[Senate Hearing 112-668]
[From the U.S. Government Publishing Office]
S. Hrg. 112-668
HEARING ON HEALTH AND BENEFITS LEGISLATION
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TWELFTH CONGRESS
SECOND SESSION
__________
JUNE 27, 2012
__________
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
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June 27, 2012
SENATORS
Page
Murray, Hon. Patty, Chairman, U.S. Senator from Washington....... 1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North
Carolina....................................................... 3
Brown, Hon. Scott P., U.S. Senator from Massachusetts............ 4
Boozman, Hon. John, U.S. Senator from Arkansas................... 5
WITNESSES
Heller, Hon. Dean, U.S. Senator from Nevada...................... 7
Ayotte, Hon. Kelly, U.S. Senator from New Hampshire.............. 9
Franken, Hon. Al, U.S. Senator from Minnesota.................... 11
Wyden, Hon. Ron, U.S. Senator from Oregon........................ 13
Prepared statement........................................... 15
Boxer, Hon. Barbara, U.S. Senator from California................ 16
Portman, Hon. Rob, U.S. Senator from Ohio........................ 17
Agarwal, Madhulika, M.D., M.P.H., Deputy Under Secretary for
Health for Policy and Services, Veterans Health Administration. 20
and
Murphy, Thomas, Director, Compensation Service, Veterans Benefits
Administration, U.S. Department of Veterans' Affairs;
accompanied by William Schoenhard, Deputy Under Secretary for
Health for Operations and Management, Veterans Health
Administration; Jane Claire Joyner, Office of General Counsel;
and Richard Hipolit, Office of General Counsel................. 21
Joint prepared statement..................................... 22
Additional views............................................. 36
Response to posthearing questions submitted by:
Hon. Patty Murray.......................................... 56
Hon. Scott P. Brown........................................ 60
Fast Letters................................................. 69
Keil, Tracy, Caregiver and Spouse of OIF Veteran................. 79
Prepared statement........................................... 82
Edney, Mark Thomas, MD, OIF Veteran, Member, Legislative Affairs
Committee of the American Urological Association............... 84
Prepared statement........................................... 87
Ansley, Heather, M.S.W., Vice President of Veterans Policy,
VetsFirst...................................................... 90
Prepared statement........................................... 92
Ilem, Joy J., Deputy National Legislative Director, Disabled
American Veterans.............................................. 97
Prepared statement........................................... 98
APPENDIX
Cleland, Max, Secretary, American Battle Monuments Commission;
prepared statement............................................. 113
American Society for Reproductive Medicine (ASMR); prepared
statement...................................................... 114
Beeler, Nathaniel, Avon, IN; letter.............................. 115
Zampieri, Thomas, Ph.D., Director of Government Relations,
Blinded Veterans Association (BVA); prepared statement......... 117
Kasold, Hon. Bruce E., Chief Judge, U.S. Court of Appeals for
Veterans Claims; prepared statement............................ 118
Wright, Dennis L., Captain, U.S. Navy (ret.), Chairman, Clark
Veterans Cemetery Restoration Association; letter.............. 120
National Coalition for Homeless Veterans; letter................. 122
Paralyzed Veterans of America (PVA); prepared statement.......... 125
Collura, Barbara, President, Resolve; letter..................... 132
Sims, Ron, Seattle, WA; prepared statement....................... 134
Klein, Morris, Esq., Attorney at Law, Bethesda, Maryland, and
Lois Zerrer, Zerrer Elder Law Office, LLC, Springfield,
Missouri, on Behalf of the Special Needs Alliance; prepared
statement...................................................... 137
Bhagwati, Anu, Executive Director, Service Women's Action
Network; prepared statement.................................... 139
Huebner, Charles, United States Olympic Committee; prepared
statement...................................................... 141
Ansley, Heather L., Esq., M.S.W., Vice President of Veterans
Policy, VetsFirst; letter...................................... 144
Wright, Dennis L., Captain, U.S. Navy (ret.), Chairman, Clark
Veterans Cemetery Restoration Association (CVCRA); letter...... 145
Wounded Warrior Project (WWP); prepared statement................ 147
Submitted by Senator Barbara Boxer of California
AMVETS Department of California Service Foundation; letter....... 150
Hampton, Brian A., Maj. USAR (ret.), President, Center for
American Homeless Veterans, Inc.; prepared statement........... 152
California Association of Veteran Service Agencies; letter....... 153
The National Coalition for Homeless Veterans; letter............. 154
Blecker, Michael, Executive Director, Swords to Plowshares;
letter......................................................... 155
Kelley, Raymond C., Director, National Legislative Service, VFW;
letter......................................................... 156
Submitted by Senator Dean Heller of Nevada
Wong, Fang A., National Commander, The American Legion; letter... 157
Gornick, Matt, Policy Assistant Director, National Coalition for
Homeless Veterans; letter...................................... 158
HEARING ON HEALTH AND BENEFITS LEGISLATION
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WEDNESDAY, JUNE 27, 2012
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:04 a.m., in
room 124, Dirksen Senate Office Building, Hon. Patty Murray,
Chairman of the Committee, presiding.
Present: Senators Murray, Burr, Isakson, Brown of
Massachusetts and Boozman.
Also present: Senators Heller, Ayotte, Franken, Wyden,
Boxer, and Portman.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Chairman Murray. Good morning. Thank you, and welcome all
of you to this hearing of the Veteran Affairs' Committee this
morning as we examine health and benefits legislation that is
before our Committee.
We have a number of Senators who are here who want to
testify about their legislation. I will make an opening
statement, then Senator Burr, and if we have any other
Committee Members we will allow them to give theirs, then turn
to other Senators. So, thank you all for being here.
Like our hearing 2 weeks ago on economic opportunity and
transition legislation, today's agenda is ambitious and
reflects important work by the Members on both sides of the
aisle. I wanted to briefly highlight two of my bills that are
on the agenda.
The Mental Health ACCESS Act of 2012 is sweeping
legislation that improves how VA provides mental health care. I
think it is fitting actually that we are here considering this
legislation on National PTSD Awareness Day.
Over the past year, this Committee has repeatedly examined
the alarming rate of suicide and the mental health crisis in
our military and veterans' populations. We know our
servicemembers and veterans have faced unprecedented
challenges, multiple deployments, difficulty finding a job when
they come home, and isolation in their communities. Some have
faced tough times reintegrating into family life, with loved
ones trying to relate but not knowing how.
These are the challenges our servicemembers and veterans
know all too well. But even as they turn to us for help, we are
losing the battle. Time and time again, we have lost
servicemembers and veterans to suicide. We are losing more
servicemembers to suicide than we are to combat, and every 80
minutes a veteran takes his or her own life. On average this
year, we have lost a servicemember to suicide once every day.
But while the Departments of Defense and Veterans' Affairs
have taken important steps toward addressing this crisis, we
know there is a lot more that needs be done. We know that any
solution depends upon reducing the wait times and improving
access to mental health care, ensuring proper diagnosis, and
achieving true coordination of care and information between the
Departments.
The Mental Health ACCESS Act would expand eligibility for
VA mental health services to family members of veterans. It
would require VA to offer peer support services at all medical
centers and create opportunities to train more veterans to
provide peer services, and this bill will require VA to
establish accurate and reliable measures for mental health
services.
This Committee has held multiple hearings on VA mental
health care, and we heard repeatedly about the incredibly long
wait times to get into care. It is often only on the brink of
crisis that a veteran seeks care. If they are told ``sorry, we
are too busy to help you,'' we have lost the opportunity to
help, and that is not acceptable.
Without accurate measures, VA does not know the unmet
needs. Without a credible staffing model, VA cannot deploy its
personnel and resources effectively.
The other bill I want to mention today is S. 3313. It is
the Women Veterans and Other Health Care Improvement Act of
2012, which builds upon previous law to improve VA services for
women veterans and veterans with families.
This bill will create a child-care pilot program for
veterans seeking readjustment counseling at Vet Centers and
increase outreach to women veterans. We know that as more of
our men and women return from Afghanistan, the VA will be
called upon to provide care for our most severely wounded
veterans. After suffering life-changing injuries on the
battlefield, these veterans now face a future forever changed.
Between 2003 and 2011, we know that more than 600
servicemembers experienced blast injuries that caused trauma to
their reproductive or urinary tracts in Iraq and Afghanistan.
Even more have experienced other injuries, like spinal cord
injuries.
Many of these veterans dream of 1 day starting a family.
But with the injuries they have sustained on the battlefield
that may not be possible without some extra help. While the
Department of Defense and TRICARE are now able to provide
advanced fertility treatment to injured servicemembers, today
the VA can only provide limited treatment. VA's services do not
even begin to meet the needs of our most seriously injured
veterans and their families.
So, my bill will help make real the dream of starting a
family by authorizing the VA to provide advanced fertility
treatment to severely wounded veterans. By authorizing these
treatments, we will bring VA services in line with what DOD and
TRICARE already provide. It is the right thing to do, and it is
what our veterans deserve.
I look forward to our second panel today where we have some
very compelling testimony from families that have been impacted
by these injuries.
So, I look forward to hearing from our VA witnesses and all
of our Committee Members and those Senators that are here today
to talk about their legislation.
With that, I will turn it over to the Ranking Member,
Senator Burr.
Senator Burr. Thank you, Chairman Murray; and I also
welcome our witnesses today. I would also like to welcome
Senator Wyden, who just introduced a bill in the last couple of
weeks together, which he will testify on today. And I welcome
the rest of my colleagues who are here that I expect to do a
similar thing.
Before turning to today's agenda, I want to say a few words
about the Caring for Camp Lejeune Veterans Act, which would
provide health care for veterans and their families who were
stationed at Camp Lejeune when the water was contaminated with
known or probable known carcinogens.
I am very pleased that we have made progress on this bill
in recent weeks, and I hope it will soon pass so that we can
finally provide these veterans and their families with the care
they need and deserve.
As we consider other bills today--particularly any that
create or expand programs--we should start by looking at how
well existing programs are working and identify any gaps and
inefficiencies. That should help us focus on changes that are
truly needed and avoid creating any more duplicative and
overlapping programs that can end up frustrating veterans and
their families.
Also, with the fiscal challenges facing our Nation, we need
to know the cost of these bills; and for any that will move
forward, we must find ways to pay for them.
With all that in mind, I look forward to a productive
discussion about the bills on today's agenda. To start with, I
would like to mention several of those bills that I have
cosponsored.
One is S. 1707, which would end the unfair process that
strips veterans and their families of the rights to own
firearms if VA believes they need help with their finances.
Under this bill, the Second Amendment rights of a VA
beneficiary could not be taken away unless a judicial authority
finds that the individual is dangerous. This would put the
decision about Constitutional rights in an appropriate forum
and base it on relevant questions.
Another bill, S. 2045, would require judges of the Court of
Appeals for Veterans' Claims to live within 50 miles of the
Court's office, a requirement that already applies to other
Federal judges.
This should increase the efficiency and effectiveness of
the Court by encouraging the judges to be present and
personally engaged on a daily basis. It would also emphasize
that the judges must be totally committed to the Court's
important work.
Then, S. 3084 would reform VA's Veterans' Integrated
Service Networks or the acronym we all know, VISNs. In 1995,
the veterans' health care system was divided into 22 geographic
areas. It now is divided into 21 VISNs. Each VISN has its own
headquarters with a limited management structure to support the
medical facilities in that region. Since then, there has been a
huge growth in staff at the VISN headquarters and increasing
duplication in the duties they carry out.
So, this bill would consolidate the boundaries of nine
VISNs, move some oversight functions away from VISN management,
and limit the number of employees at each VISN headquarters.
All of this should make these networks more efficient and
should allow resources to be reallocated to direct patient
care.
One other, S. 3202, is a bill Chairman Murray and I
introduced to give VA the tools to help ensure that veterans
and servicemembers are laid to rest with dignity and respect.
By granting VA the authority to purchase caskets or urns when
they otherwise would not be provided, veterans buried in
national cemeteries can be laid to rest in a manner befitting
their service.
Finally, S. 3270 would create a ``look-back'' period so VA
could consider whether someone applying for need-based pensions
has recently transferred away assets. As the Government
Accountability Office highlighted, there is an entire industry
aimed at convincing veterans to move assets around in order to
qualify for need-based pension benefits.
That practice not only undermines the integrity of the
pension program but can leave elderly veterans without any
adequate resources in their greatest time of need. So, this
bill aims to strengthen VA's pension program, while
discouraging companies from preying on elderly veterans.
Madam Chairman, all of these bills would provide
commonsense solutions to real issues affecting our Nation's
veterans, their families, and their survivors. I look forward
to working with you and with our colleagues to see that these
and other worthwhile bills that are on today's agenda soon
become law.
Again, I want to stress how important this hearing is, and
I want to thank you for your help with Camp Lejeune
legislation.
Chairman Murray. Of course, thank you very much, Senator
Burr. We have three Committee Members present. If any of you
would like to offer an opening statement before we turn to our
visiting Senators; Senator Isakson, Senator Brown, do you have
an opening statements?
STATEMENT OF HON. SCOTT P. BROWN,
U.S. SENATOR FROM MASSACHUSETTS
Senator Brown of Massachusetts. Yes, I do.
Thank you, Madam Chair. I am bouncing back and forth
between HSGAC and this. I appreciate the opportunity.
I want to say thank you, Senator Burr, for working on Camp
Lejeune. It is something I am a cosponsor of. I have many
Massachusetts families affected by that too. So, I appreciate
your efforts and, Madam Chair, your willingness to move forward
on that in a positive manner.
As we know, we introduced a bill last week with Senator
Burr, Housing for Families of Ill and Injured Veterans. It is
pretty simple. It gives the VA the authority to award grants to
the Fisher House Foundation for the construction of additional
temporary lodging facilities similar to the ones which
currently exist and that many people are aware are.
There is even a Fisher House in Washington State, Madam
Chair, as you are probably aware of, and today there are 21
States and additional projects are already planned in nine
other States.
If you have been to Walter Reed or visited a VA medical
center back home, you know the critical role that that facility
plays in helping troops and their families navigate the
difficult and often painful road to recovery.
Our Fisher Houses in Massachusetts are an incredible asset
for the family seeking care in our State and thankfully these
homes create, as you all know, an instant community of support
for our families.
Unfortunately, the reality is that private and corporate
charitable contributions are declining. There is a real concern
about what is going to happen with a lot of the so-called
deduction opportunities if charitable deductions is going to be
one of those on the chopping block, and this has prevented
Fisher House from producing the amount of homes required by VA
for the foreseeable future even as demand continues to rise.
In fact, Secretary Shinseki identified 19 medical centers
that desperately need a Fisher House. On the other hand, the
DOD budget is about $4 million annually to the Fisher House
Foundation to cover the cost, and my point is I do think it is
reasonable for the VA like DOD to put some skin in the game.
Our bill gives the authority to do just that.
I would also like to just make a quick reference to the
Women's Homeless Veterans Act that Senators Heller and Burr
recently introduced, and I was proud to cosponsor as well.
This Committee held a hearing back in March to learn more
about what the VA was doing on this epidemic, and we heard from
Ms. Sandra Strickland and learned firsthand about her personal
experiences. She testified that she was hung up on by folks at
the VA and felt bad that VA did not go above and beyond to
address their current needs. What is worse it is not an
isolated case. We reference that from the GAO report.
So, I want to obviously thank those Senators Heller and
Burr, and I am hopeful that we will be able to move these
matters forward.
As I mentioned, I am back and forth between hearings, and I
am going to hopefully come back and testify. If not, I will
offer questions for the record.
Thank you, Madam Chair.
Chairman Murray. Thank you very much.
Senator Boozman.
STATEMENT OF HON. JOHN BOOZMAN,
U.S. SENATOR FROM ARKANSAS
Senator Boozman. Thank you, Madam Chair, and thank you,
Ranking Member Burr, for holding this important hearing
regarding legislation to improve the health care and benefits
that each individual of our all volunteer force has earned
through their sacrifice.
