properties to, in fact, 
save money?
    Ms. St. James. There were improvements in the use of space 
and I believe our report indicated that there had been some 
improvements in that.
    Leasing is part of an initiative that is included in their 
planning as is the need for the planning of community-based 
outpatient clinics which is directly tied to trying to give 
care to the more rural community.
    So, leasing is a factor in their planning. More could be 
done in terms of better use of all space. I think it is an 
issue governmentwide of having more space than is actually 
needed, coupled with the need to take care of historical 
properties that are quite expensive to take care of.
    So, if I have not answered your question, let me know and I 
will get back to you.
    Senator Brown of Massachusetts. Thank you.
    Chairman Murray. Thank you very much, Senator Brown. I have 
some questions that I will submit for the record. If you have 
any, you can as well.
    Senator Brown of Massachusetts. Thank you.
    Chairman Murray. I want to thank each of our witnesses for 
their testimony on the lifetime costs of caring for our newest 
generation of veterans, and I especially again, Crystal, want 
to thank you and Todd for being here and for Todd's service to 
the country. You have shown incredible courage again in sharing 
your story with us.
    You are really an example to a lot of other veterans, their 
families who are traveling down this road to recovery, and I 
really believe that your testimony today will go a long way in 
helping us do a better job.
    As I said at the beginning of this hearing, caring for 
veterans is a cost of war that we have to account for. As 
today's hearing has really made clear, the cost of caring for 
this new generation of veterans is not going to end when they 
come home. It will be incurred over a lifetime.
    So, as we are here today and the deadline for reaching a 
debt ceiling agreement quickly approaches and various proposals 
to cut or cap spending are out there, we have got to remember 
the sacred responsibility we have to care for our veterans and 
servicemembers. We as a Nation must honor our obligations in 
good times and in bad.
    So, I appreciate all of you being here today to participate 
and share your perspectives on the lifetime costs of this war.
    Thank you very much. This hearing is adjourned.
    [Whereupon, at 11:39 a.m., the Committee adjourned.]
                            A P P E N D I X

                              ----------                              


 Prepared Statement of Gold Star Wives of America, Inc., Presented by 
 Vivianne Cisneros Wersel, Au.D., Chair, Government Relations Committee
    With malice toward none; with charity for all; with firmness in the 
right, as God gives us to see right, let us strive to finish the work 
we are in; to bind up the Nation's wounds, to care for him who has 
borne the battle, his widow and his orphan.''

        President Abraham Lincoln, Second Inaugural Address, March 4, 
        1865

    Chairman Murray, Ranking Member Burr, and members of the Senate 
Veterans' Affairs Committee, thank you for the opportunity to submit 
testimony for the record on behalf of Gold Star Wives of America 
pertaining to ``Examining the Lifetime Costs of Supporting the Newest 
Generation of Veterans.''
    Gold Star Wives of America, an all volunteer organization founded 
in 1945, is a congressionally chartered organization of spouses of 
servicemembers who died while on active duty or who died as the result 
of a service-connected disability during World War II, the Korean War, 
the Vietnam War, the first Gulf War, the wars in Iraq and Afghanistan, 
and every period in between.
    Gold Star Wives is an organization of those who are left behind 
when our Nation's heroes, bearing the burden of freedom for all of us, 
have fallen. We are that family minus one; we are spouses and children, 
all having suffered the unbearable loss of our spouses, fathers or 
mothers. We are those to whom Abraham Lincoln referred when he made the 
government's commitment ``* * * to care for him who shall have borne 
the battle, and for his widow, and his orphan.''
    For the purpose of this specific testimony, Gold Star Wives will 
include the silent cost of the war as well as the measurable cost of 
legislative inequities affecting surviving families of today's 
veterans; however the legislative inequities include survivors of 
previous wars.
    According to the Department of Defense, as of December 2010, 
approximately 6,128 of our Nation's military heroes have given the 
ultimate sacrifice during Operation Iraqi Freedom, Operation Enduring 
Freedom and Operation New Dawn. It's estimated approximately 49% left 
behind a family to carry on without them. After the flag is folded, the 
surviving spouse is left to carry on the duties of their family despite 
the tragic loss of their loved one. The long term cost of the war for 
Gold Star Families is unfortunately not included in the Congressional 
budget nor is it a line item in the President's budget. The lifetime 
cost of survivors has to be included in the DOD budget to include the 
survivors of the military, regardless of circumstance of death.
    Surviving spouses are faced with inequities in their survivor 
benefits as well as the emotional challenges of raising a family alone 
after the death of their spouse, or having the missed opportunity to 
even start a family.
    For the purpose of testimony I will review both the quantitative 
and qualitative costs of this war pertaining to ``Examining the 
Lifetime Costs of Supporting the Newest Generation of Veterans.''
    Presently the lifetime costs of supporting the newest generation of 
veterans does not include survivors and their benefits; only the living 
veteran. The lifetime costs for supporting the surviving spouse are 
only projected in legislative bills that have not passed and/or are not 
calculated as a reality despite the overwhelming congressional support 
of cosponsors. However the life time cost for the surviving spouses not 
receiving their entitled benefits can be estimated depending on the 
individual. These estimates reflect the lifetime quality of life for 
the surviving spouse and their family. These benefits include the 
calculation change of the Dependency Indemnity Compensation, removing 
the Survivor Benefit Plan (SBP) offset by the Dependency Indemnity 
Compensation (DIC), Education, and the dental plan for children.
    For the surviving spouse of today's veterans, financial challenges 
arise when benefits are not provided as intended. Congress created two 
programs for survivors of our military members. In 1956, Dependency and 
Indemnity Compensation (DIC) was established by the Servicemen's and 
Veteran's Survivor Benefit Act. The purpose of DIC is an indemnity 
payable to survivors when a military member dies as a result of a 
service-connected cause yet Congress enforces a dollar for dollar 
offset. It is very apparent that financial stability is the overriding 
concern of these families. Gold Star Wives believes the most 
significant long-term advantage to the family's financial security 
would be to end the Dependency Indemnity Compensation dollar for dollar 
offset to the Survivor Benefit Plan. This cost should be considered as 
a cost of war for legislation. This is not a new subject for us to 
testify about before Congress. For the survivors with children, feel 
forced to assign the SBP to their children to avoid the offset; 
however, they're placing a shelf life on the benefit as it terminates 
when the child becomes of age. We recognize that jurisdiction resides 
elsewhere, but we know each Member of this Committee can and should be 
concerned within the context of your own jurisdiction that this 
inequity should be fixed, and fixed immediately.
    In 1972, Congress created the Survivor Benefit Plan (SBP). The 
purpose of SBP is to insure that a portion of the military member's 
retirement will be provided to the surviving widow after the military 
member's death. Two different plans, one paid by retiree premiums or an 
active duty military member's life and the other paid by the Department 
of Veterans Affairs.
    The financial hardships of losing a military spouse are also 
coupled with the emotional strain of losing a loved one and parenting 
their children alone. There is a silent cost of war that is not 
projected in any military budget nor is it considered in legislation 
when addressing survivor benefits for the family of today's veteran.
    The following is a letter from a Gold Star wife in Florida named 
Jennifer. She wrote this letter back in 2009, No changes have been made 
since that time, so therefore a letter of complaint written four years 
ago is still applicable to our discussion today:

