[Congressional Record Volume 154, Number 15 (Wednesday, January 30, 2008)]
[Senate]
[Pages S493-S496]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BURR (for himself and Mr. Craig):
  S. 2573. A bill to amend title 38, United States Code, to require a 
program of mental health care and rehabilitation for veterans for 
service-related post-traumatic stress disorder, depression, anxiety 
disorder, or a related substance use disorder, and for other purposes; 
to the Committee on Veterans' Affairs.
  Mr. BURR. Mr. President, I have sought recognition to comment on 
legislation I am introducing today that will hopefully chart a new 
course for veterans with mental illness--the Veterans Mental Health 
Treatment First Act.
  As the title suggests, the bill proposes to advance a commonsense 
concept: Providing medical treatment for mental illness as a first 
priority will lead to a better quality of life for tens of thousands of 
veterans. It is a simple concept with which few would disagree.

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The problem is that the Government agency tasked with advancing that 
concept--the Department of Veterans Affairs--lacks the proper focus to 
actually deliver. Notice I didn't say VA lacked the tools to deliver. 
It has the tools--a world-class health care system, evidence-based 
therapies emphasizing recovery and rehabilitation, first-line 
medications, and the support of a dedicated group of clinical 
professionals. The problem is that, as an agency, VA doesn't coordinate 
the use of all of its resources--medical treatment, vocational 
rehabilitation, and disability compensation--to ensure what is 
universally agreed as the desired outcome of those with disabilities: 
wellness and a return to a productive life.
  Let me take a few minutes to lay out some of the facts for my 
colleagues. These facts have helped me get a better grasp of what the 
problem is, and they have truly informed my belief that a new approach 
to solving the problem is, in fact, necessary.
  Fact No. 1: There has been a steep increase in the number of veterans 
receiving disability compensation for post-traumatic stress disorder.
  In a 2005 report, the VA inspector general issued the following 
findings:

       During fiscal years 1999 through 2004, the number and 
     percentage of PTSD cases increased significantly. While the 
     total number of all veterans receiving disability 
     compensation grew by only 12.2 percent, the number of PTSD 
     cases grew by 79.5 percent, from 120,265 cases in fiscal year 
     1999 to 215,871 cases in fiscal year 2004.

  Sadly, the trend has not decelerated. Through September of 2007, 
299,672--almost 300,000--veterans with PTSD were on the compensation 
rolls, a 39-percent increase since the VA inspector general's findings.
  Now, many might argue that it is only natural that we would see an 
increase in PTSD compensation given that we have been in a war on 
terror since the year 2001. However, today there are just under 30,000 
veterans of the global war on terror on the disability compensation 
rolls for PTSD. Thus, the increase in PTSD rate represents a broad 
cross-section of the veterans community.
  No matter how far removed they are from military service, veterans 
are filing claims and being granted service-connected compensation for 
PTSD, and these staggering increases are occurring despite a decline--a 
decline--in the overall veteran population.
  Fact No. 2: Veterans with PTSD-related compensation appear never to 
get better, only to get worse.
  I just provided the sobering statistics about a 120-percent increase 
in PTSD disability rolls since 1999. Here is what the VA inspector 
general found in its 2005 review of veterans who have been added to the 
disability rolls:

       Based on our review of PTSD claim files, we observed that 
     the rating evaluation level typically increased over time, 
     indicating the veteran's PTSD condition had worsened. 
     Generally, once a PTSD rating was assigned, it was increased 
     over time until the veteran was paid at the 100 percent rate.

  This fact is even more disturbing than the first. It suggests a trend 
toward not only increasing sickness over time but also permanent 
sickness. It also suggests a certain sense of inevitability among those 
with lower disability ratings that the natural progression is for them 
to slip into total 100 percent. Then, as time wears on, total and 
permanent disability is, in fact, established.
  Mr. President, words have meanings. My greatest worry is that the 
message carried by an undesirable rating may lessen a veteran's resolve 
to seek treatment and to actually get better. They may feel themselves 
as beyond recovery, caught in the quicksand of permanent disability. If 
our current system encourages this kind of mindset, then we must change 
it.
  Fact 3: There is evidence that PTSD is treatable and that VA has the 
tools to do it.
  This may seem paradoxical, but it is true. The same agency that 
possesses disability claims showing veterans sliding toward increasing 
and permanent sickness is, in fact, the same agency that is recognized 
as having the tools necessary to successfully treat PTSD.
  On the question of whether PTSD is treatable, here is what the 
Institute of Medicine found in their 2007 report:

       The committee finds that the evidence is sufficient to 
     conclude the efficacy of exposure therapies in the treatment 
     of PTSD.