I also appreciate that you have included several bipartisan
bills in which we have been working to improve our veterans
benefits and quality-of-life. I would really like to just take
a few minutes to say a few words about some of this.
First off, I want to thank Senator Franken for his hard
work, and I want to say that I echo the sentiments that he is
going to be expressing in a little bit.
With so many of our veterans living in rural areas, our
Nation has seen fit to invest significant amount of money to
improve the accessibility and quality of the health care that
they receive. While the research of VA Office of Rural Health
Strategic Plan is a little step in the right direction, I think
it is so important for us to have a clear path forward to
improve health care for our rural veterans.
So, I would associate again myself with Mr. Franken's
sentiments and thank him for his continued partnership and hard
work in addressing the issue.
Another important bill that we have been working on is
S. 3206 to extend Paralympic Integrated Adaptive Sports
Program. I would also like to take this opportunity to thank
Senator Begich for his assistance and hard work with the bill
and so many others, many of which we will hear today, that he
has been such a great partner on the Committee and together we
have been able to raise awareness about the several key issues
to help our veterans and advance legislation through Congress.
So again, thanks to him and his staff.
S. 3206 would reauthorize this program that despite only
being operational for about 18 months is already serving
wounded warriors in more than under 50 communities in 42 States
and has collaborated with 53 VA medical centers to provide
adaptive sports programs for our disabled veterans right in
their communities. More than 500 partner organizations have
come together to help provide this important service to
thousands of our disabled veterans that have leveraged these
Federal dollars with their own funds and expertise. This type
of activity is so important to our wounded warriors in
improving quality-of-life, health, self-esteem, socialization.
Now with our recent overseas engagements winding down, it
is more important than ever that this valued program remain in
place with no interruption in its authorization which would
lapse at the end of the next fiscal year under current law.
Another bill that is important that I have been working
with Senator Baucus on, to whom I am grateful for his efforts
on this issue, is S. 1838. This is simple legislation, a nearly
identical companion of which has already passed the full House
is part of H.R. 2074.
It would create a pilot program in which the VA would
examine the feasibility of the service-dog training activities
as therapies in mental health rehab programs.
Too often many of our veterans must rely on pharmacological
therapies for seen and unseen injuries. This is not all bad,
but I think we need to examine alternatives to this, which is
why I am being very supportive of programs like Rivers of
Recovery, which recently expanded into Arkansas and that
teaches recreational therapy through fly fishing.
This dog-training program could be a four-way win by
providing therapy, teaching potential vocational skills as dog
trainers, providing highly-trained service dogs for veterans in
need, and providing a pathway for the rescue of shelter dogs
that meet the criteria for the service.
For all of these reasons, I think that this modest pilot
program is worthy of examination.
I have also been working with Senator Begich on S. 3094,
which is a commonsense adjustment to the definition of homeless
veterans so that it includes veterans who are fleeing domestic
violence situations.
With such an increasing percentage of our veterans
population being women, this Committee has been hard at work to
improve programs and benefits to meet their needs; and while it
is not only women who could fall under this adjustment, it is
important that we get our veterans the benefits and assistance
they need when they need them and this simple adjustment would
help ensure that that happens.
Finally, I would like to express my strong support for
S. 1707, the Veteran Second Amendment Protection Act. I have
been strongly advocating for this legislation for the past few
Congresses, and it is high time that we have got this done.
This bill would protect the Second Amendment rights of our
veterans who served in uniform. Right now if a veteran is
assigned a fiduciary to administer their benefits, they can be
automatically deemed adjudicated as mentally defective by a
nameless and faceless bureaucrat and be denied their Second
Amendment rights.
There is nothing just about this. So this legislation would
require that a judge or a magistrate make this determination. I
think it is commonsense and Congress should move this bill
forward.
So, again, thank you all very much for bringing all of
these things forward. We appreciate your hard work.
Chairman Murray. Thank you very much. We do have a number
of Senators who are here to testify about the legislation. We
welcome all of them. I will call on them in order of their
appearance beginning with Senator Heller.
STATEMENT OF HON. DEAN HELLER,
U.S. SENATOR FROM NEVADA
Senator Heller. Good morning. Thank you, Madam Chairwoman
and Ranking Member Burr, for the opportunity for me to
introduce this legislation, Senate bill 3308, the Homeless
Women's Veterans Act, before the Committee today; and I
appreciate your hard work and effort on behalf of the Nation's
veterans.
I know everybody here shares the same concerns about
homeless veterans as I do. A couple of weeks ago I met with a
constituent of mine, Dan Lyons, who walked from Reno, Nevada,
to Washington, DC, to raise support for homeless veterans. A 6-
month, 2800-mile journey.
He began walking on January 3, recording about 25 miles
each day. This former Marine Corps veteran who served in
Vietnam battled treacherous weather. He battled snakes and
long, lonely miles just for the chance to sit down and ask that
we do more to help struggling veterans.
All too often we see clearly what is wrong with this
society, and I think Dan reminds us of all that is right, and I
am proud to tell his story as we discuss legislation helping
homeless veterans. I commend his steadfast determination in
raising awareness for those who keep us safe, and I share his
commitment in helping veterans in need.
Too many of our Nation's heroes are coming home from
overseas to their homes underwater and high unemployment in
their communities. This economy has left far too many veterans
without work and in too many instances without a place to live;
and while a number of veterans have fallen on tough times
financially, some have also had difficulty adjusting to
civilian life.
Today there are over 100,000 veterans on America's streets,
roughly 16 percent of the homeless adult population. Congress
has established numerous programs to provide services to
homeless veterans facing economic hardship.
One program, the Grant and Per Diem Program has provided
construction costs, transportation costs, and counseling to
thousands of veterans and has been successful in combating
homelessness among veterans.
While these programs provide significant assistance to our
Nation's veterans, there are still too many without a place to
call home. Of particular concern is the growing number of
homeless female veterans.
In 1990, women made up 4 percent of all veterans. Today
that number has doubled to 8 percent, amounting to almost 1.8
million women. As the demographics of our Armed Services have
changed throughout the years so too have the needs of homeless
veterans.
Many homeless shelters today were never designed to serve
the needs of female veterans or homeless veterans with
children. The funding provided by Congress specifically
dedicated to this growing population is simply not enough to
ensure they have a safe and secure place to stay, nor do
existing programs allow the VA to be reimbursed for services
provided to children of homeless veterans.
Shelters should not have to make the untenable decision to
either lose money or deny services to children. For these
reasons, I join with Ranking Member Burr to introduce the
Women's Homeless Veterans Act. I do appreciate the support of
my friend, Senator Brown from Massachusetts, for his support on
this legislation also.
This commonsense legislation increases the percentage of
funding allocated for homeless women veterans as well as
providing the VA with the ability to reimburse shelters for
services provided to children.
Under this bill, at least 15 percent of funds allocated to
the Grand Per Diem account must be directed to the special-
needs program to greater meet the needs of homeless women
veterans. The current program does not provide an amount that
is reflective of this growing population.
The increased resources could be used to construct wings at
homeless shelters that are designed specifically for the
security and safety needs of women and children or provide more
counseling or other rehabilitative services for female
veterans.
The bill also clarifies that the VA can reimburse the cost
of dependents of veterans, ensuring that shelters providing
services will not have to turn children of veterans away.
Ensuring that all of our veterans and their children have a
safe and secure place to stay is the least that we can do.
I urge my colleagues to support this legislation to improve
the lives of our Nation's bravest. When they have sacrificed so
much for our country to preserve and protect our freedoms, we
should at least ensure that their needs are met when they fall
on hard times. I am proud that both The American Legion and the
National Coalition of Homeless Veterans have joined in support
of this legislation and ask that their letters of support be
entered to into the record.
[The letters are included in the Appendix.]
I thank Chairman Murray and Ranking Member Burr for holding
this important hearing. I am deeply appreciative of the
Committee's time and look forward to continuing this important
discussion.
And as a finishing point, Dan Lyons, who walked for 6
months, did take the train home. [Laughter.]
Thank you.
Chairman Murray. Thank you very much, Senator Heller.
Senator Ayotte.
STATEMENT OF HON. KELLY AYOTTE,
U.S. SENATOR FROM NEW HAMPSHIRE
Senator Ayotte. Thank you Madam Chair and Ranking Member
Burr for convening this hearing today.
I appreciate the opportunity to testify before this
distinguished Committee regarding the Remembering America's
Forgotten Veterans Cemetery Act of 2012, which is S. 2320,
which Senator Begich and I introduced earlier this year and
which several Members of this Committee are cosponsoring. I
would like to personally recognize and thank the Members of
this Committee that are cosponsoring my bill who are Senators
Akaka, Brown, Isakson and Wicker.
From Normandy to Panama, America's veterans' cemeteries
serve as a reminder of the extraordinary sacrifice thousands of
brave American men and women have made on distant battlefields
to protect our country.
Maintaining America's veterans' cemeteries is a well-
recognized responsibility of the Federal Government, and we
have a moral obligation to make sure that these cemeteries are
properly cared for.
One of those cemeteries is the Clark Veterans Cemetery in
the Philippines which contains the remains of more than 8,300
United States servicemembers and their dependents.
In 1991, the United States abandoned Clark Air Force Base
in the wake of a volcanic eruption; after 90 years of
maintaining custodianship, the United States also unfortunately
abandoned the graves of these brave Americans, leaving them
unattended under a thick layer of ash.
Over the next few years, the condition of the cemetery
worsened, leaving the graves of our courageous veterans in an
unacceptable state. Before you and also on the Committee
Members' iPads are pictures of what happened to the Clark
Veterans Cemetery, and you can see from these pictures that no
men or women or their dependents who have served our country
admirably should they be left, their remains, in a cemetery
that is in this condition and not cared for by our government.
Private volunteers became so concerned about the state of
this cemetery that they volunteered and attempted to honor our
servicemembers and their families buried there by maintaining
the cemetery at their own expense, and I want to thank the
Clark Veterans Cemetery Restoration Association and its
president, Denis Wright, for volunteering their own time and
resources to attempt to right this wrong and to give the
servicemembers buried at Clark the dignity that they deserve.
While these private citizens deserve our gratitude, the
United States government has a moral responsibility to care for
our veterans' cemeteries that honor the remains of those who
have bravely served our country.
For almost a century, the United States government cared
for those buried at the Clark Veterans Cemetery in the
Philippines. Now, it is time for the United States to resume
its responsibilities.
Our legislation would accomplish this by requiring the
American Battle Monuments Commission to restore, operate, and
maintain Clark Veterans Cemetery to honor the courageous
Americans that are buried there.
In fact, Senate Resolution 481, which passed the Senate by
voice vote on June 5, concluded that the United States
government should designate an appropriate United States entity
to be responsible for the ongoing maintenance of Clark Veterans
Cemetery.
Military cemeteries are managed by three Federal agencies,
the American Battle Monuments Commission and the Department of
Veterans Affairs National Cemetery Administration, and those in
the United States and Puerto Rico that is the agency that
maintains our cemeteries; and military departments also manage
cemeteries that are located on military installations.
Of these three Federal agencies, the American Battle
Monuments Commission, which is responsible for designing,
constructing, operating, and maintaining permanent American
cemeteries in foreign countries, is the most appropriate agency
to assume responsibility for the Clark Veterans Cemetery
because the Cemetery is a permanent American cemetery in a
foreign country.
Although the American Battle Monuments Commission focuses
much of its efforts on historical cemeteries and monuments in
Europe, the Commission also maintains a Corozal American
Cemetery in Panama, which is very, very similar to the Clark
Veterans Cemetery.
I am very pleased that the military coalition, which
represents 34 military veterans and uniformed services
organizations totaling nearly 5.5 million members, and the
National Military Veterans Alliance, which represents 3.5
million members in our country, as well as The American Legion,
the Military Officers Association, and others have written
endorsement letters or passed resolutions supporting this
legislation. Millions of current and former servicemembers and
dozens of service organizations have spoken.
They all agree. We must do the right thing for Clark
Veterans Cemetery. Madam Chair, I would ask that these letters
be submitted for the record.
Chairman Murray. The information will be included in the
record.
Senator Ayotte. The American veterans buried in Clark
Veterans Cemetery deserve a dignified and well-maintained final
resting place. There is no reason that the brave servicemembers
buried at Clark should be deprived of the honor that they have
earned and that veterans at other cemeteries are afforded. It
is time for the United States government to fulfill its
responsibility to care for this sacred ground.
Again, I would like to thank you, Madam Chair, and Ranking
Member Burr, for agreeing to hold this hearing. I am optimistic
that we can move forward on this legislation and ensure that
the United States government fulfills its responsibility to
honor the final resting ground of those who have sacrificed and
made the alternate sacrifice many of them for our country.
Chairman Murray. Thank you very much for your statement.
[The letters are included in the Appendix.]
Chairman Murray. We will turn to Senator Franken.
STATEMENT OF HON. AL FRANKEN,
U.S. SENATOR FROM MINNESOTA
Senator Franken. Thank you, Madam Chairwoman.
Chairwoman Murray and Ranking Member Burr, Members of the
Committee, thank you for the opportunity to testify on behalf
of the Rural Veterans' Health Care Improvement Act.
I apologize. I am going to have to leave immediately
following my testimony today.
I am very pleased to be working together with Senator
Boozman on this legislation. His commitment to our Nation's
veterans, like his unflappable disposition, is well known and
undisputed. I am honored that he is the lead sponsor of this
legislation which was considerably improved through his work on
it.
The purpose of our legislation is very straightforward and
very important: to improve access to quality health care for
our Nation's veterans living in rural areas.
Like many States, Minnesota has a great many veterans who
live in rural areas. Nationwide over 40 percent of all veterans
enrolled in the VA system live in rural areas. That presents a
challenge to accessing quality health care through the VA.
To address this challenge, the VA created the Office of
Rural Health or ORH in 2007. Congress has provided over $1
billion in support of ORH through fiscal year 2012. That is a
significant investment.
But the reality and the results are not yet where they need
to be. The funds that Congress has provided have enabled the
Office of Rural Health to undertake hundreds of initiatives
throughout the country.
Unfortunately, there has been no coherent strategic plan
for those hundreds of initiatives, and I think this speaks to
the Ranking Member's opening statement about making sure that
we are not wasting money and that we are not having duplicative
plans but we are having well-thought-out, strategically-
thought-out responses to these needs.
As a result, improvements in veterans' access to health
care in rural areas has been piecemeal and uneven. Last year, a
VA Inspector General found that ORH lacked reasonable assurance
that a majority of its funds, this is amounting to $273 million
in fiscal years 2009 and 2010, actually no assurance that they
actually improved access to and quality of care for rural
veterans. That is a failure. It fails our veterans and it fails
the public that funds VA's programs.
When we are talking about that much money and such an
important mission, we are not going to let VA muddle through.
We are going to demand that they get it right, and they get it
right now.
The ORH has an essential goal, to bring quality health care
to veterans in rural areas. To achieve that, the VA needs to
undertake careful, strategic planning, including the careful
stewardship of taxpayer resources. That is the purpose of our
legislation, which requires the VA to produce a strong and
comprehensive strategic plan for ORH.
Now, I appreciate that VA has taken some steps to address
problems identified by the Inspector General's report, but
these steps are simply not enough.
First, the strategic plan that the VA put out, which was
already out when the IG made its findings does not move beyond
the piecemeal approach ORH has been taking and does not develop
a comprehensive strategy.
The research of the ORH plan, as Senator Boozman said in
his opening, the research of the ORH plan that VA issued late
last year was an improvement over the initial plan, but not yet
enough of an improvement.
Second, while some of the features required by our
legislation are included in the plan that VA put out others are
not. If ORH is to be successful, it needs to address all of the
important goals and objectives we have identified in the
legislation.
The Disabled American Veterans in their testimony note a
couple of these areas. The full and effective use of mobile
outpatient clinics and the provision and coordination of care
for women veterans in rural areas.