          ``I have to begin by asking why our sacrifice as military 
        families, not spouses alone but whole families, being devalued. 
        I am the widow of a Marine killed in Iraq. I have three very 
        young children to raise. At the time of his death, our children 
        were 7, 5 and 1, the eldest have required therapy from the time 
        that they lost their father. As the benefits we receive do not 
        fully cover this I was happy to pay the rest to ensure my 
        children would be able to cope with all of the devastation to 
        their lives. From the day I received the phone call about my 
        husband's injury through to his death my children lost me as 
        well. I was beside him in Germany then Bethesda for two months. 
        After my husband's passing I was so scared I was no longer the 
        Mom they had always known. I was now the only thing they had to 
        cling to and I was falling apart. I needed help with almost 
        everything just to keep them safe and well. I am still scared, 
        I have many years ahead of me where I have to provide for my 
        children and myself. I am confused by the arguments that seem 
        to play back infinitely when the questions regarding SBP/DIC 
        offset are raised, `We can't afford to do it' or 'We can't find 
        the mandatory spending offsets' due to other more important 
        issues' Do we lack importance? Some of these programs deemed 
        `more important' are $250 billion sometimes $300 billion. Where 
        is the $6 billion for military widows? When do we become worth 
        it? When do our children become worth it? When do you turn 
        around and say you deserve it for your sacrifice? We are simply 
        asking for what is due to us. If this were a civilian insurance 
        policy they would have to pay. An offset would never enter the 
        discussion. The government, ironically would make them, so why 
        then does the government relinquish itself from this 
        responsibility of payment by way of exercising this ``offset''?
          ``By my understanding DIC is a compensation paid for Military 
        members who were killed while on active duty or died from 
        service-connected physical problems after retirement. It was 
        clearly created for a very different reason than was SBP. SBP 
        is a benefit for servicemembers to ensure that their family is 
        cared for in the event of their death.''

    She further stated that it appears that Congress gives with their 
right hand for everyone to see but they take out of our back pocket 
with their left.

          She continues in her letter ``I don't think there is any 
        recipient of the `special allowance' who perceives getting $50 
        (now $60) a month as adequate compensation when they are 
        entitled to over 20 times that amount.''
          ``It makes me ill to reduce my husband's sacrifice, his life, 
        to a dollar amount but I can't raise his children on letters, 
        flags and Veteran's Day speeches. If any of the words that I 
        hear are to ring sincere then remove this offset and speak to 
        us, impact us through your actions.''
            For your consideration, very sincerely,
            Jennifer