  The Institute of Medicine also recommended additional research 
regarding the efficacy of other forms of PTSD treatment, but at a 
minimum, it concluded that the evidence suggests that at least one form 
of treatment worked.
  What specific assets does the VA have to help veterans with PTSD? 
Well, let me list those assets, and let me also remind my colleagues 
that the VA health care system has been widely lauded by independent 
experts as one of the top health care providers in the United States.
  The VA has 215 readjustment counseling centers, or Vet Centers, which 
offer readjustment counseling for PTSD for afflicted veterans. The VA 
has PTSD clinic teams or specialists at each of its 153 medical centers 
across the country. The VA has 8 specialized PTSD inpatient units, 10 
PTSD residential rehabilitation programs, 9 PTSD domiciliary programs, 
7 women's trauma recovery programs, 10 day hospital outpatient 
programs, 10 substance use PTSD outpatient programs, and 22 women's 
stress treatment outpatient programs. These programs offer a full 
spectrum of therapies, including exposure therapies and medications to 
treat our veterans for PTSD. In total, VA is planning to spend more 
than $3 billion on health care services this year--roughly one-tenth of 
its total medical care budget.
  So how do we explain this paradox? Why does a look at the 
compensation rolls show us that veterans with mental illness are 
getting progressively worse even though the VA health system is 
recognized as having the tools to make them better?
  That question leads me to my fourth and final fact: There is a poor 
linkage between the arm of VA that treats PTSD--the Veterans Health 
Administration--and the arm of the VA that awards disability 
compensation--the Veterans Benefits Administration.
  One of VA's strategic objectives is to restore the capabilities of 
disabled veterans to the greatest extent possible. Most would agree 
with that objective, and most would conclude that restoring capability 
involves a focus on treatment and rehabilitation and not a rush to, in 
fact, award disability compensation.
  The problem is that the VA is inconsistent in how it measures whether 
it is achieving its objective. On the health care side, VA measures 
whether it is obtaining this objective by measuring meaningful outcome 
data regarding wellness and disease prevention. On the disability 
benefits side, it measures it by how fast and accurate a disability 
claim can in fact be decided.
  There is a serious disconnect here. One side emphasizes health and 
wellness, the other emphasizes a rush to award compensation confirming 
the existence of illness. There is no requirement that these two sides 
work together. Thus, disability compensation can be awarded and 
increased over the years without a veteran ever receiving medical 
treatment.
  To me, there is something backward about how this works. The Veterans 
Disability Benefits Commission honed in on this point in its 2007 
report. There is little interaction between the Veterans Health 
Administration, which examines veterans for evaluation of severity of 
symptoms, and treats veterans with PTSD, and the Veterans Benefits 
Administration, which assesses disability ratings and may or may not 
require periodic reexamination.
  A further disconnect seen by the Veterans Disability Benefits 
Commission, the Senate Committee on Veterans' Affairs held a hearing 
last week at which the chairman of the Disability Commission, GEN James 
Terry Scott, testified. I asked General Scott specifically to expand on 
the Commission's findings and, more importantly, their recommendations. 
General Scott told me it was not his intent to offend anyone, but that 
we have been paying people with PTSD to go away; not to treat them, to 
go away. He went on to say that disability compensation has precluded, 
in the judgment of the Commission, any effort to make veterans with 
PTSD better, the No. 1 objective, I believe, of our system.
  General Scott then made the following statement that represents the 
heart of the Commission's findings on the link between PTSD 
compensation and treatment:


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       It is our judgment that one of the principal goals of the 
     VA and of the Commission, was that we want to make people 
     better so they can return to the fullest extent possible, 
     into ordinary lives without treatment. I do not see how we 
     are fulfilling our obligation.

  These facts lead me, and I hope they will lead my colleagues as well, 
to the inescapable conclusion that the current approach to helping our 
veterans diagnosed with PTSD simply is not working. It is abundantly 
clear that we need to try something new. Again to quote the Veterans 
Disability Benefits Commission report:

       The Commission believes that PTSD is treatable, that it 
     frequently reoccurs and remits, and that veterans with PTSD 
     would be better served by a new approach to their care.

  The Veterans Disability Benefits Commission says:

       Veterans with PTSD would be better served by a new approach 
     to their care.