I will add another just by way of example. I believe you
will not find the word emergency or emergencies in the VA's
current plan. Yet, the VA Inspector General has again and again
reported the difficulties that many veterans in rural areas
face trying to get care in an emergency.
Understandably, many rural clinics are not equipped to
handle many types of emergencies including heart attacks,
strokes, and mental health emergencies. They simply go beyond
the capacity of these relatively small clinics. But we know
that emergencies will happen, and we need to be prepared.
To address this, our legislation will require VA to ensure
that all rural health care providers are actually identifying
their clinical capacity and have a contingency plan for how
they handle emergencies that exceed that capacity.
That way, if a veteran shows up with a mental health
emergency, for example, he or she will really get the best care
possible in addressing that emergencies. We cannot have
veterans committing suicide or suffering intense psychological
anguish because they could not get care.
I have also heard some Minnesota County veterans' services
officers about veterans who get taken to a hospital for a heart
attack because the VA clinic does not have an emergency room
and then have real trouble getting reimbursed, getting it
covered. They have to pay for it themselves. The coordination
of care that our bill promotes will also make that situation
far less likely.
Finally, finally, our bill brings much-needed
accountability to the VA's Office of Rural Health. I appreciate
that VA wants ORH to achieve its mission. This legislation will
make that happen and happen faster. I would also note that the
Appropriations Committee in its report accompanying the
military construction/VA appropriations express its belief,
quote, that ``the VA must do more to plan for and provide
quality health care to veterans living in rural and highly
rural areas.''
ORH is dedicated to the provision of health care to rural
veterans, and the Congress has provided substantial funds for
that very important purpose. But thus far the results have not
been good enough and this speaks so clearly, I think, to what
the Ranking Member said in his opening.
Our legislation will ensure that the VA improves access to
care for rural veterans so they can get the excellent health
care that they deserve. We owe them nothing less. Thank you.
Chairman Murray. Thank you, Senator Franken.
With that, we will turn now to Senator Wyden.
STATEMENT OF HON. RON WYDEN,
U.S. SENATOR FROM OREGON
Senator Wyden. Thank you, Madam Chair.
Madam Chair, I would ask first that my statement, my
statement's entirety could be put in the record and perhaps I
could just summarize. I know you have additional colleagues who
are waiting to testify.
Chairman Murray. Absolutely. Every Senator's statement will
be printed in the record.
Senator Wyden. Thank you, Madam Chair, and first of all,
Madam Chair, as your Pacific Northwest neighbor, let me just
thank you for the extraordinary advocacy that you have brought
to the cause of veterans. I get to see it, and most recently
the work that you are doing now to up the ante in the fight
against PTSD is extraordinarily important. I want you to know I
appreciate it and want to help.
And to Senator Burr, my friend, we have worked together for
a lot of years on these kinds of issues, and you have just been
tireless and a terrific partner, and I thank you for it.
Madam Chair, what Senator Burr and I are sponsoring is
S. 3270. This is a piece of legislation that comes about as a
result of a lengthy undercover investigation done by the
Government Accountability Office. It was done on behalf of
Senator Burr, yourself, and several of us from the Senate Aging
Committee.
So, lots of times around here you cannot get one Committee
to agree. We have now been able to get two committees to work
together in a bipartisan way.
The heart of the problem and what the GAO found, and I
started looking at some of these senior abuses, you know, years
ago when I was codirector of the Oregon Gray Panthers and the
Senior Citizens Law Program, is they really uncovered some of
the sleaziest practices in terms of older veterans that I have
seen in the years that I have spent working in this field.
What it essentially involves is a program called Aid and
Attendance. This program is essentially a lifeline for the
poorest and most vulnerable who have served our country. It is
for very sick veterans, folks who are no longer able to care
for themselves and do not have the resources to pay for their
care.
What you have is essentially several hundred financial
firms. They are called pension poachers, and we see them around
the country basically trying to find ways to either talk these
vulnerable veterans out all their resources or tie up their
assets in a way that is good for the financial firm.
These case, just to highlight, that we saw in our hearings
was one from Montana. A veteran there was referred by the
management of the retirement home to one of these pension
poaching companies from Mississippi for assistance with the Aid
and Attendance benefit.
So, what the poachers did was charge the veteran a very
substantial sum, $2,500, to fill out the application paperwork
that they essentially can get for free, and it was eventually
filed with the VA but it was denied because the paperwork was
never actually signed by the veteran.
What the poachers did, however, and this is a very common
kind of practice, is to get the veteran's signature on a power
of attorney and that way they can tie up their assets in one of
these corporations that are located out of State.
That has been a special magnet for these pension poachers.
They try to sell these inappropriate financial instruments,
deferred annuity, certain types of trusts. That way they can,
in effect, benefit while the veteran's money, in effect,
becomes unusable during the veteran's lifetime.
So, what the Government Accountability Office recommended,
you know, Madam Chair, was the establishment of a look-back
approach similar to what has been used for years with Medicaid
or Social Security.
This would take away the incentive for the pension poacher
to target older veterans. Senator Burr and I have joined in
sponsoring this bill. It is legislation that would, in effect,
implement the recommendations from the Government
Accountability Office that come from this undercover
investigation.
For colleagues who would like to see the tapes of this
undercover inquiry, Senator Burr and I can make it available to
you. But I will tell you that having worked in this field now
for many years and going back to the days with Gray Panthers
and always watching how unfortunately there are some people out
there who try to rip off older people and here they are ripping
off older veterans.
This is some of the sleaziest stuff I have ever seen. We
ought to take away the incentive to rip off the people who
desperately need this benefit.
My sense is in this kind of financial climate, and the
Chair of the Committee did important work on the Super
Committee, if people keep ripping off this program, people are
going to say, well, maybe this is something we should not have
any longer.
Senator Burr and I want to make sure that this program
remains for the most needy and most vulnerable and that is why
I very much appreciate the chance to come here.
I know Senator Boxer and Senator Portman are waiting. If
the rest of my remarks could be put into the record, I would
very much appreciate it.
Chairman Murray. We will do that. Thank you very much,
Senator Wyden.
Senator Wyden. Thank you, Madam Chair, Senator Burr.
[The prepared statement of Senator Wyden follows:]
Prepared Statement of Hon. Ron Wyden, U.S. Senator from Oregon
Chairman Murray and Senator Burr, I want to thank you for allowing
me the time to appear before the Committee on Veterans' Affairs today.
The legislation that I'm here today to discuss is the result of the
great bipartisan efforts of the two of you and well as this Committee
and the Senate Committee on Aging. I think this demonstrates the
importance of this issue.
Senator Burr, you especially have been a relentless driving force
behind this bill, and I'm honored to have introduced it with you.
As you'll recall, a few weeks ago the Senate Special Committee on
Aging held an investigative hearing on scams targeting elderly veterans
using a specific VA pension as a lure.
The Aging Committee found that some financial planners, lawyers and
others are using the VA's ``enhanced pension with aid and attendance,''
or simply, Aid and Attendance, to enrich themselves at our veterans'
and taxpayers' expense.
What makes this even worse is the fact that Aid and Attendance was
specifically designed to help infirm and impoverished elderly veterans,
so many of the victims of these pension poachers are the ones who can
afford it least.
At the hearing, the Government Accountability Office testified
about the undercover investigation they conducted at the request of
Senators Murray, Burr, Kohl and I. They found versions of this scam
nationwide, with over two hundred pension poaching companies in
operation.
GAO's recommendation to Congress was the establishment of a look-
back period, similar to Medicaid or Social Security, to take away the
incentive for the Pension Poachers to target elderly veterans, and
preserve this benefit for the veterans it is intended to help.
This recommendation has been echoed by veterans' advocacy groups
and the VA itself.
Senator Burr and I authored S. 3270, which would provide this look-
back. We worked closely with the VA and other experts to ensure our
bill fixes the problem, but does not create collateral damage like an
increased backlog of claims.
We knew we had to drain the swamp and get rid of these pension
poachers, but we also had to ensure the benefits our veterans need
would be accessible quickly and without excessive red tape.
We also didn't want to inadvertently punish veterans who were
misled by the false or inaccurate promises, so we've included specific
waiver authority to address this.
``Aid and Attendance'' is an invaluable lifeline for many veterans.
This program is for the very sick--veterans who are no longer able to
care for themselves and who do not have the resources to pay for care.
It is a benefit intended to ensure that those who served their nation
with honor can live out their final days in dignity.
I believe the bill that Senator Burr and I have introduced, which
already has strong bipartisan support, will preserve the Aid and
Attendance benefit, while protecting our veterans from pension poachers
who are driven only by greed.
I'm pleased to announce we've received formal support from AMVETS,
recognizing the importance of this legislation in protecting our
veterans.
We've also received a letter from the Assisted Living Federation of
America, supporting this bill and pledging to help in the development
of industry best practices to further ensure veterans are treated with
the integrity they deserve.
I hope that this Committee will support this legislation, and help
put an end to the malicious practices of these pension poachers.
Chairman Murray, Thank you again for the time to speak this
morning. I truly appreciate your consideration of such an important
matter.
Chairman Murray. Senator Boxer.
STATEMENT OF HON. BARBARA BOXER,
U.S. SENATOR FROM CALIFORNIA
Senator Boxer. Madam Chairman, Ranking Member Burr, and
Members of the Committee, my friends, you know, I am in the
middle of some very interesting negotiations right now that are
looking good; but even though that is the case, I want you to
know how honored I am to be sitting here listening to my
colleagues come forward with such good ideas, and to have this
forum is such an honor.
I just want to say, I am in awe of the Chairman for the
work she is doing and the Ranking Member beside her, and to
serve with the Ranking Member as the Chair of the Military
Families Caucus is a great honor.
So, I come here and I will stick within the time limit
because I know how much work you have to do, and that you have
to hear from a lot of people. I came here to talk to you about
the epidemic of veteran homelessness and to offer an idea that
does not cost any money that I think would be terrific
involving the American people in fighting this epidemic.
You know, I would say probably all of those in this room--I
certainly hope all of us in this room--have safe, comfortable,
permanent homes to live in, and we take it for granted. Yet
every night 67,500 of our Nation's veterans are homeless.
Again, 67,500 of our veterans are homeless. This is inexcusable
because no veteran should ever have to spend the night on the
streets, and I know we all agree with that.
Ensuring that our veterans have safe, stable housing is
also a smart thing to do because research has shown that a home
is the very foundation on which a veteran can build and sustain
a successful life.
In my homestate of California I met a veteran, Holbert Lee.
When Mr. Lee returned home from Vietnam, he ended up addicted
to drugs and homeless on the streets of San Francisco.
We have an organization there called Swords to Plowshares,
and they helped him turn his life around, Madam Chairman. With
the help of a housing voucher and VA support services, Mr. Lee
now has a home to call his own; and today as a vocational
specialist at the San Francisco VA. He is working to assist
other veterans.
Holbert Lee is a success story and proof of what can happen
when we end a cycle of homelessness. But there are too many
more men and women who we have not reached.
Now, our government announced a goal to end veterans'
homelessness by 2015, and I would like to think when we
announce a goal like that we mean it. This is not just
something we throw out but yet Secretary Shinseki admitted,
quote, while we are not where we need to be just yet, we have
movement, but it is too early to begin high-fiving one another.
It is clear from those words that we have a long way to go.
So, I introduced S. 1806, the Check the Box for Homeless
Veterans' Act of 2011. Very straightforward. It creates a
check-off box on the annual Federal tax return. Taxpayers can
decide to make a voluntary contribution of one dollar or more
to support programs that prevent and combat veterans'
homelessness.
The donations are deposited in a new homeless veterans'
assistance fund established at the Treasury that can only be
used to supplement Congressionally appropriated funds for these
various programs to help veterans.
Now, let me be very clear. These funds in the check-off box
will not be allowed by law to replace any budgeted dollars.
There needs to be a maintenance of effort but they would be
used to supplement those dollars.
So, colleagues, I want to say, well, before I do my real
close, I want to place in my record with your permission, Madam
Chair, letters of support from the Veterans Foreign Wars, from
the National Coalition for Homeless Veterans, from Team AMVETS,
from the Center for American Homeless Veterans, Inc., and from
the California Association of Veterans Services, and Swords to
Plowshares. Might I put those in the record?
Chairman Murray. We will do that.
[The letters are included in the Appendix.]
Senator Boxer. And I think if you read these letters, they
strongly support this approach.
So, in conclusion, I would say that our veterans have given
so much. You are dealing with this every day and a lot of them
suffer and they suffer mightily and having a home is the least
we can do, and I think that all Americans want a chance to
help. They feel sometimes helpless but with a dollar and a
check off if every American paying, you know, their taxes did
that we could do something special.
I hope you will consider this. I will work with you to make
it happen. I thank you for your dedication.
Chairman Murray. Thank you very much.
We will turn to Senator Portman.
STATEMENT OF THE HON. ROB PORTMAN,
U.S. SENATOR FROM OHIO
Senator Portman. Thank you, Madam Chair, I appreciate it. I
got used to calling you Madam Chair in another little Committee
we served on.
Chairman Murray. I remember it.
Senator Portman. This one is more super than that one was.
[Laughter.]
Chairman Murray. And I agree.
Senator Portman. Thank you what you do every day for our
veterans, and Ranking Member Burr, I was just with him in North
Carolina recently, another champion for our veterans. Senator
Isakson and Senator Boozman who testified on the floor last
night about veterans.
I am here to ask you to support this bill, S. 2244, the
Veterans Missing America Act. It has been a privilege to work
with my colleague, Senator Begich, on this, and it helps bring
light to a critical issue that many of us are becoming aware
of.
At funeral homes and mortuaries all across this great
country, thousands of veterans ashes and remains go abandoned,
unclaimed; and in response to these unfortunate circumstances,
a handful of veterans service volunteers began this project
called Missing in America Project. It is a terrific group of
volunteers who have been very active in my homestate of Ohio,
and I am sure in many of your States.
Regrettably, when individuals pass away, and there is no
next of kin identified, the remains sometimes stay at funeral
homes or mortuaries, without anyone laying them to rest,
indefinitely.
Of the hundreds of thousands of unclaimed remains in this
country, it is estimated that over 10,000 are remains of our
veterans. The Missing America Project tries to identify anyone
who is a veteran among those unclaimed remains and then provide
a proper burial and funeral.
Sometimes these dedicated volunteers have run into
bureaucracy and complications because they tried to do that. It
is a noble cause but, due to limitations on third-party
involvement, it has become difficult for them.
So, this legislation attempts to address these
complications, recognizing their tireless work and dedication
and in cooperation with numerous veterans service organizations
have put together a legislative approach here that we think
will help identify unclaimed remains and ensure that the
Department of Veterans Affairs will work with these volunteers
to see every veteran receives the respect that they deserve.
As I mentioned, in Ohio we have taken a leadership role on
this. Despite some of these roadblocks we are talking about we
are trying to fix today, the Department of Veterans Affairs in
Ohio, along with these volunteers from the Missing America
Project, have had an initial burial of 10 veterans at the
Dayton National Cemetery in May of this year.
These were veterans of World War I, World War II, and
Korea; and in this case, the remains had been at funeral homes
for between 15 and 25 years.
It was a very moving ceremony. There were a few hundred
people who showed up to pay their respects, none of whom knew
the veterans but they were there to pay their respects for
their service to our country.
Although we have had some successes like those, the work of
these volunteers is encumbered by the Department of Veterans
Affairs next-of-kin requirements. The bill, therefore, directs
the Secretary of Veterans Affairs to work with veterans service
organizations to assist entities in identifying veterans
eligible for burial in a national cemetery.
If the remains are of an eligible veteran, the Secretary of
the Department of Veterans Affairs is then required to provide
the burial benefits already authorized to that veteran.