    Losing a spouse is devastating; however, when a child loses a 
parent, the impact is greater than anyone can grasp. We continue to 
hear of studies regarding the effects of war on children. We put to you 
there is no greater cost than that of a parentless child. Approximately 
4,300 children have lost a parent in the Iraq and Afghanistan wars. The 
numbers are higher when including service-connected deaths or line of 
duty non-hostile deaths.
    It is a known fact that a wartime death presents unique hardships 
for children. Many families relocated shortly after a death and lost 
their network of support. For boys, besides losing a father, they lost 
their male role model to guide them through their lives. It is a 
consensus of our organization that today's surviving spouses have 
significant challenges with raising boys alone without their dad. 
Again, this cannot be found on a CBO score card and is not considered a 
financial cost of war, but a ripple effect of war.
    According to my son, the day he lost his father was also the day he 
also lost his mother; I was not the same mother to him and he wanted 
her back. No solution for this problem has been found since it was 
identified during the Vietnam war era as noted in the book After the 
Flag has been Folded, A Daughter Remembers the Father She Lost to War 
and the Mother Who Held The Family Together by Karen Spears Zacharias. 
Again, the cost of holding the family together as well as lost 
opportunities for these children for a lifetime is immeasurable.
    Kristen, whose husband was recently killed in Afghanistan, spoke 
about the challenges of raising a 12 year old son alone. According to 
Kristen, ``Children of the Fallen as they try to move forward in their 
lives, they want to be a normal child. However, I think when I take my 
son to events like a baseball game they always thank the servicemembers 
and first responders, but never say anything about the fallen soldiers 
or children that could be there.'' Measuring the cost of missed 
opportunities going to a sporting event with dad cannot be scored.
    Many of our children have been treated for depression and 
unfortunately some of our members' children have attempted suicide. One 
child, five years out from death shared with his counselor that he had 
few memories of his Dad because he was perpetually deployed prior to 
his death. It is difficult to measure the dynamic challenges of a child 
grieving the loss of a parent as it can change as they age. The lack of 
access to local VA care for mental health requires some members to seek 
services from the public sector with a cost involved.
    When Congress improves survivor benefits, not all survivors are 
included. The practice of selective benefit entitlement for different 
circumstances and eras must stop. Every time Congress institutes a 
cutoff period for a program, some child, or some surviving spouse is 
left behind wondering when the servicemembers' death will count.
    Many of our members are not able to return to work after an 
unexpected death, yet their benefits are not significant enough to pay 
their existing mortgage and or rent. Some of our young members have 
been diagnosed and treated for Post Traumatic Stress Syndrome (PTSD) 
yet awareness is not prevalent. Others suffer and cope with their loss 
while raising their children, frustrated and worried about the future, 
the clock ticking until their SBP terminates when the children become 
of age, if they chose child option.
    Costs are measured in dollars, there is another cost that is not 
calculated; the silent cost. The question asked is what are the long 
term costs of war? The child who sits solemnly alone while other 
fathers visit the school classroom already knows. The young daughter 
walking down the marital aisle without her loving father already knows. 
The young surviving spouse who is so exhausted from serving in the 
roles of both mother and father already knows. The family with the 
empty seat at a meal already knows. The long term caregiver who suffers 
from secondary PTSD and caregiver stress, whose own health has failed 
already knows. The military commander who sends someone to knock on the 
door to notify the family of the Fallen already knows.
    This testimony provides you with information about the cost of war 
for the Gold Star Family and should be considered when determining 
passing legislation as a line item for the cost of war. The mission of 
the VA is clearly stated ``To care for him that has borne the battle 
his widow and his orphan.'' We are waiting for this statement to be 
evident. The issues affecting surviving spouses and children need to be 
remedied. Long standing queued issues such as the SBP/DIC offset 
elimination, requests to increase DIC to 55 percent of 100% disability 
compensation, increases in education benefits (in line with other 
Federal survivor programs), programs to assist with dental and vision 
remain unimplemented.
    Secretary of Veterans Affairs, Eric Shinseki, stated, ``Taking care 
of survivors is as essential as taking care of our Veterans and 
military personnel. By taking care of survivors, we are honoring a 
commitment made to our Veterans and military members.'' We're asking 
you to honor that commitment.
    Thank you for this opportunity to testify. The families of the 
Nation's fallen have already suffered the greatest loss; there is no 
need to make these families struggle further.
    Gold Star Wives appreciates the compassionate work the Members of 
this Committee and the staff do on our behalf. We always stand ready to 
provide this Committee with any additional you may need.
    Gold Star Wives Legislative Issues:

I. Increase Dependency and Indemnity Compensation (DIC)
    In 1956, Dependency and Indemnity Compensation (DIC) was 
established by the Servicemen's and Veteran's Survivor Benefit Act. The 
purpose of DIC is an indemnity payable to survivors when a military 
member dies as a result of a service-connected cause.
    GSW seeks parity with other Federal survivor programs when 
calculating DIC. This affects more than 330,000 widows. DIC is 
currently paid to widows at 43% of the VA Compensation received by the 
veteran with a 100% service-connected disability. Other Federal 
survivor programs provide 55% of the disability pay of the Federal 
employee to the widow. Bringing DIC's computation to 55% would provide 
parity with other Federal survivor programs and would increase DIC by 
approximately $300 per month. Why military widows are forced to accept 
a lower percentage than other Federal survivor programs is 
incomprehensible to GSW. In addition, DIC has had no increase since 
1993, 18 years since the flat-rate replaced the ranked-based DIC.
    The continued economic stresses our country is now enduring places 
widows one step away from a car that stops running or an unpaid house 
payment or utility bill. Many of our elderly widows are in financial 
distress, unable to pay for food and utilities. Equalizing the 
computation of DIC would offer some relief from worry and would improve 
financial independence and confidence for GSW members. The increase in 
DIC should not subject the SBP to further offset.
    GSW recently received a call from an elderly DIC widow inquiring 
why the DIC payment has not changed in years. When explained that DIC 
would increase if there was a Cost of Living Allowance (COLA) increase, 
she stated that whoever determines COLA apparently never visited her 
town because her rent, gas and electric has increased and so has the 
price of milk and bread. She then said, ``I can't cut any more 
corners.'' These types of calls are received frequently from our 
members.
    Congress should make the ethical decision now to change the DIC 
compensation to 55% which is afforded other Federal survivors.
II. Eliminate the Dependency and Indemnity Compensation (DIC) Offset to 
        the Survivor Benefit Plan (SBP)
    GSW encompasses approximately 10,000 DIC recipients. Some of our 
members are eligible for and receive SBP. For those widows who receive 
SBP, either the retired military member chose to purchase SBP upon 
retirement or the military member died while on active duty.
    When a widow is eligible for both SBP and DIC, the widow becomes 
subject to the ``widow's tax''--a dollar-for-dollar reduction in the 
SBP by the amount of DIC received. Military members dying on active 
duty did not pay premiums. (Prior to 9/11, a servicemember dying on 
active duty had to be retirement eligible for his survivor to receive 
SBP without payment of premiums.) Their surviving spouse became 
eligible for SBP on the date of the active duty death. Retired military 
members chose to purchase SBP and pay premiums with hard-earned 
retirement. Until 2005 and the implementation of concurrent receipt, 
some disabled retirees received no retirement pay with which to pay 
premiums. Many were forced to pay from disability compensation. The 
offset, never mentioned to the military member, only becomes visible to 
their widow once the military member has died.
    Surviving spouses impacted by the DIC offset to their SBP are quite 
often shocked to learn they are subject to an offset. Completely 
unaware of the offset and how it would affect them financially forces 
them to make many hard adjustments in their day-to-day lives to 
accommodate the offset's effects.
Attempts to Fix the Offset
    Congress has chosen not to eliminate the offset for eleven years 
for the small group of widows impacted by the offset. Instead, Congress 
further divided and subdivided this small group with Band-Aid fixes for 
the offset. Three of the Band-Aid fixes, also called options, create 
even more confusion about benefits and who is eligible and often do 
little to eliminate the financial distress initially caused by the 
offset in the first place. Even reporting these options and their 
consequences to Congressional members is difficult as they do not 
understand the impact, ramifications and end-result these options 
caused. The options are outlined below.
    First, the reassignment of a spouse's SBP to her children. In 2003, 
a new law passed, Public Law 108-136, authorizing active duty widows 
the ability to assign the SBP annuity to their children, if any, 
permanently forfeiting any right the widow had to SBP. This 
reassignment allows full receipt of SBP by the child(ren) without 
offset until they reach the age of majority, when the benefit 
terminates. The widow is forced to make this decision very soon after 
notification of her spouse's death and her decision then becomes 
irrevocable. Complications from this new law often require that the 
widow be granted guardianship of her own child(ren) by a court of law. 
A widow whose husband died in retirement is not eligible for this 
option.
    Second, remarriage. In August 2009, the U.S. Court of Appeals in 
the matter of Sharp, et al. v. The United States, 82 Fed. Cl. 222 
(2008), ruled that DIC payments may not be deducted from SBP annuities 
if a person, entitled to both benefits has remarried after age 57. It 
does not make sense to have two separate standards in the law, one that 
allows payment of full SBP and DIC for widows who remarry after age 57 
and another forcing a dollar-for-dollar offset between the SBP and DIC 
for all others. GSW is concerned that the Federal Government now 
requires a remarriage in order for an annuity to be paid in full.
    Third, Special Survivor Indemnity Allowance (SSIA). The NDAA FY 
2008 established a Special Survivor Indemnity Allowance for widows who 
are the beneficiary of the SBP annuity and their SBP annuity is 
partially or fully offset by the DIC. The SSIA also applies to the 
widows of members who died on active duty whose SBP annuity is 
partially or fully offset by their DIC. SSIA began at $50 per month and 
increases each fiscal year until 2017, when the SSIA terminates.
    GSW understands that Congress does not permit the private sector or 
other Federal benefit programs to reduce or terminate retired annuities 
because the survivor is also eligible for DIC. So it begs the question, 
how can the full receipt of SBP and DIC be considered double dipping 
when in 2004 it was determined by Congress that the 100% disabled would 
receive their full retirement and disability compensation payments? 
Survivor compensation is provided to widows based on the military 
member who is rated at 100% disabled. There is no greater disability 
than death.
III. Education Benefits
    GSW seeks an increase in the monthly stipend for Chapter 35 
benefits as it has not kept current with the increases in educational 
tuition and fees. While tuition increases vary state-by-state, all have 
increased, some dramatically. A housing allowance also should be 
included with the Chapter 35 education benefits.
    GSW further requests that the New G.I. Bill allow the transfer of 
educations benefits to a qualified widow or child who is not eligible 
for the Gunnery Sergeant John David Fry Scholarship Program (Fry 
Scholarship).
    GSW is greatly encouraged by the Fry Scholarship and requests this 
program be included in the Yellow Ribbon Education Program (Yellow 
Ribbon Program). The Yellow Ribbon Program does not currently apply to 
children of the fallen, yet it would help ensure these children have a 
brighter future. We believe this was an oversight when the Fry 
Scholarship was created with the intention of matching education 
benefits to the New G.I. Bill.
    Additionally, many encounter a problem transitioning from Chapter 
35 education benefits to the Fry Scholarship that greatly delays 
payments. We are willing to work with both the Senate and House VA 
Committees to help rectify this unique problem and the backlog 
experienced with the Chapter 35 education benefit.
    GSW is grateful and appreciates that surviving children have access 
to an education program that is above and beyond Chapter 35 through the 
Fry Scholarship. However, many other surviving children do not qualify 
for this scholarship and are in need of more adequate support. We would 
appreciate the opportunity to work with the VA to help remedy these 
issues and avoid future problems with the benefits.
    GSW requests that the time period for eligibility to utilize 
Chapter 35 education benefits for military widows of retirees who died 
of a service-connected cause be extended from ten (10) to twenty (20) 
years. This extension would allow all military widows a greater 
opportunity to use the education benefit and improve their quality of 
life. In addition, it brings into alignment the time period for widows 
of both active duty deaths and widows of retirees who died of a 
service-connected cause.
                                 ______
                                 