  I believe the legislation I am introducing today is, in fact, that 
new approach. Before I describe the legislation and how it works, let 
me describe how the present system is working or, as the evidence 
suggests, not working.
  Let's say a young marine who is 2 years removed from his service in 
Iraq comes to the VA because he is suffering from PTSD-related 
flashbacks and cannot hold down a steady job. As a consequence, he is 
having trouble paying his bills. We all would.
  That veteran needs help immediately. First and foremost, he needs 
mental health treatment before his condition worsens, but he also needs 
short-term financial help during his treatment period. If we cannot 
address that, we cannot be assured that the correct amount of 
rehabilitation takes place.
  Under the current system, the veteran might first be counseled to 
file a disability claim with the Veterans Benefits Administration. And 
who could blame him. It is the source of money. He sees that as the 
quickest route to solving his immediate financial crisis.
  Although medical care would be made available at that time, the 
veteran cannot simply afford to put his life on hold to get well. We 
can all associate with this. After a 6-month wait, the average time it 
now takes to process a disability claim--average; some are sooner, more 
are later, but the average is 6 months--the veteran might be rated 
service connected due to disability. But by that time, a critical 
window of opportunity for wellness would have come and gone. The 
veteran's experience with the VA will have been one that emphasizes his 
sickness and the level of his disability rather than wellness through 
an aggressive treatment program.
  What would my legislation do? It would establish a program to refocus 
the existing system to one that emphasizes and incentivizes wellness. 
It would say to a veteran eligible for VA health care who suffers 
from service-related PTSD, depression, anxiety disorder, or related 
substance use disorder, that our focus is to make certain you are given 
the best efforts to get healthy and to feel better.

  It would do this by providing--get this--a wellness stipend, a 
wellness stipend for up to 1 year to any veteran diagnosed with these 
conditions so long as the VA diagnosing physician judges the conditions 
to be plausibly related to military service.
  All the veteran would have to do is to agree faithfully to attend the 
prescribed treatment regime, in other words, go get the services that 
are already provided, and hold off on filing disability for those 
illnesses until you have completed your rehab schedule. So if the rehab 
schedule the doctor prescribes is 6 months, we want you to hold off 
filing the disability claim for 6 months so we can give you the 
financial help you need to get through it, we can focus you into 
treatment, and at the end of the time you and the system can assess 
where you are.
  That is it. And we will do that for up to a year. Here is how it 
works for the marine whom I spoke about earlier. Upon diagnosis and 
treatment with the conditions of the program, an immediate $2,000 
wellness stipend is made to him. All of a sudden the immediate 
financial crisis could be over; no lengthy claims process, no 6-month 
delay in getting needed financial help.
  With this immediate financial infusion, our marine can focus on 
getting well and not worrying about how he pays the next month's rent. 
More importantly, every 90 days that he participates, every 90 days 
that they can say ``he came to rehab,'' it translates into an 
additional $1,500 of a wellness stipend, a reward for continued 
participation. Finally, at the end of the treatment program, in this 
case the end of a year, a final $3,000 wellness stipend would go to the 
marine. Thus, in the total of a 1-year treatment program, we would pay 
the maximum wellness stipend of $11,000.
  Think about this. We are actually taking the most difficult piece, 
which is the financial obligation, and we are setting that aside so we 
can focus on what I believe is our obligation: to make sure that we 
provide the best course of rehab, of prevention, of wellness.
  I recognize treatment programs will vary depending on the medical 
needs of the veteran. My legislation gives the VA complete discretion 
to develop a recovery plan of an appropriate type and duration. Hence, 
if our marine only needs a 4-month program, he would receive $2,000 of 
wellness stipend up front, $1,500 after 90 days, and $3,000 at the end 
of the program, for a total of $6,500.
  Hopefully, at the conclusion of the treatment of our marine, he will 
then be healthy, or at least healthy enough to reenter society and move 
on to a productive life. If the opposite is true and the marine did not 
get well, his option to file a disability claim is still available in 
total. We have not deprived any veteran of their right to file 
disability claims.
  What we have asked is: Set it aside, let's focus on treatment, let's 
make sure you are not financially strapped, and at the end of intense 
treatment, focus on that treatment, let's get back together, and if you 
are still in a situation where you are disabled, then we file the 
disability claim.
  I know some might think this is a nonconcept, paying people to come 
in for what is basically free health care. But I think it is time for 
all of us to recognize what the Veterans Disability Benefits Commission 
and the Dole-Shalala commission have already recognized: treatment, 
rehabilitation, and recovery need to be the primary focus of our VA 
health and benefits system. And, more importantly, they need to be the 
focus of our mental health services.
  Let me quote the Disability Commission on this very point.

       The Commission believes that a new, holistic approach to 
     PTSD should be considered. This approach should couple PTSD 
     treatment, compensation, and vocational assessment.