It is important to note to this Committee that since we
introduced the legislation with Senator Begich in March and
along with our counterparts in the House, there is companion
legislation in the House, we have worked closely with the
Department of Veterans' Affairs to ensure the measure is
appropriately worded to meet the sheer intent that we have; and
through those discussions and their technical suggestions, we
have amended the language including refining the burial
eligibility criteria to ensure that benefits are provided to
qualifying veterans.
We stand ready to submit these technical amendments and
refinements to the Committee during your markup of the bill.
Our intent is to add no new spending through this provision and
we will work with the Committee very closely and, of course,
with the Department to achieve that goal.
I am proud to say that the National Association of State
Directors of Veterans Affairs has expressed support for the
Missing America Project and has urged our Nation's leaders to
take action. Additionally, this effort has the support of the
National Funeral Directors Association and The American Legion.
Those who gave their life in service to our country deserve
an honorable burial, and this bill is a step toward ensuring
that eligible veterans do receive that burial in a national
cemetery given the respect that they rightly deserve.
Thank you very much for the opportunity to testify on that
this morning, and I look forward to working with the Committee
on this going forward along with all of the other good work
that you are doing.
While I am here, Madam Chair, I would also like to thank
you for having S. 3238 on the docket this morning. This measure
would designate the Department of Veterans Affairs Community
Based Outpatient Clinic in Mansfield, Ohio, in the name of
Private First Class David F. Winder. I am pleased to cosponsor
this measure along with Senator Sherrod Brown as we seek to
honor this Metal of Honor recipient from Vietnam who provided
medical aid to his soldiers in Vietnam and died in doing so.
So again, thank you for your help on both of these
important pieces of legislation, and I look forward to working
with the Committee further.
Chairman Murray. OK. Thank you very much.
I will just let all the Senators know who have been
testifying today that we are going to be working with them and
their staff and the Administration on all of these bills.
As Senator Burr mentioned, we do have to pay for all of the
legislation that comes before this Committee. So, we have a lot
of work to do, but we will be scheduling a markup on all of
these pieces of legislation toward the middle of July, and I
will be working with Senator Burr on that. So, thank you very
much.
At this time then, I would like to welcome and introduce
our first panel. From the Department of Veterans Affairs, we
have Dr. Madhulika Agarwal, the Deputy Under Secretary for
Health Policy and Services at the Veterans Health
Administration.
Also joining us today from the VA is Thomas Murphy,
Director of the Compensation Service at the Veterans Benefits
Administration. Accompanying Dr. Agarwal and Mr. Murphy is
Deputy Under Secretary for Health for Operations and Management
at the Veterans Health Administration William Schoenhard, as
well as Jane Claire Joyner and Richard Hipolit from the Office
of General Counsel.
We appreciate all of you being here today.
The Department's full statement will be entered into the
record and, Dr. Agarwal, please begin.
STATEMENT OF MADHULIKA AGARWAL, DEPUTY UNDER SECRETARY FOR
HEALTH POLICY AND SERVICES, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Agarwal. Chairman Murray, Ranking Member Burr, and
other Members of the Committee, thank you for the opportunity
to address the health care bills on today's docket.
My colleague, Mr. Murphy, will address the VBA bills under
consideration. I will highlight some of the critical issues
that are themes of many of the bills on the agenda and a
detailed discussion of these bills can be found in my written
statement.
First, Chairman Murray, thank you for your continued
efforts to emphasize the health care needs of women veterans. I
am proud of VA's efforts in improving women's health, and I
know we can make further enhancements working with the
Committee.
Your bill, S. 3313, the Women's Veterans Health and Other
Care Improvement Act, among other features includes
reproductive health issues. The VA's goal is to restore the
capabilities of veterans with disabilities to the greatest
extent possible. VA does not yet have a position on S. 3313 but
we have had productive discussions with your staff which we
look forward to continuing.
Second, several bills address programs for rural veterans.
VA is committed to improving access and quality of health care
for this population. My written testimony outlines what VA is
doing to meet this challenge, including greater use of
telehealth technologies and collaboration with other Federal
and State agencies and community providers to provide more
points of care.
This work is especially important to increase access to
mental health services for veterans in rural areas. We note in
our testimony that some features of the bills would overlap
with our current efforts. We will be glad to discuss how we can
best advance the goals of the legislation before us.
Third, while we do not have views today on S. 3340
regarding the Mental Health ACCESS Act of 2012, we will follow-
up with the Committee as soon as possible.
We fully recognize there is no more critical need than
effective and timely mental health care. We strive to improve
all facets of mental health services. To increase our capacity
to meet current and future demand, we have launched a new
hiring initiative to increase staff, and we will continue our
efforts to increase access to quality mental health care.
Fourth, we regret we do not have a position this morning on
S. 3049 which expands the definition of homelessness. We will
provide information on that to the Committee as soon as
possible.
Let me assure the Committee that whatever the technical
considerations may be on a statutory definition, VA never would
and never will turn away a homeless veteran who finds
themselves on the street because they are fleeing domestic
violence.
Finally, turning to Ranking Member Burr's legislation on
VISN reorganization, we have been working for the past year to
review VISN operations.
My written testimony describes these ongoing efforts, and
we would like to brief the Committee in greater detail on these
plans. We believe S. 3804 is too prescriptive in legislating
particular boundaries and structures and Mr. Schoenhard will be
glad to discuss this issue.
Madam Chairman, this concludes my statement. Mr. Murphy
will now address the pending VBA legislation and we will then
be ready to answer your questions.
Chairman Murray. Mr. Murphy.
STATEMENT OF THOMAS MURPHY, DIRECTOR, COMPENSATION SERVICE,
VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS; ACCOMPANIED BY WILLIAM SCHOENHARD, DEPUTY UNDER
SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS
HEALTH ADMINISTRATION; JANE CLAIRE JOYNER, OFFICE OF GENERAL
COUNSEL; AND RICHARD HIPOLIT, OFFICE OF GENERAL COUNSEL
Mr. Murphy. Chairman Murray, Ranking Member Burr, and other
Members of the Committee, thank you for the additional time to
comment on the extensive agenda before us today. As Dr. Agarwal
did, I will only touch on a few highlights, as you have our
detailed testimony for the record.
VA wholeheartedly supports Senate Bill 2259, the Veterans
Cost of Living Adjustment Act. It would express in a tangible
way this Nation's gratitude for the sacrifices made by our
service-disabled veterans and their surviving spouses and
children and would ensure that the value of their well-deserved
benefits will keep pace with the increased cost of living.
Two bills on the agenda concern the burial needs of the
indigent veterans whose remains are unclaimed. Senate Bill
2244, the Veterans Missing in America Act and Senate Bill 3202,
the Dignified Burial of Veterans Act.
VA appreciates the Committee's continued attention to
ensure that these veterans, including, no doubt, homeless
veterans, are honored and are not forgotten. We look forward to
continuing to work with you to ensure that all veterans receive
dignified and respectful burials, which they earned through our
service to our Nation.
We are supportive of these efforts and welcome discussions
with the Committee on those few points in the testimony where
he recommend improvements in the bill.
For Senate Bill 1707, the Veterans Second Amendment
Protection Act, we appreciate the objectives of this
legislation to protect the firearms rights of veterans
determined by VA to be unable to manage their own financial
affairs.
VA determinations of mental incompetency are based
generally on whether a person lacks the mental capacity to
manage his or her own financial affairs due to injury or
disease. We believe that there are adequate protections in the
law now such that a veteran with a determination of
incompetency has two procedures available to make a showing to
restore his or her ability to purchase a firearm.
In the interest of time, I will then herein refer the
Committee to my written statement. I would be happy to answer
any questions you or the Members of the Committee may have.
[The prepared joint statement of Dr. Agarwal and Mr. Murphy
follows:]
Prepared Statement of Dr. Madhulika Agarwal, Deputy Under Secretary for
Health for Policy and Services, Veterans Health Administration, U.S.
Department of Veterans Affairs
Chairman Murray, Ranking Member Burr, and other Members of the
Committee, I am pleased to provide the views of the Department of
Veterans Affairs (VA) on pending legislation. Joining me today are Tom
Murphy, Director, Compensation Service, Veterans Benefits
Administration; William Schoenhard, Deputy Under Secretary for Health
for Operations and Management, Veterans Health Administration; Jane
Clare Joyner, Deputy Assistant General Counsel; and Richard Hipolit,
Assistant General Counsel.
VA regrets not having sufficient time to formulate views for
S. 1391; S. 3049; S. 3206; S. 3270; S. 3238; S. 3282; S. 3308; S. 3309;
S. 3313; S. 3316; S. 3324; S. 3336; a draft bill to amend title 38,
United States Code, to improve the multifamily transitional housing
loan program of the Department of Veterans Affairs; and a draft bill
entitled the ``Mental Health Access to Continued Care and Enhancement
of Support Services Act of 2012'' or ``Mental Health ACCESS Act of
2012.'' VA will provide views for these bills at a later date.
s. 1264--veteran voting support act of 2011
VA has a tradition of successfully supporting and facilitating
Veteran voting, without disrupting the delivery of health care and
services to Veterans. Facilities use posters and flyers to emphasize
the issue of voting to patients and visitors, and VA volunteers assist
Veterans in registering to vote. VA facilitates transportation to the
polls for Veterans to vote, using VA resources and volunteers. VA
tracks these voter registration and facilitation activities.
The Department's voter assistance policy (VHA Directive 2008-053)
focuses on Veterans who are inpatients at VHA facilities. Under this
directive, Veterans staying at VA facilities are currently provided the
same type and level of assistance and support that would be required
under the bill. During the 2008 election cycle more than 9,000 posters
were placed at VA facilities, more than 225,000 flyers were provided to
new inpatients through their welcome packets and comfort kits, and
1,100 volunteers were recruited specifically to provide voter
information and assistance to Veterans. VA also partnered with non-
partisan groups to conduct more than 80 informational ``voter drives.''
As a result, close to more than 5,900 inpatients received assistance in
registering to vote. While not a principal focus, voter assistance does
reach Veterans using outpatient services as well.
Section 3 of this bill would require VA to provide a ``mail voter
registration application'' to each Veteran seeking enrollment in VA
health care and to all enrolled Veterans any time there is a change in
enrollment status or address. It would also require VA to provide
assistance with voter registration to Veterans unless they refuse such
assistance, and would require VA to accept completed voter registration
forms and transmit them to the appropriate state election official
within 10 days of receipt (unless they are received within 5 days of
the registration deadline, in which case they must be sent within 5
days). Section 3 also would prohibit VA from influencing Veterans or
displaying any political preference and would prohibit VA's use of this
information for any purpose other than voter registration. The bill
would allow anyone aggrieved to provide notice of the violation to the
facility director or the Secretary and would require the director or
the Secretary to respond within 20 days. If a violation is not
corrected within 90 days, the aggrieved person may provide written
notice to the Attorney General and Election Assistance Commission.
Section 3 also authorizes the Attorney General to bring a civil action
for violations.
Section 4 would require VA, consistent with state and local laws,
to assist Veterans residing in VA facilities with absentee balloting.
Section 5 would require the Secretary to permit nonpartisan
organizations to provide voter registration information and assistance
at Department health care facilities, subject to reasonable
limitations.
Section 6 would similarly prevent VA from prohibiting any election-
administration official from providing voter information to Veterans at
any VA facility. Moreover, it would require VA to provide reasonable
access to VA health care facilities to state and local election
officials for providing nonpartisan voter registration services.
Section 7 would require VA to submit an annual report to Congress on
the agency's compliance with this Act as well as the number of Veterans
served by VA's health care system, the number of Veterans who requested
information or assistance with voter registration, the number who
received information or assistance, and information regarding notices
of violations.
As noted previously, VA is committed to helping Veterans exercise
their right to vote, and, especially in recent years, has increased the
non-partisan assistance provided to Veterans. While VA applauds the
bill's goals, it opposes S. 1264 as it is overly burdensome and, in
some respects, duplicates the agency's existing voter assistance
efforts.
As described above, Section 3 of the bill would require VA to
provide a voter registration application form to each Veteran who seeks
to enroll, and to enrolled Veterans any time there is a change in the
enrollment status of that Veteran, or a change in the address of the
Veteran. As VA facilities treat patients from multiple jurisdictions
under a national system, implementing these requirements would be
extraordinarily complicated. Under this national system, Veterans have
the ability to use VA facilities not necessarily in their home
jurisdiction. It would require VA to keep and apply authoritative
information on elections, voter registration deadlines, and voter
registration requirements in all 50 states.
The multi-jurisdictional nature of VA also creates complications
for providing the assistance with absentee ballots outlined in Section
4 of S. 1264; however, Section 4 is limited to Veteran inpatients,
those residing in Community Living Centers, and domiciliaries.
This bill would also require the Secretary to permit nonpartisan
organizations to provide voter assistance at facilities of the VA
health care system. In addition, S. 1264 provides that the Secretary
shall not prohibit any election official from providing voting
information to Veterans at any facility of the Department of Veterans
Affairs. Though the legislation allows VA to set reasonable time, place
and manner restrictions on visits by election officials and nonpartisan
groups, it is not clear that VA could entirely exclude election
officials from certain facilities. There are some places within VA,
such as National Cemeteries, psychiatric facilities, and Vet Centers,
which are not appropriate locations for voter information and
assistance activities from outside entities. Moreover, the definition
of election official is overly broad as it could be interpreted to
include volunteer ``election judges'' or ``election monitors'' who are
assigned by campaigns or political parties to watch polling locations
for irregularities on the day of an election. Directive 2008-053
currently provides nonpartisan organizations and election officials
access to VA health care facilities for the purpose of providing voter
information and assistance.
The costs for the requirements of this bill are significant. They
include an initial mail-out to approximately 8.2 million enrollees at a
cost of $5.3 million and estimated recurring costs of $1.2 million
annually. VHA would have to create a Voter Assistance Program in VA
Central Office and in the field to support the proposed legislation. VA
estimates the entire cost of implementing S. 1264 would be $26.0
million in FY 2013, $6.1 million in FY 2014, $113.3 million over 5
years, and $242.4 million over 10 years.
S. 1631--A BILL TO AUTHORIZE THE ESTABLISHMENT OF A CENTER FOR
TECHNICAL ASSISTANCE FOR NON-DEPARTMENT HEALTH CARE PROVIDERS
FURNISHING CARE TO VETERANS IN RURAL AREAS
Section 1(a) of S. 1631 would authorize the Secretary of Veterans
Affairs to establish a center responsible for providing technical
assistance to non-VA health providers who furnish care to Veterans in
rural areas. Were the Secretary to exercise this authority, section
1(b) of the bill would permit VA to refer to the center as the ``Rural
Veterans Health Care Technical Assistance Center'' (the ``Center''). It
would also require the Secretary to appoint a Director for the Center
from candidates who are qualified to carry out the duties of the
position and who possess significant knowledge and experience working
for, or with, a non-VA health care provider that furnishes care to
Veterans in rural areas.
Section 1(c) of S. 1631 would require the Secretary of Veterans
Affairs to select the location of the Center and, in doing so, to give
preference to a location that meets a set of detailed criteria relating
to available infrastructure and a high number of Veterans in rural and
highly rural areas, among other factors.
Section 1(d) of S. 1631 would require the Center to carry out the
following tasks:
Develop and disseminate information, educational
materials, training programs, technical assistance and materials, and
other tools (1) to improve access to health care services for Veterans
in rural areas and (2) to otherwise improve health care provided to
Veterans by non-VA health care providers;
Improve collaboration on health care matters, including
the exchange of health information, for Veterans receiving health care
from both VA and non-VA providers serving rural populations;
Establish and maintain Internet-based information on
mechanisms to improve health care for Veterans in rural areas
(including practical models, best practices, research results, and
other appropriate information);
Work with existing Government offices and agencies,
including those specified in the bill, on programs, activities, and
other mechanisms to improve health care for rural Veterans;
Track and monitor fee expenditures incurred by VA in using
non-VA health care providers to serve rural populations; and
Evaluate the Center through the use of an independent
entity that is experienced and knowledgeable about rural health care
matters, non-VA providers serving rural populations, and VA programs
and services.