       Prepared Statement of Paul Sullivan, Executive Director, 
                       Veterans for Common Sense
                              introduction
    Veterans for Common Sense (VCS) thanks Committee Chairman Patty 
Murray, Ranking Member Richard Burr, and Senators on the Senate 
Committee on Veterans' Affairs for allowing us to submit this written 
statement for the record for your hearing, ``Examining the Lifetime 
Costs of Care for the Newest Generation of Veterans,'' specifically the 
enormous escalating human financial consequences of the Iraq and 
Afghanistan conflicts for the United States.
    VCS is a non-profit based in Washington, DC, focusing on the 
causes, conduct, and consequences of war. We provide public relations 
and government relations advocacy for our servicemembers, veterans, and 
families.
                             vcs leadership
    VCS continues leading the national effort uncovering the human and 
financial costs of the Iraq and Afghanistan wars. Our servicemembers, 
veterans, families, and the American public have a right to know the 
facts about the costs of war. In their groundbreaking book published in 
2008, The Three Trillion Dollar War: The True cost of the Iraq 
Conflict, Linda Bilmes and Joseph Stiglitz wrote:

          By now it is clear that the U.S. invasion of Iraq was a 
        terrible mistake * * *. Understanding the costs of the war has 
        not been easy, and it would not have been possible without the 
        help of many. The fact that so much of the data and information 
        that should have been publicly available was not meant that 
        some critical pieces of information have had to be obtained 
        through the Freedom of Information Act (FOIA). We thank Paul 
        Sullivan of Veterans for Common Sense, who helped us to 
        understand the situation facing returning Iraq and Afghanistan 
        war veterans, and who provided us with crucial data from the 
        Defense Department and Department of Veterans Affairs obtained 
        under FOIA.

    In the past year, VCS was honored to provide DOD and VA reports to 
Catherine Lutz at Brown University for her larger study on the costs of 
the Iraq and Afghanistan wars. Please see the web site http://
costsofwar.org/ for further details.
  key facts: one million patients by 2013, with a 40-year cost of $1 
                                trillion
    VCS begins by presenting the Committee with the most current and 
salient official government statistics about the human and financial 
costs of the current conflicts. These are facts VA and DOD refuse to 
provide on a consistent, complete, or transparent manner to the 
Congress or the public.
    As of December 2010, VA reports reveal 654,384 new, first-time 
veteran patients were treated VA hospitals and clinics since 2001. 
Based on an average of nearly 10,000 new patients each month, VCS 
estimates the count of new Iraq and Afghanistan war veteran patients 
treated by VA will exceed 720,000 on July 31, 2011.
    According to their September 30, 2010, testimony before the House 
Committee on Veterans' Affairs, Linda Bilmes and Joseph Stiglitz now 
estimate the financial cost of the Iraq and Afghanistan wars to be in 
the trillions of dollars. Bilmes and Stiglitz have criticized the 
government for failing to collect current and future cost data. Using 
data obtained by VCS, it is estimated that:

          Taking these costs into account, the total budgetary costs 
        associated with providing for America's war veterans from Iraq 
        and Afghanistan approaches $1 trillion.
                   vcs request for action by congress
    VCS has two major requests today. We urge Congress to pass a new 
law mandating the Administration collect robust, consistent, and 
accurate data in a transparent manner so DOD, VA, and Congress can 
accurately estimate, monitor, and plan for the influx of post-war 
casualties from the current wars as well as any future wars.
    Furthermore, VCS urges Congress to establish a Trust Fund so future 
generations of veterans are protected from unwarranted assaults on 
funding for VA healthcare and benefits.
                       recent official statistics
    Government statistics pieced together from several reports paint a 
disturbing picture of enormous human suffering among our Iraq and 
Afghanistan war servicemembers and veterans. VCS obtained the following 
facts from DOD and VA using FOIA:

    According to DOD:

     At the end of June 2011, a total of 6,098 U.S. 
servicemembers died in the Iraq War and Afghanistan War combat zones; 
this includes 289 confirmed suicides.
     At the end of June 2011, a total of 100,600 U.S. 
servicemembers wounded in action or medically evacuated due to injuries 
or illnesses that could not be treated in the war zones.
     The grand total of U.S. battlefield casualties reported by 
DOD is nearly 107,000.

    According to VA:

     As of December 2010, VA treated and diagnosed 654,384 new, 
first-time Iraq War and Afghanistan War veteran patients. Based on our 
analysis of 10,000 new patients per month, VCS estimates VA will have 
treated 720,00 patients as of July 31, 2011.
     Please note that VA's report excludes veterans who sought 
private care, retired veterans treated by the military, and student 
veterans treated at campus clinics. VA's count also excludes medical 
treatment for wounded, injured, or ill civilian contractors from the 
U.S. deployed to the war zones.
     As of December 2010, VA received 552,215 disability 
compensation and pension claims filed by our Iraq War and Afghanistan 
War veterans.

    VCS Analysis:

     When VA and DOD reports are viewed side-by-side, VA data 
reveals more than 100 new, first-time veteran patients for each 
battlefield death reported by DOD.
     At the current rate of nearly 10,000 new veteran patients 
and claims entering the VA medical and benefits systems each month, VCS 
estimates a cumulative total of one million patients and claims by the 
end of 2013.
VCS Sources:
DOD, ``Global War on Terrorism--Operation Enduring Freedom, By Casualty 
            Within Service, Oct. 7, 2001, Through July 5, 2011'' 
            (Afghanistan War).
DOD, ``Global War on Terrorism--Operation Iraqi Freedom, By Casualty 
            Category Within Service, Mar. 19, 2003, Through July 5, 
            2011'' (Iraq War, Mar. 2003 through Aug. 2010).
DOD, ``Global War on Terrorism--Operation New Dawn, By Casualty Within 
            Service, Sep. 1, 2010 Through July 5, 2011'' (Continuation 
            of Iraq War since Sep. 2010).
VA, ``VA Benefits Activity: Veterans Deployed to the Global War on 
            Terror,'' Through Sep. 2010, Feb. 2011.
VA, ``Analysis of VA Health Care Utilization Among US Global War on 
            Terrorism Veterans, 1st Quarter, Fiscal Year 2011,'' Apr. 
            2011.
VA, ``VA Facility Specific OIF/OEF Veterans Coded with Potential PTSD 
            Through 1st Quarter FY 2011,'' Apr. 2011.
                 missing facts prompt need for reports
    In order for VA and DOD to properly manage the human and financial 
cost of providing medical care for our casualties, more robust data 
must be collected by the Administration and then and analyzed 
immediately by the Administration, Congress, academics, and advocates 
in a transparent and easy to understand manner. In short, the best 
policies for our servicemembers and veterans are designed, implemented, 
and then evolve over time with the best available information.