  The Disability Benefits Commission felt so strongly about focusing on 
treatment for those with mental illness, particularly PTSD, that it 
recommended that we condition the receipt of compensation on the 
receipt of treatment.
  I am not proposing that we condition it as the Commission has 
proposed to Congress, but I want my colleagues to understand, you 
cannot have multiple commissions look at this issue and say: It is 
broken. It does not focus on the wellness our veterans need. It needs 
to be changed.
  Senator Dole and Secretary Shalala's commission recommended providing 
transition payments for injured service personnel while they receive 
treatment and rehabilitation services, and they recommended an 
incentive bonus payment designed to reward participants in a rehab 
program for achieving certain milestones, that if they actually 
accomplished a milestone that was set, we give them a financial 
incentive.
  Why? Because today's veteran, in many cases, has expectations that 
are unlike any generation before. Because of their age, because of the 
types of injuries they are exposed to, what their expectations are with 
an artificial limb--I lose no mobility, I am just as productive, I can 
play golf, I can run, I can play basketball, I can even pass a physical 
to stay in the Army. That is the reality. If we lose them up here, we 
have done them an injustice relative to their expectations for life. I 
think both commissions focused on an innovative approach to wellness, 
and the Disability Commission approach goes farther than mine in that 
it is a negative incentive as opposed to a positive one, but the 
underlying concepts are the same. The current system is not working. 
Let's try something new.

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  I want to make a few points clear. First, under my legislation, no 
veteran would have to give up his or her right to receive disability 
compensation. Veterans can file a claim whenever they want. If they 
decide when they are presented this option right at the beginning that 
they want to file a disability claim and roll the dice on rehab, they 
can do that. If they get a month into rehab and they decide: I do not 
think this is working, they can file a disability claim. They will not 
get a financial stipend at the end of 90 days. They can drop out. They 
can continue to access VA benefits. They can continue to stay in rehab. 
But they may feel compelled to go ahead and file a disability claim. 
They can do that. The financial stipend ends, but we still continue the 
treatment, we just do not have an incentive for them to attend.
  The wellness stipend, as I said, will be paid only if the veteran 
agrees to stay faithful to the program and holds off on filing the 
claims during that treatment period of up to 1 year.
  Second, none of the nearly 300,000 veterans already in receipt of 
PTSD-related compensation and the thousands of others in receipt of 
compensation for depression and anxiety disorder would have to give up 
their compensation in order to participate in the treatment first 
program. For them, my legislation would pay a wellness stipend that is 
one-third the amount I mentioned earlier, so long as they agreed not to 
file a claim to increase their disability rating during this treatment 
period.
  Let me draw a distinction. For somebody who has already filed a 
disability claim, regardless of how old they are, and annually goes to 
be rerated, if they delay that rerating, if they go into an intense 
rehabilitation program, if, in fact, one has been identified by a 
medical professional within the Veterans' Administration for them to 
enter into, if they agree not to be rerated until the completion of 
that program, we will actually include them in the cash stipend, but it 
will be one-third the amount of somebody who enters the system for the 
first time. So whether you are a veteran who has never filed a claim 
before, a veteran with a claim pending, a veteran already in receipt of 
compensation, the treatment first program would be available to all.
  Finally, my legislation contains no requirement that disability 
compensation be reevaluated at the end of the treatment period. If 
treatment works--and the Institute of Medicine says it does--then 
veterans will have better lives because of it. That is the only goal of 
this legislation. I think we can all look at it, with what we know 
about the health care system, we can probably find a rationale to say, 
if we invest now in these veterans, we might save money on the back end 
for taxpayers in actual health care services that might be provided to 
somebody who drops out of the workforce who doesn't regard their health 
as important because they have now become locked into a monthly 
disability check for their livelihood.
  But for the ones who could end up there that we have now gotten into 
rehab successfully and increased or changed the quality of their life, 
the likelihood is the back end health care cost is minimal, if any.
  In conclusion, the status quo is not working. We need a new and bold 
approach. My legislation represents a direct challenge to all of us to 
think outside the box, to think about things that work elsewhere, but 
we haven't tried. Doing so sometimes requires taking steps that are a 
little unknown and a little bit unique. I am sure not only Members of 
the Senate but the veterans service organizations and, I am sure, the 
veterans themselves will look at this and say: Where is the cash?
  There is no cash. For once, we have a piece of legislation that is 
focused on how to make people better. We are willing to put our money 
where our mouth is because it is that important to a 19-year-old who 
comes back from Iraq who can truly be made well with the right type of 
rehab and who may, because of financial decisions in his own life, not 
choose to fully exhaust the rehabilitation needed to overcome that 
mental health challenge. This at least would give the American people 
the assurance that we have done everything possible for that 19-year-
old to get the services he or she would need to lead a productive and 
fruitful life.
  I ask my colleagues for their support. It is time to put the 
treatment of our veterans with mental health illnesses first.
                                 ______