Finally, section 1(e) of S. 1631 would authorize the Center, in
discharging its functions, to enter into partnerships with: (1) persons
and entities that have demonstrated expertise in the provision of
education and technical assistance to Veterans in rural areas; (2)
health care providers serving rural populations; and (3) persons and
entities seeking to enter into contracts with the Federal Government in
matters relating to functions of the Center (including the provision of
education and technical assistance relating to telehealth,
reimbursement for health care, improvement of quality of care, and
contracting with the Federal Government).
VA appreciates the aims of this legislation, but does not support
S. 1631. VA's Office of Rural Health (ORH) currently supports a number
of programs and initiatives that are accomplishing many of the
activities proposed for the Center for Technical Assistance.
Specifically, ORH currently funds ``The Health and Resource Initiative
for Veterans Everywhere (THRIVE) On-Line,'' a collaboration with
Stanford University School of Medicine, eCampus Rural Health, and VA
Palo Alto Health Care Systems. THRIVE also partners with multiple VA
services and community agencies. Participating VA staff are from a
number of complementary Department programs, such as mobile medical,
homeless outreach, Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn (OEF/OIF/OND), women's outreach, and incarcerated
Veterans re-entry teams. Successful partnerships have been established
with local homeless shelters, employment agencies, and county health
clinics. THRIVE On-Line also provides technical assistance, materials,
and other tools to VA and non-VA providers alike, to improve the health
care of our Veterans in rural areas.
In addition, ORH currently funds three Veterans Rural Health
Resource Centers (VRHRCs). These centers function as field-based
clinical laboratories for demonstration projects. A number of these
projects are focused on developing models of care as well as innovative
clinical practices and systems of care for rural Veterans. The VRHRC--
Western Region is located in Salt Lake City, Utah. Much of the work of
this center focuses on outreach, access issues, and the special needs
of Native American Veterans and aging Veterans. One of its major
efforts has been to establish an outreach program to build partnerships
with community agencies and organizations that serve rural communities.
Through these partnerships, rural Veterans receive information about,
and assistance in identifying, VA benefits for which they may be
eligible. The VRHRC--Central Region is located in Iowa City, Iowa. This
center focuses on evaluating rural health programs and piloting new
strategies to help Veterans overcome identified barriers to access to
(quality) care. The VRHRC--Eastern Region has three locations:
Gainesville, Florida; Togus, Maine; and White River Junction, Vermont.
Their collective focus is on developing models to deliver specialty
care and services to rural areas and on educating and training VA's
next generation of rural health care providers. VRHRC staff members
also serve as rural health experts for VA providers Nation-wide, and
they provide training and education services to both VA and non-VA
providers caring for rural Veterans.
ORH also funds and oversees Veterans Integrated Service Network
(VISN) Rural Consultants (VRCs). There is a VRC in each VISN that
serves as the primary interface for ORH, the VISN, and the community
regarding rural activities. The VRCs work closely with internal and
external stakeholders to introduce, implement, and evaluate ORH-funded
projects. The VRCs are also instrumental in conducting outreach to
develop strong partnerships with community members, state agencies,
rural health providers, and special interest groups. Since being
established, ORH has funded well over 500 projects across the VA health
care system. These projects cover a myriad of areas, such as education,
home-based primary care, long-term care, mental health, case
management, telehealth, primary care, and specialty care. ORH also
funds ``Project Access Received Closer to Home (ARCH),'' which is a 3-
year pilot program to provide health care services to rural Veterans
through contractual arrangements with non-VA care providers.
VA has also recently drafted a memorandum of understanding (MOU)
between the Department of Veterans Affairs (VA's Office of Rural
Health) and the Department of Health and Human Services (Offices of the
National Coordinator for Health IT and Rural Health Policy) to ensure
interoperability between VA and rural health care providers to allow
and promote the effective exchange of health information.
Information on practical models, best practices, research results,
and other appropriate information on mechanisms to improve health care
for Veterans in rural areas, is already available on the ORH Web site
at http://www.ruralhealth.va.gov/, at THRIVE On-Line, http://
ruralhealth.stanford.edu/, and on the VA Internet at http://
www.va.gov/.
As to the bill's requirement to monitor and track fee expenditures
in this area, the VHA Support Service Center (VSSC) already tracks all
fee expenditures down to the Veterans' Zip Code in the ``Non-VA Care
Cube.''
In sum, S. 1631 is duplicative of VA's on-going efforts to improve
access to quality health care for Veterans residing in rural areas. VA
has committed considerable resources not only to ORH and other affected
VA program offices but also to our collaborative projects with other
Government Departments and Agencies. To date, these and related efforts
have proven, and continue to prove, successful in developing models of
care, providing education to VA and non-VA providers through the
Internet, establishing an MOU for health information exchange, and
developing innovative clinical activities and systems of care. As we
continue to monitor, expand, and improve our efforts in this area, we
will be glad to keep the Committee advised of our activities and
progress.
VA estimates the costs associated with enactment of S. 1631 to be
$2.1 million for FY 2013, $11.7 million over a 5-year period, and $25.8
million over a 10-year period.
S. 1705--TO DESIGNATE THE DEPARTMENT OF VETERANS AFFAIRS
MEDICAL CENTER IN SPOKANE, WA
S. 1705 would designate the Veterans Affairs Medical Center in
Spokane, Washington as the ``Mann-Grandstaff Department of Veterans
Affairs Medical Center.'' VA defers to Congress in the naming of this
facility.
S. 1707--VETERANS SECOND AMENDMENT PROTECTION ACT
S. 1707, the ``Veterans Second Amendment Protection Act,'' would
provide that a person who is mentally incapacitated, deemed mentally
incompetent, or unconscious for an extended period will not be
considered adjudicated as a ``mental defective'' for purposes of the
Brady Handgun Violence Prevention Act in the absence of an order or
finding by a judge, magistrate, or other judicial authority that such
person is a danger to himself, herself, or others. The bill would have
the effect of excluding VA determinations of incompetency from the
coverage of the Brady Handgun Violence Prevention Act.
We understand and appreciate the objective of this legislation to
protect the firearms rights of veterans determined by VA to be unable
manage their own financial affairs. VA determinations of mental
incompetency are based generally on whether a person because of injury
or disease lacks the mental capacity to manage his or her own financial
affairs. We believe adequate protections can be provided to these
veterans under current statutory authority. Under the NICS Improvement
Amendments Act of 2007 (NIAA), there are two ways that individuals
subject to an incompetency determination by VA can have their firearms
rights restored: First, a person who has been adjudicated by VA as
unable to manage his or her own affairs can reopen the issue based on
new evidence and have the determination reversed. When this occurs, VA
is obligated to notify the Department of Justice to remove the
individual's name from the roster of those barred from possessing and
purchasing firearms. Second, even if a person remains adjudicated
incompetent by VA for purposes of handling his or her own finances, he
or she is entitled to petition VA to have firearms rights restored on
the basis that the individual poses no threat to public safety.
Although VA has admittedly been slow in implementing this relief
program, we now have relief procedures in place, and we are fully
committed going forward to implement this program in a timely and
effective manner in order to fully protect the rights of our
beneficiaries.
We also note that the reliance on an administrative incompetency
determination as a basis for prohibiting an individual from possessing
or obtaining firearms under Federal law is not unique to VA or
veterans. Under the applicable Federal regulations implementing the
Brady Handgun Violence Prevention Act, any person determined by a
lawful authority to lack the mental capacity to manage his or her own
affairs is subject to the same prohibition. By exempting certain VA
mental health determinations that would otherwise prohibit a person
from possessing or obtaining firearms under Federal law, the
legislation would create a different standard for veterans and their
survivors than that applicable to the rest of the population and could
raise public safety issues.
The enactment of S. 1707 would not impose any costs on VA.
S. 1755--COVERAGE UNDER DEPARTMENT OF VETERANS AFFAIRS BENEFICIARY
TRAVEL PROGRAM OF CERTAIN DISABLED VETERANS FOR TRAVEL FOR CERTAIN
SPECIAL DISABILITIES REHABILITATION.
S. 1755 would amend VA's beneficiary travel statute to ensure
beneficiary travel eligibility for Veterans with vision impairment,
Veterans with spinal cord injury or disorder, and Veterans with double
or multiple amputations whose travel is in connection with inpatient
care in a VA special disabilities rehabilitation program.
This legislation could be construed to apply for travel of
specified Veterans only in connection with their inpatient care in
special rehabilitation program centers, and would apply only to
Veterans with the specified medical conditions who are not otherwise
eligible for beneficiary travel under 38 U.S.C. Sec. 111. VA provides
rehabilitation for many injuries and diseases at numerous specialized
centers, including programs for Closed and Traumatic Brain Injury
(CBI+TBI), Post Traumatic Stress Disorder (PTSD), other mental health
issues, Parkinson's Disease, Multiple Sclerosis, Epilepsy, War Related
Injury (WRIIC), Pain Management, and various addictions. In addition,
many of VA's specialized treatment centers, including blind, SCI, and
amputee centers, provide rehabilitation--both initial and ongoing--on
an outpatient basis using on and off-station lodging. This legislation
clearly would not apply to travel for those specified Veterans
receiving care on an outpatient basis and thus would provide disparate
travel eligibility to a limited group of Veterans. Therefore, VA does
not support S. 1755 as written.
VA does support expansion of travel benefits to a larger group of
Veterans (including blind, SCI, and amputees) and those with other
special needs who may not be otherwise eligible for VA travel benefits.
VA welcomes the opportunity to work with the Committee to craft
appropriate language as well as ensure that resources are available to
support any travel eligibility increase that might impact upon
provision of VA health care.
VA estimates that the total cost for S. 1755 would be $3 million
during FY 2013, $17.6 million over 5 years and $43.1 million over 10
years. This estimate is based on workload projections for inpatient
services at specialized SCI, Blind, and Amputee centers.
S. 1799--ACCESS TO APPROPRIATE IMMUNIZATIONS FOR VETERANS ACT OF 2011
S. 1799 would amend the definition of ``preventive health
services'' in 38 U.S.C. 1701 to include the term ``recommended adult
immunization schedule'' and define it to mean the schedule established
by the Advisory Committee on Immunization Practices (ACIP). S. 1799
would also amend section 1706 of title 38, to require the Secretary to
develop quality measures and metrics to ensure that Veterans receive
immunizations on schedule. These metrics would be required to include
targets for compliance and, to the extent possible, should be
consistent and implemented concurrently with the metrics for influenza
and pneumococcal vaccinations. The bill would require that these
quality standards be established via notice and comment rulemaking.
S. 1799 would also require that details regarding immunization
schedules and quality metrics be included in the annual preventative
services report required by 38 U.S.C. 1704. VA notes that the effective
dates under this proposal would be retroactive to July 1, 2011 for the
publication of the proposed measures and metrics and January 1, 2012
for the implementation of the measures and metrics.
VA does not support this legislation, as VA now provides prevention
immunizations at no cost to the Veteran. In addition, VHA is
represented as an ex-officio member of the ACIP and follows its
recommendations. VHA is also an ex-officio member of the Department of
Health and Human Services (HHS) National Vaccine Advisory Committee.
VA develops clinical preventive services guidance statements on
immunizations in accordance with ACIP recommendations (VHA Handbook
1120.05). All ACIP-recommended vaccines are available to Veterans at VA
medical facilities. These vaccines currently include: hepatitis A,
hepatitis B, human papillomavirus, influenza, measles/mumps/rubella,
meningococcal, pneumococcal, tetanus/diphtheria/pertussis, tetanus/
diphtheria, varicella, and zoster. As the recommendations change, VHA
policy reflects those changes. The delivery of preventive care that
includes vaccinations has been well established in the VHA Performance
Measurement system for more than 10 years with targets that are
appropriate for the type of preventive service or vaccine. VA updates
the performance measures to reflect changes in medical practice over
time.
Adding the statutory requirement for regulations to the development
of targets would be burdensome and lengthy. Moreover, the process does
not allow for nimble and quick changes as new research or medical
findings surrounding a vaccine come to light. Because the clinical
indications and population size for vaccines vary by vaccine, blanket
monitoring performance of all vaccines can be cost prohibitive and may
not have a substantial positive clinical impact at the population
level.
VA estimates the costs associated with enactment of S. 1799 to be
as follows: $654,000 for FY 2013; $3.5 million over a 5-year period;
and $7.7 million over a 10-year period.
S. 1806--DESIGNATION OF CONTRIBUTIONS TO THE HOMELESS VETERANS
ASSISTANCE FUND
S. 1806 would amend the Internal Revenue Code of 1986 to establish
in the Treasury a trust fund known as the ``Homeless Veterans
Assistance Fund,'' and would allow taxpayers to designate a specified
portion (not less than $1) of any overpayment of tax to be paid over to
the Homeless Veterans Assistance Fund. Amounts in the Fund would ``be
available, as provided in appropriations Acts, to supplement funds
appropriated to the Department of Veterans Affairs [(VA)], the
Department of Labor [(Labor)] Veterans Employment and Training Service,
and the Department of Housing and Urban Development [(HUD)] for the
purpose of providing services to homeless veterans.'' S. 1806 would
require that in the President's annual budget submission for fiscal
year 2013 and each year thereafter, VA, Labor, and HUD include a
description of the use of the funds from the Homeless Veterans
Assistance Fund from the previous fiscal year and proposed use of such
funds for the next fiscal year.
While S. 1806 is well-intended, VA is opposed to its enactment. VA
views its services to homeless Veterans as an obligation of the Nation,
earned by those Veterans by their service. That is also reflected in
Congress' enactment of laws to allow VA to provide these services. The
Secretary has made clear that this is in fact one of VA's most
important obligations. While we appreciate sincerely the motive of
bringing this issue before the taxpayers, we believe the presence of a
check-off could lead some to see these obligations as a discretionary
charity. VA does involve charities and community organizations in its
work, and they are vital. But VA prefers that all Federal funding come
from affirmative appropriations taken by the Congress, rather than
voluntary apportionments through the tax code.
S. 1838--DEPARTMENT OF VETERANS AFFAIRS PILOT PROGRAM
ON SERVICE DOG TRAINING
S. 1838 would require the Secretary, within 120 days of enactment,
to commence a pilot program for a 3-year period to assess the
feasibility and advisability of using service-dog training activities
to positively affect Veterans with post-deployment mental health and
Post Traumatic Stress Disorder (PTSD) symptoms and produce specially
trained service dogs for Veterans. The bill would require the Secretary
to conduct the pilot program at one Department of Veterans Affairs (VA)
medical center other than in the Department of Veterans Affairs Palo
Alto health care system.
The bill requires that the VA medical center selected as the
program site have an established mental health rehabilitation program
that includes a clinical focus on rehabilitation treatment of post-
deployment mental health disorders and PTSD and a demonstrated
capability and capacity to incorporate service dog training activities
into the rehabilitation program. In addition, the Secretary would be
required to review and consider using recommendations published by
experienced service dog trainers with regard to space, equipment and
methodologies. In selecting the program site, the Secretary must give
special consideration to Department of Veterans Affairs' medical
centers located in States that the Secretary considers rural or highly
rural. The pilot program must be administered through VA's Patient Care
Services Office as a collaborative effort between the Rehabilitation
Office and the Office of Mental Health Services. The national pilot
program lead must be from Patient Care Services and have sufficient
administrative experience to oversee the pilot program site.
The bill also includes provisions concerning the service dogs
themselves. The bill requires VA to ensure that each service dog in
training is purpose-bred for this work with an adequate temperament,
has a health clearance, and is age appropriate. Dogs in animal shelters
or foster homes are not to be overlooked as candidates, but only if
such dogs meet the service-dog candidate selection criteria under the
bill. The Secretary must also ensure that each service dog in training
is taught all basic commands and behaviors required of service dogs,
that the service dog undergo public access training and receives
additional training specifically tailored to address the mental health
conditions or disabilities of the Veteran with whom the dog will be
paired. In other words, that VA independently and internally train or
produce service dogs for Veterans with mental health conditions or
disabilities.