     VA must be able to answer simple, straightforward 
questions. For example, what is the total number of unique deployed 
Iraq and Afghanistan war veterans who have received any VA benefit 
since returning home? The list of benefits includes, but is not limited 
to healthcare at VA clinics and hospitals, counseling at VA Vet 
Centers, disability compensation, life insurance benefits, home loan 
guaranty, and vocational rehabilitation. VCS remains highly alarmed VA 
remains incapable and unwilling to answer these easy questions. 
Congress can and must fix this now with a new law mandating reports.
     DOD and VA must prepare an official accounting of the 
financial costs for VA benefits. What did taxpayers pay for treatments 
and benefits? For the past several years, VCS has requested this 
information from VA and DOD using the Freedom of Information Act. VA 
has not provided any cost data. Starting in 2001, VA employees urged VA 
leaders to begin tracking war-related benefit use and costs, and nearly 
all requests were refused by political appointees of the previous 
administration.
     DOD must provide an accounting of all discharges by type 
and branch of service, sorted by year, to monitor trends for both 
deployed and non-deployed servicemembers since 1990. Two prior hearings 
by Congress documented how the military improperly discharged tens of 
thousands of servicemembers. In many cases these veterans were at high 
risk of readjustment challenges due to Traumatic Brain Injury (TBI) and 
Post Traumatic Stress Disorder (PTSD). As the number of less than fully 
honorable discharges increases, additional highly vulnerable veterans 
flood into society. Many of these veterans either don't seek VA 
assistance or are refused VA help, instead turning to private, state, 
local, or university campus programs for assistance that should have 
been provided by the Federal Government. VCS also believes the 
military, in many cases, releases servicemembers from active duty with 
less than fully honorable discharges in an effort to avoid long-term 
healthcare and disability benefit costs.
     VA should monitor negative post-deployment outcomes, such 
as homelessness, suicides, divorce, and crime, as well as state, local, 
and privately funded expenditures on veterans. The most important 
oversight remains the Administration's inability to provide complete 
and accurate active duty, Reserve, National Guard, and veteran suicide 
data. Every year DOD has set new, and highly disturbing, records of 
active duty suicides. Most of the initial monitoring began with FOIA 
requests from advocacy organizations or journalists investigating 
patterns of disturbing developments such as suicides, homicides, 
unemployment, and homelessness. VA and DOD only began limited 
monitoring and research after repeated advocacy organization, media, 
and Congressional inquiries.
     The Department of Labor should monitor unemployment and 
underemployment, both for veterans and families. Veterans often move 
from the military installation to their home town shortly after 
discharge. Often, these cross-country moves uproot spouses from their 
jobs. The use of the Post-9/11 GI Bill, legislation introduced by 
Senator Jim Webb of Virginia, by hundreds of thousands of Iraq and 
Afghanistan war veterans may be masking already alarming reports of 
high unemployment among returning veterans.
     VA and DOD should monitor and report on the positive post-
combat, post-deployment, and post-military outcomes of our veterans. 
For example, new businesses started by veterans, higher wages earned by 
veterans, diplomas earned by veterans, increased homeownership among 
veterans, and other signs of a vibrant post-war adjustment to civilian 
life. We ask for this information because our Nation remains woefully 
ignorant of the tremendous positive benefit of the Post-World War II 
``GI Bill'' social programs that provided government funded assistance 
for higher education and home purchases, creating a post-war economic 
recovery that lasted decades.
     VA and DOD are urged to sort the data. For example, 
National Guard and Reserve status are often overlooked as key 
demographic factors among returning veterans. In addition, standard 
sorting methods, such as age, gender, rank, and branch of service 
should be available, too.
              urgent need for trust fund and national plan
    In September 2010, VCS testified before the House Committee on 
Veterans' Affairs in support of a National Trust to provide care and 
benefits for veterans. We believe our Nation must learn from the past 
so we do not repeat mistakes. VCS endorses the Vietnam Veterans of 
America, when they remind us that, ``Never again shall one generation 
of veterans abandon another.''
    This is why Veterans for Common Sense fully endorses the proposal 
by Linda Bilmes and Joseph Stiglitz to create a Trust Fund to make sure 
our veterans receive the healthcare and benefits they earned.
    As a non-profit advocacy organization, VCS uses FOIA to obtain data 
from DOD and VA to monitor and publicize the needs of our veterans. VCS 
was honored to provide our data to Linda Bilmes and Joseph Stiglitz for 
their book. The authors called for the creation of ``A Veterans Benefit 
Trust Fund * * * so that veterans' health and disability entitlements 
are fully funded as obligations occur.'' In their book, the experts 
stated:

          There are always pressures to cut unfunded entitlements. So, 
        when new military recruits are hired, the money required to 
        fund future health care and disability benefits should be set 
        aside (``lockboxed'') in a new Veterans Benefit Trust Fund. We 
        require private employers to do this; we should require the 
        Armed Forces to do it as well. This would mean, of course, that 
        when we go to war, we have to set aside far large amounts for 
        future health care and disability costs, as these will 
        inevitably rise significantly during and after any conflict 
        (``Reform 12,'' page 200).