Other provisions of the bill concern participation in the pilot and
the actual instruction of the service dogs. Veterans diagnosed with
PTSD or other post-deployment mental health conditions would be
eligible to volunteer to participate. The Secretary would be required
to give a hiring preference for service-dog training instructor
positions to Veterans who have PTSD or some other mental health
condition. The bill would also require the Secretary to provide or
refer participants to business courses for managing a service-dog
training business. In addition, the bill contemplates the Secretary
providing ``professional support for all training under the pilot
program.''
VA would be required to collect data on the pilot program and
determine the effectiveness of the program in positively affecting
Veterans with PTSD or other post-deployment mental health condition
symptoms. The data must also indicate the feasibility and advisability
of expanding the pilot program to additional VA medical centers. VA
would be required to submit an annual report to Congress following the
end of the first year of the pilot program and each year thereafter to
inform Congress about the details of the program and its effectiveness
in specific areas. At the conclusion of the pilot program, the
Secretary must submit to Congress a final report that includes
recommendations with respect to the extension or expansion of the
program.
VA is not opposed to Veterans diagnosed with PTSD, or other post-
deployment mental health conditions, training service-dog candidates
for persons with disabilities as a component of a treatment plan, so
long as the determination of placement with a particular Veteran is
made by the service-dog training program that acquires the VA service-
dog-in-training candidate and completes the final service-dog training.
However, VA cannot support S. 1838 because as written the bill
focuses on training of the dog as opposed to the therapeutic activities
that such Animal Assisted Therapy or Animal Facilitated Therapy may
provide the Veteran if appropriately administered as a component of a
comprehensive mental health treatment program. It is also VA's opinion
that a pilot is unnecessary as current efforts at the Palo Alto program
focus on the training activity as part of the comprehensive treatment
program which incorporates the training of dogs in basic obedience and
preparing the dogs to complete the Canine Good Citizen (CGC) test.
Establishing another pilot in addition to the existing Palo Alto
program would be duplicative, unnecessary and fiscally inefficient.
While excepted from consideration as the pilot program site in
S. 1838, the Service Dog Training Program initiated in July 2008 at the
Palo Alto Veterans Healthcare System (Menlo Park Division), in
collaboration with Bergin University, is an example of a program where
Veterans diagnosed with PTSD participate in the training of dogs as one
activity in their comprehensive recovery program. The training of these
dogs by Veterans participating in the PTSD Treatment Program includes
basic obedience training, and the participation is designed to provide
the Veterans with opportunities in skills development and community
reintegration. The program provides a bridge to community involvement
as a component of the dog-training activities. After completion of the
basic obedience training program, the dogs that complete training are
transitioned to an external Assistance Dogs International (ADI)-
accredited organization where they complete a rigorous training regimen
to become service dogs and are paired with disabled Veterans.
The Palo Alto program is not an example of VA independently
training or producing service dogs for Veterans through all phases of
training. The dogs involved in the Palo Alto program were actually
trained to become service dogs by an external ADI-accredited
organization, over an extended period of time and subject to ADI
standards as adopted and applied by that organization. The Palo Alto
program training focuses on basic obedience (e.g., commands such as
``sit,'' ``stay,'' and ``heel'') and public access skills (sensitizing
dogs to different environments) to prepare the dogs to become service
dogs for disabled persons. That is because VA does not have the
expertise, experience, or resources to develop independent training
criteria or otherwise train or produce safe, high quality service dogs
for Veterans. Such training is highly specialized and includes the
training of the Veteran who is to receive the service dog. VA requires
that a service dog candidate that is found to have the requisite
ability to behave and learn skills at the service dog level, be
``given'' to a service dog training organization that has the
personnel, skills, and specialized abilities to pair the dog with a
disabled person (in this case a disabled Veteran) and train the dog and
Veteran on the specific tasks that the dog will perform for that
individual Veteran. VA believes its reliance on the recognized
expertise of a public or private organization is well-reasoned.
It is unclear in S. 1838 whether subsection 1(d)(5)(C) is concerned
with the volunteer Veteran participants who are training the dogs or
the Veteran recipients of the dogs. Either interpretation is
problematic. If subsection 1(d)(5)(C) is interpreted to refer to the
Veterans with whom the dogs are paired to provide actual service dog
services, rather than targeting the act of training as therapy and a
component of a treatment plan for a particular Veteran, it would
require VA to focus on determining what the dog's specialty will be or
which category of disabled Veteran it will serve. In other words, the
specialized training requirement shifts the goal to the successful
training of the service dogs instead of the therapeutic benefit to the
Veteran derived from the act of training the dog. Veterans would only
be qualified to provide basic training. The advanced stages of
specialized training must be turned over to accredited service dog
training experts. The dogs' eventual roles or skills will depend on the
outcome of this specialized training. If subsection 1(d)(5)(C) is
intended to refer to the volunteer Veteran participants with whom the
dogs are paired, it is equally inappropriate, as the dogs are not
paired with a specific Veteran in the training process, but will almost
certainly be trained by several Veterans who are participating in the
residential program and who will work with the dogs as a team. Patients
come and go based upon their individual clinical indications, and it is
unlikely that all volunteer Veteran participants in the treatment/
rehabilitation program will be there for the length of time it takes to
train a dog to enter a service-dog training program.
Subsection 1(d)(6) states that in designing the program, the
Secretary must provide professional support for all training under the
pilot program. It is not clear whether this is a mandate that third
party organizations actually conduct the training and that Veterans
assist or that the bill allows for Veterans to in fact act as ``owner-
trainers'' with assistance of third parties.
The requirement to give a hiring preference to Veterans who have
PTSD or other mental health conditions may be counterproductive to the
goals and objectives of the pilot program. VA understands the pilot is
aimed at creating a therapeutic treatment modality that will help
patients currently suffering from and in treatment for PTSD and post-
deployment mental health conditions. VA interprets the primary goal of
the pilot to be finding better ways to improve the health of this
Veteran population by exploring treatments, specifically Animal
Assisted Therapy or Animal Facilitated Therapy that will prepare dogs
to become service dogs for Veterans. For these reasons, it is
critically important that the trainers selected be experts at their
job, which is to train Veterans to train dogs as a component of
treatment and as a member of the treatment team. It would be beneficial
if they also appreciated the importance of serving Veterans and
possessed a working knowledge of the needs of this Veteran population,
but it is necessary not to confuse the role of the clinical staff with
the role of the trainer which is that of training the Veteran to train
the dog. The bill also envisions VA hiring trainers as employees.
Allowing VA to contract for these services would afford VA more
flexibility and access to already available training experts,
particularly as there is no Government Service (GS) occupation training
service dogs for disabled individuals. Although on the surface this
sounds reasonable, should the program prove to be inappropriate for
expansion/spread there would be no position available for a dog trainer
in the system.
VA is highly doubtful that the requirements of the bill can be
accomplished within 120 days of the enactment. VA would have to
establish selection criteria, advertise for sites (through a Request
for Proposal), evaluate candidates and make selections. We are
available to work with the Committee to provide advice on the
components of what could be a workable program, and an appropriate
mechanism to evaluate the current programs as to whether training
service dogs is a clinically appropriate form of treatment based on
information gleaned from the Palo Alto program and other related animal
therapy programs currently in place within the VA.
VA estimates the cost for the 3-year period of the pilot as
follows: $635,281 in FY 2013; $658,151 in FY 2014; and $682,502 in FY
2015 for a total of $1,975,934.
S. 1849--RURAL VETERANS HEALTH CARE IMPROVEMENT ACT
Section 2(a) of S. 1849 would require VA's Director of the Office
of Rural Health (ORH) to develop a 5-year strategic plan for improving
access to, and the quality of, health care services for Veterans in
rural areas. In developing this plan, the Director would be required to
consult with the Director of VA's Health Care Retention and Recruitment
Office, VA's Office of Quality and Performance, and VA's Office of Care
Coordination Services. It would also require the Director to develop
this plan not later than 180 days after the date of enactment, with the
5-year period beginning on the date of the plan's issuance.
Section 2(b) of the bill would require the strategic plan to
include the following elements:
Goals and objectives for the recruitment and retention of
VA health care personnel in rural areas;
Goals and objectives for ensuring timeliness and improving
quality in the delivery of VA health care services furnished to
Veterans in rural areas through the use of contract providers and fee-
basis providers;
Goals and objectives for the implementation, expansion,
and enhanced use of VA telemedicine in rural areas (through
coordination with other appropriate VA offices);
Goals and objectives for ensuring the full and effective
use of mobile outpatient clinics to provide health care services in
rural areas;
Procedures for soliciting from each VA facility that
serves a rural area a statement of the facility's clinical capacity;
its procedures in the event of a medical, surgical, or mental health
emergency outside the scope of the facility's clinical capacity; and
its procedures and mechanisms to provide (and coordinate) health care
for women Veterans (including procedures and mechanisms for
coordination with local hospitals and facilities, oversight of primary
care and fee-basis care, and management of specialty care);
Goals and objectives for modifying funding allocation
mechanisms of the ORH to ensure that it distributes funds to
Departmental components, to best achieve its goals and objectives in a
timely manner;
Goals and objectives for the coordination and sharing of
resources between VA and the Department of Defense, Department of
Health and Human Services, Indian Health Service, and other Federal
agencies, as appropriate and prudent, to provide health care services
to Veterans in rural areas;
Specific milestones for the achievement of the goals and
objectives developed for the plan; and
Procedures for ensuring the effective implementation of
the plan.
Section 2(c) of the bill would require, not later than 90 days
after the date of the plan's issuance, that the Secretary transmit the
strategic plan to Congress (along with any comments or recommendations
that the Secretary considers appropriate).
VA does not believe that S. 1849 is necessary. VA's past and
continuing efforts already provide a comprehensive approach to ensuring
access to quality health care for Veterans in rural areas.
Specifically, in 2010, VHA's ORH produced a 5-year strategic plan for
fiscal years (FY) 2010-2014 to ensure that ORH programs and initiatives
meet the health care needs of rural Veterans. That plan was refreshed
in FY 2011, for FY 2012-2014, to better align ORH's resources with
identified health care needs, especially in light of new technologies
and delivery systems for rural Veterans.
The plan was updated by a committee of stakeholders comprised of
the following members: Veterans Rural Health Advisory Committee;
Veterans Integrated Service Network (VISN) rural consultants; Veterans
Rural Health Resource Centers; ORH; VA Medical Center Directors; VA's
Office of Telehealth Services; VA's Office of Mental Health Services;
VA's Office of Geriatrics and Extended Care, State VA Offices; VA's
Office of Health Informatics; VA's Office of Academic Affiliations; VA
Employee Education System; and VA's Healthcare Retention and
Recruitment Office.
The Committee updated each of the six ORH strategic goals in line
with broadly agreed-upon initiatives (and associated action items) that
respond to the specific findings of ORH's Nation-wide assessment to
identify gaps in care at rural VA facilities and unmet clinical needs
of rural Veterans. Input obtained at numerous town hall meetings and
listening sessions also helped the Committee to better understand the
perspective of rural Veterans and in particular the barriers that
prevent them from accessing VA health care.
The new initiatives included in the revised strategic plan include:
an action plan to improve communications and outreach to rural areas;
continued support of community-based outpatient clinics and outreach
clinics; developing, implementing, and evaluating new models of
specialty care; implementing and evaluating rural women's health care
initiatives, increased collaboration and partnership with non VA
community networks and providers, increasing student training
opportunities in rural health; enhancing telehealth capabilities in
rural areas; and increasing training for rural providers. We will
continue to monitor implementation of these initiatives under the plan
and revise them as necessary. ORH will also continue to evaluate its
on-going programs, especially the host of pilot and demonstration
projects that ORH currently funds across the VA health care system, to
assess their effectiveness in delivering quality care to rural Veterans
and improving those individuals' access to care.
One ORH initiative is the ``Rural Health and Education Training
Initiative.'' It will provide infrastructure support for up to five VA
sites of care to establish rural health training and education programs
for medical residents, dental, nursing, and allied health professions
students from affiliated institutions. Under the program, these
trainees will receive particular instruction on providing care to
Veterans residing in rural areas. This will include instruction on the
special challenges associated with providing health care in rural areas
and how VA is working to overcome these challenges. Once they complete
their training, VA hopes to recruit and retain them in rural VA health
care positions throughout the country.
ORH is also supporting an initiative to provide rural clergy with
both information on VA benefits and services and local VA contact
information. This initiative will also educate clergy-participants
about post-deployment readjustment challenges, the spiritual and
psychological effects of war-trauma on survivors, and the important
role that religious institutions can play in helping to reduce the
societal stigma associated with mental illness and to assist Veterans
in their parishes and communities to obtain care and services for their
mental health issues. It will also address other ways in which they, as
vital community partners, can help support Veterans and their families.
Finally, as discussed in connection with S. 1631, VA and the
Department of Health and Human Services (HHS) are working on a
memorandum of understanding (MOU) to address shortages in the rural
Health IT workforce and the need for the effective exchange of health
care information between VA providers and rural providers furnishing
care to Veterans. The MOU will serve to:
Increase the number of trained health IT and health
information management professionals;
Diversify training programs to meet a wider range of
training needs;
Reach out to potential workers and employers to inform
them about career pathways in health information management and
technology;
Support employers in staffing health IT positions; and
Examine ways to leverage existing resources to develop
potential pilot sites for Health Information Exchange between rural
providers and VHA.
As indicated above, the 2010-2014 ORH strategic plan refresh will
be re-evaluated periodically but at least on an annual basis to
determine if additional initiatives or actions are needed. At the end
of FY 2014, ORH will draft a new strategic plan based on its
evaluations of the success of projects undertaken to date and up-dated
assessments of the health care needs of Veterans residing in rural
areas.
VA estimates the costs associated with enactment of S. 1849 to be
as follows: $215,000 for FY 2013; $368,000 over a 5-year period; and
$768,000 over a 10-year period.
s. 2045--to require judges on the united states court of appeals for
veterans claims to reside within 50 miles of the district of columbia
S. 2045 would amend 38 U.S.C. 7255, to require that active judges
of the U.S. Court of Appeals for Veterans Claims reside within 50 miles
of the District of Columbia. This bill also would amend section
7253(f)(1) to provide that violation of this residency requirement may
be grounds for removal of a judge from the court. The absence of such a
residency requirement in current law has not created difficulties for
VA. Thus, VA perceives no need for this legislation.
If enacted, S. 2045 would result in no costs or savings for VA.
S. 2244--VETERANS MISSING IN AMERICA ACT OF 2012
S. 2244, the ``Veterans Missing in America Act of 2012,'' would
direct the Secretary to cooperate with Veterans Service Organizations
to assist entities in possession of unclaimed or abandoned human
remains in determining whether such remains are those of Veterans or
other persons eligible for burial in a national cemetery. If unclaimed
remains are identified as those of Veterans or other eligible persons,
VA would provide for burial of the remains in a national cemetery and
would cover the cost of preparation, transportation, and burial of the
remains. The bill would further direct VA to establish a publicly
accessible national database of such identified individuals.
VA strongly supports the goal of ensuring that those who have
earned the right to burial in a national cemetery are accorded that
honor. VA commends organizations and volunteers who work to ensure that
unclaimed and abandoned remains of our Nation's Veterans are identified
and if eligible, receive a proper burial in a national cemetery. To
ensure eligible Veterans receive burial in a national cemetery, VA
currently works with States, counties, municipalities and private
organizations to determine the eligibility of unclaimed and abandoned
remains that are held at funeral homes or coroner's offices. In this
regard, VA's National Cemetery Scheduling Office (NCSO) located in St.
Louis, Missouri coordinates with Federal, State and local agencies to
verify a deceased individual's military service and identity. NCSO also
provides eligibility review assistance to entities such as the Missing
In America Project (MIAP), to identify unclaimed remains and inter all
eligible individuals. In FY 2011, NCSO processed 663 requests for
burial eligibility determinations that were submitted by the MIAP,
which works on behalf of entities, such as city and county coroners'
offices, to ensure eligible Veterans receive proper burial. Currently,
NCSO is working with the State of Oregon to identify unclaimed remains
recently found in that state and determine eligibility for burial in a
national cemetery.
VA does not, however, support this bill in extending existing
funeral and transportation benefits to certain non-Veterans and placing
no cap on the amount of such payments. Section 3(b) would require VA to
pay the cost of the burial, preparation, and transportation of the
unclaimed or abandoned remains of any individual who is eligible for
national cemetery burial when there are insufficient alternative
resources to cover such expenses. Under current law, VA provides
reimbursement benefits, up to maximum amounts specified by statute, for
funeral and transportation costs associated with the burial of certain
Veterans. However, not all Veterans who are eligible for burial in a
national cemetery qualify for these benefits; for example, Veterans who
were not in receipt of disability compensation at the time of death
generally do not qualify for reimbursement of funeral or transportation
costs. VA would support extending current funeral and transportation
benefits under sections 2302(a)(2) and 2308 of title 38, United States
Code, to all unclaimed remains of Veterans, subject to the same
monetary caps generally applicable to such payments. However, VA does
not support the current bill insofar as it would provide benefits for
non-Veterans that are unavailable for many Veterans eligible for burial
in a national cemetery and would lift the generally applicable monetary
caps for this benefit.
Section 3(c) of S. 2244 would direct VA to establish a database of
the names of any Veterans or other individuals who are determined,
under the identification process described in this bill, to be eligible
for burial in a national cemetery. We believe this provision is
unnecessary. Currently, VA maintains a publicly-accessible database,
commonly known as the National Gravesite Locator (NGL), which already
performs the functions proposed in the bill. The public can use the NGL
to search for burial locations of Veterans and other individuals
interred in VA National Cemeteries, State Veterans cemeteries, and
various other military and Department of the Interior cemeteries. The
NGL also provides information about Veterans buried in private
cemeteries when the grave is marked with a Government-furnished
headstone or marker. Names of Veterans or other individuals who are
eligible for burial and whose remains are unclaimed or abandoned would
be made available to the public through the NGL once they are interred.
NCA continues to work to make this database even more accessible by
implementation of a mobile application.
S. 2244 would impose recurring costs on VA by extending entitlement
to burial and transportation reimbursement benefits for a new category
of individuals, without a monetary limit on the amount of such
reimbursement. At this time, VA is unable to estimate the likely extent
of those costs.
S. 2259--VETERANS' COMPENSATION COST-OF-LIVING ADJUSTMENT ACT OF 2012
S. 2259, the ``Veterans' Compensation Cost-of-Living Adjustment Act
of 2012,'' would require VA to increase, effective December 1, 2012,
the rates of disability compensation for service-disabled Veterans and
the rates of dependency and indemnity compensation for survivors of
Veterans. Current estimates suggest that the consumer price index will
increase by 1.9 percent. This bill would increase these rates by the
same percentage as the percentage by which Social Security benefits are
increased effective December 1, 2012.
VA wholeheartedly supports this bill, which is consistent with the
President's FY 2013 budget request. It would express, in a tangible
way, this Nation's gratitude for the sacrifices made by our service-
disabled Veterans and their surviving spouses and children and would
ensure that the value of their well-deserved benefits will keep pace
with the increased cost of living.
VA estimates that this bill would result in first-year benefit
costs of $772 million in FY 2013, 5-year benefit costs of $4.9 billion,
and 10-year benefit costs of $10.9 billion. However, as annual cost-of-
living adjustments are assumed in the baseline for the Disability
Compensation program, no PAYGO costs are associated with this proposal.
S. 2320--REMEMBERING AMERICA'S FORGOTTEN VETERANS CEMETERY ACT OF 2012
S. 2320, the ``Remembering America's Forgotten Veterans Cemetery
Act of 2012,'' would direct the American Battle Monuments Commission to
restore, operate, and maintain Clark Veterans Cemetery in the Republic
of the Philippines, subject to the availability of appropriations. This
bill would make Clark Veterans Cemetery a permanent cemetery under the
auspices of the American Battle Monuments Commission, pursuant to
section 2104 of title 36, United States Code.
Because S. 2320 pertains to the American Battle Monuments
Commission's authority under current chapter 21 of title 36 to allocate
resources for the care and maintenance of military cemeteries and
monuments in foreign countries, VA defers to the views of that
Commission on this bill.
S. 3052--NOTICE TO VETERANS OF AVAILABILITY OF SERVICES FROM VSOS
S. 3052 would amend title 38 to require the Secretary of Veterans
Affairs to provide Veterans who electronically file claims for VA
benefits with notice that relevant services are available from
Veterans' Service Organizations (VSOs). The bill would require the
Veterans Benefits Administration (VBA) to notify each claimant who
files a claim for benefits electronically that VSOs are available to
provide services, and to provide a list of VSOs, and their Web site and
contact information.
S. 3052 is unnecessary, as VBA already provides notice to Veterans
who file claims electronically that VSO representation is available. In
addition, links to VSOs and private attorneys who offer representation
on claims for VA benefits are currently available on VA's eBenefits Web
site, which also contains a directory of all recognized VSOs with their
contact information.
S. 3052 would not impose any costs on VA.
S. 3084--VISN REORGANIZATION ACT OF 2012
Section 2 of S. 3084 would require VHA to consolidate its 21
Veterans Integrated Service Networks (VISN) into 12 geographically
defined VISNs, would require that each of the 12 VISN headquarters be
co-located with a VA medical center, and would limit the number of
employees at each VISN headquarters to 65 FTE. VA does not support
section 2 for a number of reasons. By increasing the scope of
responsibility and span of control of each VISN headquarters while
reducing the number of employees at each, the legislation would impede
VA's ability to implement the national goals of the Department.
Currently, VISN headquarters are capable of providing assistance to
supplement resource needs at facilities and are able to support
transitions in staff within local facilities when there are personnel
changes; with a responsibility for oversight of more facilities and
fewer staff, the VISN headquarters would lose the opportunity to
provide this sometimes essential service.
VHA has already reviewed each VISN headquarters and is in the
process of working with each to streamline operations, create
efficiencies internal to each VISN, and to realign resources to
facilities. This will achieve savings while not creating the negative
outcomes of the restructuring and new organizations proposed in
S. 3084. Current VHA plans are to reduce VISN staffing levels.
VA currently maintains close relationships with other health care
organizations, including those from other governmental, public, and
private health care entities, when appropriate. The language appears to
require VA to create new alliances with entities which may not be
available or appropriate. VA's health care system has benefited from
developing an expertise in the clinical and cultural needs and demands
of Veterans. Requirements to further partner with other organizations
could lead to distractions and unintended outcomes.
This section's requirement that VISN budgets be balanced at the end
of each fiscal year may have other unintended consequences. Currently,
at the end of each fiscal year, each VISN's accounts must be balanced,
and this is sometimes achieved by providing additional resources from
VHA Central Office. Additional resources may be needed for a number of
reasons, including greater than anticipated demand, a national disaster
or emergency, new legal requirements enacted during the year, and other
factors. By codifying a requirement that the VISN budget be balanced at
the end of each fiscal year, VA may lose this flexibility to supplement
VISNs with additional resources, and Veteran patient care would suffer
as a result.
Section 2 also requires the Department to identify and reduce
duplication of functions in clinical, administrative, and operational
processes and practices in VHA. We are already doing this by
identifying best practices and consolidating functions where
appropriate. Furthermore, while section 2 describes how the VISNs
should be consolidated, it fails to clearly articulate the flow of
leadership authority. In fact, by moving certain oversight
responsibilities to regional centers, S. 3084 would create no clear
lines of authority from VHA Central Office, regions, VISNs, to medical
centers, actually producing less oversight and more confusion.
Additionally, the proposed combination of VISNs simply combines
VISNs to arrive at a reduction in the total number of Networks and
employees without considering the underlying referral patterns within
each VISN. The original VISN boundaries were drawn based upon local
population health needs. Each VISN is charged with managing quality and
access of health care while increasing the efficient delivery of
population health. S. 3084 fails to take this into account in aligning
VISN boundaries. For example, it is unclear why VISNs 19 and 20 should
be consolidated, which would produce a single Network responsible for
overseeing 12 states, 15 VA health care systems or medical centers, and
a considerable land mass, while VISN 6, which oversees three states and
eight health care systems or medical centers, remains its own entity.
VA would appreciate the opportunity to review the Committee's criteria
for determining these boundaries.
Last, Section 2 of S. 3084 seems to assume that locating the
management function off campus from a medical center represents an
inefficient organizational approach. We believe that assumption is not
valid for all cases. Currently, six VISNs (1, 2, 3, 20, 21, and 23) are
co-located with a VA medical center; the legislation's requirement for
co-location with a VA medical center would require either construction
to expand existing medical centers, using resources that would
otherwise be devoted to patient care to cover administrative costs, or
would require the removal of certain clinical functions to create space
for VISN staff in at least nine VISNs given the bill's proposed
realignment of VISNs 1, 2, and 3, as well as 20 and 21.
As a result of this legislation, Veterans may be forced to travel
to different locations for services that were previously available at
the new host facility, or may be unable to access new services that
would have been available had construction resources not been required
to modify existing facilities to accommodate VISN staff. While section
4 of the bill states that nothing in the bill shall be construed to
require any change in the location or type of medical care or service
provided by a VA medical center, the logistical reality of required co-
location with medical centers would necessitate this result.
VA also does not support section 3 of S. 3084. Section 3 would
require VA to create up to four regional support centers to ``assess
the effectiveness and efficiency'' of the VISNs. Section 3 identifies a
number of functions to be organized within the four regional centers
including:
financial quality assurance;
OEF/OIF/OND outreach;
homelessness effectiveness assessments;
women's Veterans programs assessments;
energy assessments; and
such other functions as the Secretary deems appropriate.
This would present several challenges, as certain services are more
appropriately organized as fully consolidated national functions
instead of regional ones. The functions identified for homelessness and
women Veterans would create capabilities that duplicate existing
national services. The current structure (VISN accountability and
national oversight) is directly linked with ensuring accountable
leadership oversight that is much more proximate to health care
services provided to Veterans in facilities. The proposed structure
creates two national-level entities competing for oversight analysis
relationships with facilities. Furthermore, the proposed functions may
not be the most appropriate ones to offer for consolidation into four
centers. VHA has created seven Consolidated Patient Account Centers to
achieve superior levels of sustained revenue cycle management,
established national call centers to respond to questions from Veterans
and their families, and is assessing consolidation of claims payment
functions to achieve greater efficiencies and accuracy. These types of
functions are more appropriate to move off-station without damaging the
necessary management/accountability relationship between leadership,
line management, and staff. The rationale behind the selected functions
does not appear to have been based on a thorough analysis of the types
of functions best suited to consolidation.
S. 3084 appears to propose a reduction in the FTE associated with
regional management, but the proposed regional service centers are
likely to increase the overall staffing requirement. We believe this
actually will result in a diversion of resources away from critical
patient care. The proposed legislation would result in VISN management
staff of roughly 780 persons. If each of the four regional centers is
just 110 FTEE, a not unrealistic assumption given the scope of
responsibilities identified in the legislation, then the proposed model
would result in overall growth of regional staff compared with VHA's
current plans.
It is not possible currently to identify costs for the proposed
legislation but it is expected that the requirement to co-locate
functions with medical centers would result in costlier clinical leases
or additional construction. Additionally, the proposed VHA Central
Office, Regional Center, and VISN structure would require increased
staff.
S. 3202--DIGNIFIED BURIAL OF VETERANS ACT OF 2012
S. 3202, the ``Dignified Burial of Veterans Act of 2012,'' would
amend section 2306 of title 38, United States Code, to authorize VA to
furnish a casket or urn, of such quality as the Secretary considers
appropriate for dignified burial in a national cemetery, of the remains
of a Veteran for whom the Secretary is unable to identify next of kin,
if there are not otherwise sufficient resources available to furnish a
casket or urn. The bill would also require VA to submit a report to the
Senate and House Committees on Veterans' Affairs within 180 days of
enactment, to describe industry standards for caskets and urns, and
assess compliance with such standards at VA national cemeteries.
VA does not object to enactment of the main feature of S. 3202,
provided Congress identifies appropriate cost offsets, but believes its
reporting requirement is unnecessary. Section 2 of the bill, would
assist in ensuring that a suitable casket or urn is provided for
interment in a national cemetery of the remains of any Veteran without
family and necessary resources. This legislation is consistent with
VA's continued efforts to address the needs of homeless Veterans--many
of whom die as unclaimed and indigent individuals. Section 3 of the
bill, requiring a report on industry standards for caskets and urns and
VA's compliance with such standards at national cemeteries, is
unnecessary. Currently, NCA relies upon licensed funeral directors who
prepare remains to comply with relevant Federal, State, and local laws
regarding the preparation of Veterans' remains. When caskets or urns
are presented for burial, NCA cemetery directors assess containers to
determine any possible health or safety risks and whether the caskets
or urns are sufficiently constructed to allow for necessary handling
for burial. On rare occasions when caskets or urns do not meet these
standards, NCA instructs the funeral director to return to the cemetery
with remains in a proper container to facilitate burial. For the
remains of Veterans with next of kin, NCA respects the wishes of
families regarding their choice of containers so long as there are no
public health or safety concerns.
VA recognizes that S. 3202 complements other bills recently
introduced in Congress that seek to address issues relating to the
unclaimed remains of Veterans.
S. 2244 and H.R. 2551, both titled the ``Veterans Missing in
America Act,'' generally propose to expand VA's authority to provide an
allowance to those who assist with the transportation and interment of
unclaimed remains of Veterans. VA will continue to provide technical
assistance to the Committees on these bills.
At this time, VA is unable to estimate the extent of costs that
would result from enactment of S. 3202 because it is difficult to
project the number of unclaimed Veteran remains that may be affected by
this legislation. In 2009, the National Funeral Directors Association
projected that the average cost for a metal casket was $2,295.
Chairman Murray, this concludes my statement. I would be happy to
answer any questions you or the other Members of the Committee may
have.
______
______
Enclosure
VA Views
S. 1391--IMPROVING THE DISABILITY COMPENSATION EVALUATION PROCEDURE FOR
VETERANS WITH POST TRAUMATIC STRESS DISORDER OR MENTAL HEALTH
CONDITIONS RELATED TO MILITARY SEXUAL TRAUMA, AND FOR OTHER PURPOSES
S. 1391 would amend 38 U.S.C. Sec. 1154, Consideration to be
accorded time, place, and circumstances of service, by adding a new
subsection (c) that would liberalize the standard of proof for service
connection of Post Traumatic Stress Disorder (PTSD) and a new
subsection (d) that would lower the standard of proof for service
connection of ``covered mental health conditions'' related to military
sexual trauma.
Proposed new section 1154(c) would require the Department of
Veterans Affairs (VA) to accept as sufficient proof of service
connection for PTSD alleged to have been incurred or aggravated by
military service: (1) a diagnosis of PTSD by a ``mental health
professional;'' (2) written testimony by the Veteran that the PTSD was
incurred or aggravated during service; and (3) a written statement by
the mental health professional relating the PTSD to the claimant's
service, if the claimed incurrence or aggravation of PTSD is consistent
with the circumstances, conditions, or hardships of the Veteran's
service.