    The issue of establishing a Trust Fund is timely because we have 
now endured nearly ten years of war in Afghanistan, and more than seven 
years of conflict in Iraq. In 1995, Congress was forced to intervene 
and appropriate $3 billion in emergency funding for VA. One of the main 
reasons cited by VA for the funding crisis was the unexpected and 
unanticipated flood of Iraq and Afghanistan war veterans. Thanks to the 
strong pro-veteran leadership of Senator Patty Murray, the daughter of 
a World War II veteran, VA was given additional resources to meet the 
tidal wave of new, first-time Iraq and Afghanistan war veteran patients 
flooding into VA. With her leadership, and the efforts of this 
Committee and staff, there has been a sustained and deeply appreciated 
effort to fund VA at a higher level to meet the obligation of our 
country to our veterans.
    The threat against veterans in Congress is real. As recently as 
July 2011, Senator Tom Coburn introduced an amendment to eliminate the 
presumption of service connection for Vietnam War veterans exposed to 
the poison Agent Orange. Fortunately, for veterans, the proposal was 
defeated. Similarly, in January 2011, Representative Michele Bachmann 
proposed cutting $4.3 billion from VA's healthcare and benefits budget. 
After an outcry from veteran organizations led by VCS, she withdrew her 
plan.
                     prior administration failures
    The significant post-deployment statistics about our veterans must 
be contrasted with serious mistakes made during 2002. Nine years ago 
the previous Administration prepared no casualty estimate for the Iraq 
War. There was no plan to monitor or estimate fatal or non-fatal 
casualties, even though VA staff sought to create such systems. There 
was no plan to provide long-term medical treatment and disability 
compensation for non-fatal casualties.
    Honoring and remembering our fallen, our wounded, our injured and 
ill, VCS quotes the eloquent poetry of Archibald MacLeish, a World War 
I veteran and former head of the Library of Congress. During World War 
II, MacLeish wrote:

          They say, We leave you our deaths: give them their meaning: 
        give them an end to the war and a true peace: give them a 
        victory that ends the war and a peace afterwards: give them 
        their meaning.

    As an organization of war veterans, Veterans for Common Sense is 
here today to give meaning to all of our Nation's fallen, wounded, 
injured, and ill who deployed to Southwest Asia since 1990: Our Nation 
must learn the painful lessons from prior wars and take care of our 
veterans who enlist in our military to protect and defend our 
Constitution, even when the American public does not support the war. 
This also means monitoring post-war activity among veterans so their 
needs are promptly met.
    VCS tried to inform our Nation about past government mistakes. On 
March 10, 2003, as our Nation prepared to re-invade Iraq, VCS 
petitioned for calm and reason. As war veterans who actually served on 
Iraqi battlefields during 1991, VCS wrote a detailed letter to 
President George W. Bush co-signed by 1,000 veterans:

          Over the long term, the 1991 Gulf War has had a lasting, 
        detrimental impact on the health of countless people in the 
        region, and on the health of American men and women who served 
        there. Twelve years after the conflict, over 164,000 American 
        Gulf War veterans are now considered disabled by the U.S. 
        Department of Veterans Affairs. That number increases daily * * 
        * . Further, we believe the risks involved in going to war, 
        under the unclear and shifting circumstances that confront us 
        today, are far greater than those faced in 1991. Instead of a 
        desert war to liberate Kuwait, combat would likely involve 
        protracted siege warfare, chaotic street-to-street fighting in 
        Baghdad, and Iraqi civil conflict. If that occurs, we fear our 
        own nation and Iraq would both suffer casualties not witnessed 
        since Vietnam.

    We regret to inform you the White House never answered our letter. 
Our veterans who raised serious, legitimate concerns about escalating 
the Gulf War with another invasion of Iraq were brushed aside in the 
rush to war. This must not happen again.
    Earlier, on October 12, 2002, our VCS Executive Director, Charles 
Sheehan Miles, published an editorial criticizing the Congressional 
Budget Office (CBO) for failing to estimate the cost of caring for war 
and post-war casualties. The decorated Gulf War veteran wrote:

          In a surprisingly rosy cost estimate of something which can't 
        be accurately estimated, the Congressional Budget Office Monday 
        released an analysis of what Gulf War II might cost in real 
        dollars paid by U.S. taxpayers. Only they left out the most 
        important part: the casualties. The CBO estimate is naive and 
        unrealistic when you consider the kind of war we are preparing 
        to enter--an open-ended war of regime-change and occupation and 
        empire building that may involve heavy casualties in an urban 
        setting such as Baghdad. The CBO report is illuminating and 
        instructive for what it avoids. CBO uses the word ``assume'' 30 
        times, ``uncertain'' 8 times, ``unknown'' 4 times. Finally, 
        twice it says there is ``no basis'' for an estimate on key 
        items. In other words, it's a wild guess: kind of like taking 
        your broker's advice to buy Enron or WorldCom last summer. CBO 
        states up front: ``CBO has no basis for estimating the number 
        of casualties from the conflict,'' therefore, any discussion of 
        casualties was simply excluded.

    VCS advocates pre- and post-deployment exams, as required by the 
1997 Force Health Protection Act (PL 105-85) as well as hiring more DOD 
medical professionals to provide exams and treatment. VCS believes 
early evaluation and treatment are best because treatments are the most 
effective and often the least expensive. Recently published medical 
research conducted by Dr. Susan Frayne, of the VA Palo Alto Health Care 
System and Stanford University supports our VCS advocacy. Dr. Frayne 
told Businessweek on September 24, 2010:

          Looking to the future, the impetus for early intervention is 
        evident. If we recognize the excess burden of medical illness 
        in veterans with PTSD who have recently returned from active 
        service and we address their health care needs today, the 
        elderly veterans of tomorrow may enjoy better health and 
        quality of life.

    As of July 2010, the military began implementing the Force Health 
Protection Act on a limited basis. VCS urges full DOD compliance with 
the law: universal face-to-face medical exams and prompt treatment for 
our servicemembers when needed. We also thank the President for sending 
condolence letters to the families of our servicemembers who completed 
suicide in the war zone. President Barack Obama has improved 
understanding of war-related mental health conditions and reduced 
stigma and discrimination against veterans with a stroke of his pen.
    There are very serious lessons to be learned from the 
Administration's failure to monitor returning veterans. As of 2009, the 
widely respected and credible Institute of Medicine, part of the 
National Academy of Science, estimated as many as 250,000 Gulf War 
veterans remain ill after exposures to toxins while deployed to 
Southwest Asia during Desert Shield, Desert Storm, and Provide Comfort 
between 1990 and 1991. This research, mandated by the ``Persian Gulf 
Veterans Act of 1998,'' is confirmed by VA's Research Advisory 
Committee on Gulf War Veterans' Illness. If DOD and VA had not fought 
so viciously against Gulf War veterans and scientific research, then 
facts and research would have been found sooner. Sadly, despite 
extensive scientific researcher, a few top officials at DOD and VA 
still deny the existence of Gulf War illness.
                               conclusion
    Thank you for the opportunity to submit this statement for the 
record. VCS hopes to hear from this Committee as well as individual 
Senators about how they intend to force DOD and VA to prepare reports 
about the consequences of the war. We also hope to hear from Senators 
about establishing a Trust Fund so veterans never again face attacks to 
cut our earned healthcare and benefits.
    If we are to truly demonstrate our Nation cares for our veterans, 
then we must do more than provided funding, care, and benefits. Our 
nation must also assure our servicemembers, veterans, families, and 
citizens the government is constantly paying attention to the needs for 
those who protect and defend our Constitution. VCS wants future 
generations of Americans to want to server our Nation and know our 
Nation will care for them when they return home.

    Contact Information:
                       Veterans for Common Sense
                    900 Second Street, NE, Suite 216
                          Washington, DC 20002
                         Phone: (202) 558-4553
                E-Mail: [email protected]
                Web Site: www.VeteransForCommonSense.org
                                 ______
                                 
                Prepared Statement of Sheldon Whitehouse
    Chairman Murray, Ranking Member Burr, and distinguished Members of 
the Committee, I thank you for the opportunity to weigh in on such an 
important issue. I commend the Chairman for her passionate advocacy on 
veterans' issues and her tireless efforts to ensure that our veterans 
get the care they need and the benefits they deserve.
    Today's hearing is crucial to understanding the extent to which the 
current wars are impacting the newest generation of veterans and their 
families and determining what it will take to meet their needs as they 
return home. Our veterans have given so much for our country, and they 
deserve our steadfast support.
    For the last ten years, hundreds of thousands of our women and men 
in uniform have been making enormous sacrifices on our behalf. They 
have asked for little in return, despite the high operational tempo, 
which has required repeated deployments and unprecedented use of our 
Reserve components. These repeated deployments often put severe strain 
on families and broader communities. I have seen the impact firsthand 
in my home state of Rhode Island, where our Guard and Reserve members 
are, per capita, the second most deployed from any state.
    From working closely with the military and veterans community in my 
state, I've learned that we must identify and address the emergent 
needs of our returning servicemembers in all aspects of their 
transition back to civilian life. We must ensure that returning 
servicemembers have access to the best medical care, and that they have 
the training and resources to find good jobs in the civilian economy. 
We also must make sure that our military families have ample time to 
get their finances in order. To that end, I was pleased to work with 
Chairman Murray and other Members of this Committee to better protect 
servicemembers against wrongful foreclosures.
    In addition, we must be cognizant of the mental and emotional 
effects that repeated tours of duty in tense combat conditions can have 
on our returning veterans. All too often, complications from combat 
related trauma, such as Post-Traumatic Stress Disorder (PTSD), can 
contribute to criminal offenses committed by veterans. For many of 
these individuals, their offending behavior would not have occurred 
prior to their repeated deployments. As a former prosecutor, I have 
focused close attention on the increasing numbers of veterans and 
active duty military personnel entering the criminal justice system.
    In my home state, a coalition of leaders from the legal and 
veterans communities are developing a pilot program for veterans who 
enter the criminal justice system. The Rhode Island veterans' court 
program, which is led by Chief Judge Jeanne LaFazia of the Rhode Island 
District Court, seeks to identify and address the underlying causes of 
criminal behavior by referring veterans to treatment programs or 
providing other alternatives that can keep them out of jail and help 
them to lead safer, more productive lives. Last month, U.S. Attorney 
General Eric Holder joined me in Rhode Island for a roundtable 
discussion on the program.
    I also held a hearing in my Judiciary Subcommittee on Crime and 
Terrorism last week to examine how specially designed veterans courts 
can be cost-effective solutions for protecting public safety and 
reducing recidivism. We heard from Chief Judge LaFazia and several 
other witnesses, who testified that veterans' courts are a cost-
effective and safe way to rehabilitate low-level offenders, and to 
provide those who have served dutifully a chance for a future. Today, 
as the Senate Veterans' Affairs Committee examines the costs of 
supporting today's generation of veterans, I urge members to consider 
how veterans courts can provide cost savings and other benefits for our 
veterans and our country.

    I thank the Committee for the opportunity to submit this statement 
for the record, and thank the Chairman and Ranking Member for their 
leadership.
      

                                  
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