Proposed new section 1154(d) would similarly require VA to accept
as sufficient proof of service connection for covered mental health
conditions-defined as PTSD, anxiety, depression, or ``other mental
health conditions the Secretary determines to be related to military
sexual trauma''-when the condition is claimed to result from military
sexual trauma during active service: (1) a diagnosis of the covered
mental health condition by a ``mental health professional;'' (2)
written testimony by the Veteran of the alleged trauma; and (3) a
written statement by the mental health professional relating the mental
health condition to the claimed trauma, if the claimed trauma is
consistent with the circumstances, conditions, or hardships of the
Veteran's service.
Proposed sections 1154(c) and (d) would require departure from
current practice for adjudicating both PTSD claims and claims based on
other covered mental health conditions. In the case of PTSD claims,
current procedures under 38 CFR Sec. 3.304(f) require credible
supporting evidence that an in-service stressor occurred in order to
establish that current PTSD symptoms are related to an event in
service. This generally means objective and verifiable documentation
that the stressor actually occurred.
Section 3.304(f) currently provides particularized rules for
establishing stressors related to combat, former prisoner-of-war (POW)
status, fear of hostile military or terrorist activity, and personal
assault. These particularized rules are based on an acknowledgement
that certain circumstances of service may make the claimed stressor
more difficult to corroborate. At the same time, they require threshold
evidentiary showings designed to ensure accuracy and fairness in
determinations as to whether the claimed stressor occurred. Evidence of
a Veteran's service in combat or as a prisoner of war generally provide
an objective basis for concluding that claimed stressors related to
such service occurred. Evidence that a Veteran served in an area of
potential military or terrorist activity may provide a basis for
concluding that stressors related to fears of such activity occurred.
In such cases, VA also requires the opinion of a VA or VA-contracted
mental health professional, which enables VA to ensure that such
opinions are properly based on consideration of relevant facts,
including service records, as needed. For PTSD claims based on a
personal assault, lay evidence from sources outside the Veteran's
service records may corroborate the Veteran's account of the inservice
stressor, such as statements from law enforcement authorities, mental
health counseling centers, family members or former servicemembers, as
well as other evidence of behavioral changes following the claimed
assault.
S. 1391 would require VA to accept as proven the occurrence of
military sexual trauma or a PTSD stressor without even the minimal
threshold evidence currently required in most compensation claims to
support a Veteran's account of events in service. The claimant would be
required merely to state that PTSD was incurred or aggravated in
service or that a military-sexual-trauma stressor or event occurred in
service. As long as there was a current diagnosis of PTSD, or other
covered mental health condition, and a mental health professional
offered a medical opinion that the symptoms were related to military
service, service connection would be granted. This would occur whether
the mental health professional had access to the Veteran's service
records or not or was otherwise able to evaluate the veracity of the
claimant's statements regarding the occurrence of the claimed in-
service stressor or event.
The regulatory provisions at 38 CFR Sec. Sec. 3.303 and 3.304(f)
have established equitable standards of proof and the evidence for
corroboration of an in-service injury, disease, or event, for purposes
of service connection. Further, 38 U.S.C. Sec. 1154 properly requires
consideration of the time, place, and circumstances of service when
evaluating disability claims and provides for acceptance of lay
statements concerning combat-related injuries, provided evidence
establishes that the Veteran engaged in combat. S. 1391 would expand
section 1154 to require VA to accept lay statements as sufficient proof
of in-service events in all PTSD claims and military sexual trauma
claims involving covered mental health conditions, based solely on the
nature of the claim and without requiring the objective markers, such
as combat service, that are essential to the effective operation of
section 1154. Without the requirement of any evidentiary threshold for
the mandatory acceptance of a lay statement as sufficient proof of an
occurrence in service, this legislation would eliminate, for discrete
groups of Veterans, generally applicable requirements that ensure the
fairness and accuracy of claim adjudications.
VA is committed to serving our Nation's Veterans by accurately
adjudicating MST claims in a thoughtful and caring manner, while fully
recognizing the unique evidentiary considerations involved in such an
event. The Under Secretary for Benefits has spearheaded the efforts of
the Veterans Benefits Administration (VBA) to ensure that these claims
are adjudicated compassionately and fairly, with sensitivity to the
unique circumstances presented by each individual claim.
VA is aware that, because of the personal and sensitive nature of
the MST stressors in these cases, it is often difficult for the victim
to report or document the event when it occurs. To remedy this, VA
developed regulations and procedures specific to MST claims that
appropriately assist the claimant in developing evidence necessary to
support the claim. As with other PTSD claims, VA initially reviews the
Veteran's military service records for evidence of MST. VA's regulation
also provides that evidence from sources other than a Veteran's service
records may corroborate the Veteran's account of the stressor incident,
such as evidence from mental health counseling centers or statements
from family members and fellow Servicemembers. Evidence of behavior
changes is another type of relevant evidence that may establish
occurrence of an assault, such as a request for transfer to another
military duty assignment. Veterans are provided notification regarding
the types of evidence that may establish occurrence of an in-service
personal assault and are requested to submit or identify any such
evidence.
VBA has also placed a primary emphasis on informing VA regional
office personnel of the issues related to MST and providing training in
proper claims development and adjudication. VBA developed and issued
Training Letter 11-05, Adjudicating Posttraumatic Stress Disorder
Claims Based on Military Sexual Trauma, in December 2011. This was
followed by a nationwide Microsoft Live Meeting broadcast on MST claims
adjudication. The broadcast focused on describing the range of
potential markers that could indicate occurrence of an MST stressor and
the importance of a thorough and open-minded approach to seeking such
markers in the evidentiary record. In addition, the VBA Challenge
Training Program, which all newly hired claims processors are required
to attend, now includes a module on MST within the course on PTSD
claims processing. VBA also provided its designated Women Veterans
Coordinators with updated specialized training. These employees are
located in every VA regional office and are available to assist both
female and male Veterans with their claims resulting from MST.
VA believes these actions ensure that MST claimants are given a
full and fair opportunity to have their claim considered, with a
practical and sensitive approach based on the nature of MST. VA
believes that processes and training in place now provide MST claimants
a full and fair opportunity to present their claim. VA has recognized
the sensitive nature of MST-related PTSD claims and claims based on
other covered mental health conditions, as well as the difficulty
inherent in obtaining evidence of an in-service MST event. Current
regulations provide multiple means to establish an occurrence, and VA
has initiated additional training efforts and specialized handling
procedures to ensure thorough, accurate, and timely processing of these
claims.
In summary, VA opposes S. 1391 because we believe it would go too
far in relaxing standards requiring service connection for a current
disability to be based on credible supporting evidence of an injury,
disease, or event in service.
Benefit costs are estimated to be $137.1 million during the first
year, $2.0 billion for 5 years, and $7.1 billion over 10 years. Costs
for general operating expenses are estimated to be $5.0 million during
the first year, $24.1 million for 5 years, and $52.5 million over 10
years. IT costs are estimated to be $196 thousand during the first
year, $531 thousand for 5 years, and $967 thousand over 10 years.
S. 3049--EXPANDING THE DEFINITION OF HOMELESS VETERAN
S. 3049 would broaden the definition of ``homeless veteran'' found
in 38 U.S.C. Sec. 2002(1) to include ``any individual or family who is
fleeing, or is attempting to flee, domestic violence, dating violence,
sexual assault, stalking, or other dangerous or life-threatening
conditions in the individual's or family's current housing situation,
including where the health and safety of children are jeopardized, and
who have no other residence and lack the resources or support networks
to obtain other permanent housing.'' It would do this by adding to the
Title 38 definition a reference to an additional subsection of the
general definition of homeless individual found in the McKinney-Vento
Homeless Assistance Act, at 42 U.S.C. Sec. 11302.
VA supports the intent of S. 3049. VA understands that the
Department of Housing and Urban Development (HUD) uses the definition
found in 38 U.S.C. Sec. 2002(1) in the application of some of its
programs. Therefore, we suggest the Committee consult with HUD
regarding any changes to that definition.
VA has taken steps to address the critical issue of domestic
violence. In recognition of the unique and emerging health challenges
posed by victims of domestic violence, the Deputy Under Secretary for
Health for Policy and Services recently chartered a Domestic Violence
Task Force to ``develop a national plan/policy on domestic violence to
address identification of domestic violence and access to services for
Veterans, who need help planning for and achieving physical, emotional,
and psychological safety and well being; and define the scope of
domestic violence to be addressed.'' As evidenced by this task force,
VA intends to study this population and VA's options for serving this
population; however, at this time, VA lacks subject matter experts to
implement programming directly targeted at victims of domestic
violence. Furthermore, in the event VA would be expected to reach and
target this population, VA needs time and resources to implement
systems, protocol, and policies to ensure timely interventions and meet
the needs of this vulnerable population. Domestic violence is a complex
health issue and addressing it involves collaboration between many
programs and external local, State and Federal agencies to address
identification, prevention, provision of safety supports, treatment,
and legal consequences.
VA is not able to provide an accurate cost estimate for S. 3049
since we currently lack information regarding the size and
characteristics of the potential population. For example, VA's
estimates of the homeless population do not include individuals fleeing
domestic violence. Many VA providers have only minimal training on
domestic violence. S. 3049 would likely require additional training for
VA employees and providers, which may have some costs, depending upon
the scope of the training.
S. 3206--MONTHLY ASSISTANCE ALLOWANCE TO DISABLED VETERANS TRAINING OR
COMPETING FOR THE PARALYMPIC TEAM AND ASSISTANCE TO UNITED STATES
PARALYMPICS, INC.
Section 1 of S. 3206 would extend the authority for appropriations
to fund the payment of the monthly monetary allowance under 38 U.S.C.
Sec. 322(d) (to Veterans training for or selected to compete on the
U.S. Paralympic team) for a period of 5 years (through FY 2018). VA
supports such an extension.
By its own terms, the cost of enactment of this section would be $2
million in FY 2014, with a total 5-year cost (FY 2014 through FY 2018)
of $10 million.
Section 2 of S. 3206 would extend (through FY 2018) VA's authority
to award grants to United States Olympic Committee (USOC) for its U.S.
Paralympics Integrated Adaptive Sports Program. Under current law, VA
has provided grants totaling $7.5 million to the USOC in each FY 2010
and FY 2011. Due to identified need, VA currently is processing an $8.0
million USOC grant request in FY 2012. VA supports extending the
authority for this program, which has positively impacted the lives of
thousands of Veterans.
S. 3270--PENSION AMENDMENTS
Section 1(a) of S. 3270 would amend the net worth limitations
applicable to Veteran's pension in 38 U.S.C. Sec. 1522 to provide that
when a Veteran (or Veteran's spouse) disposes of ``covered resources''
for less than fair market value (including transfers to annuities or
trusts) on or after the beginning date of a 36-month look-back period,
the disposal may result in a period of ineligibility for pension. In
addition, section 1(a) would provide a method for calculating the
period of ineligibility for pension resulting from a disposal of
covered resources at less than fair market value. The period of
ineligibility, expressed in months, would be determined by dividing the
total value of all applicable covered resources disposed of by the
Veteran (or the Veteran's spouse) by the amount of pension that would
have been payable to the Veteran under 38 U.S.C. Sec. Sec. 1513 or 1521
without consideration of the transferred resources.
Section 1(b) of S. 3270 would amend 38 U.S.C. Sec. 1543 to apply to
a surviving spouse's or surviving child's pension the same restrictions
pertaining to disposal of covered resources at less than fair market
value as would apply to Veterans under subsection (a).
Section 1(c) of S. 3270 would specify the effective date and
applicability of the amendments made by section 1(a) and (b). Section
1(d) of S. 3270 would require VA to provide annual reports to Congress
regarding: (1) the number of individuals who applied for pension during
the period covered by the report; (2) the number of individuals who
received pension during that period; and (3) the number of individuals
whose pension payments were denied or discontinued during that period
because covered resources were disposed of for less than fair market
value.
Currently, if a pension claimant (or the spouse of a Veteran
pension claimant) disposes of assets before the date of the pension
claim, VA does not consider those assets as part of the claimant's net
worth, so long as the transfer was not a gift to a relative living in
the same household as the claimant. S. 3270 would provide that such
disposals of ``covered resources'' for less than fair market value
during a 36-month look-back period may result in a period of
ineligibility for pension.
VA supports the objectives of S. 3270 to provide for consideration
of recent asset transfers for less than fair market value in evaluating
a pension claimant's net worth and to impose a period of ineligibility
for pension where such transfers occur. The bill would clarify current
law by prescribing that pension applicants cannot create a financial
need, qualifying them for VA pension, by disposing of assets that the
applicant could use for the applicant's own maintenance. It would also
clarify that an applicant cannot create pension eligibility by
restructuring assets during the 36-month period preceding a pension
application through transfers to certain financial products or legal
instruments, such as annuities and trusts. A recent Government
Accountability Office study found that there is a growing industry that
markets these products and instruments to vulnerable Veterans and
survivors and potentially causes them harm. The amendments contemplated
by S. 3270 would enable VA to implement necessary program integrity
measures.
However, VA is concerned that the provisions of S. 3270 specifying
how the period of ineligibility will be calculated would be
unnecessarily complex and burdensome to administer. The provisions of
section 1(a) of S. 3270 to be codified at 38 U.S.C.
Sec. 1522(a)(2)(E)(ii) would require VA to divide the total value of
all applicable covered resources disposed of by the Veteran (or
Veteran's spouse) by ``the amount of the monthly pension that would be
payable to the veteran under section 1513 or section 1521 of this title
without consideration of such resources under paragraph (1).'' Sections
1(a) and 1(b) of S. 3270 would provide for similar calculations under
38 U.S.C. Sec. Sec. 1522(b)(2)(E)(ii), 1543(a)(4)(E)(ii), and
1543(b)(2)(E)(ii). It appears that the divisor used to calculate the
ineligibility period under these provisions would require VA to develop
for and adjudicate up to 3 years' worth of countable income. Such a
complex calculation would significantly increase VA's adjudicative
burden and, as a result, delay the payment of pension claims to
eligible Veterans.
VA suggests modifying this calculation method. The goals of S. 3270
could be achieved more efficiently by revising the language describing
the divisor to refer to ``the monthly amount a claimant would have
received based on the maximum annual pension rate including any amount
of increased pension payable on account of family members, but not
including any amount of pension payable because a person is in need of
regular aid and attendance or is permanently housebound.'' It would be
burdensome and inefficient to require VA to develop income and expense
information to determine up to 3 years' worth of countable income in a
decision that would deny pension in any event. By using less claim-
specific criteria tied to the maximum annual pension rate, VA would be
able to quickly determine the length of the penalty period and conserve
adjudication resources for expeditious processing of claims.
The use of such less-specific criteria is not without precedent.
Congress used similar language in 38 U.S.C. Sec. 1503(a)(8) in
establishing the rule for calculating the 5-percent threshold for
medical expense deductions in VA pension, which is based on the maximum
annual pension rate including increased pension payable on account of
family members, but without regard to special monthly pension.
At this time, VA has no objection to this section but is unable to
estimate the costs or savings associated with this proposal because
sufficient data is not available.
S. 3238--A BILL TO DESIGNATE THE DEPARTMENT OF VETERANS AFFAIRS
COMMUNITY BASED OUTPATIENT CLINIC IN MANSFIELD, OHIO, AS THE DAVID F.
WINDER DEPARTMENT OF VETERANS AFFAIRS COMMUNITY BASED OUTPATIENT
CLINIC, AND FOR OTHER PURPOSES
S. 3238 would designate the Department of Veterans Affairs
community based outpatient clinic located in Mansfield, Ohio, as the
``David F. Winder Department of Veterans Affairs Community Based
Outpatient Clinic.'' VA defers to Congress in the naming of this
facility.
S. 3282--A BILL TO AMEND TITLE 38, UNITED STATES CODE, TO REAUTHORIZE
THE VETERANS' ADVISORY COMMITTEE ON EDUCATION, AND FOR OTHER PURPOSES
S. 3282 would amend 38 U.S.C. Sec. 3692 to extend the expiration
date of the Veterans Advisory Committee on Education (Committee) to
December 31, 2014. It would also change the composition of the
Committee to include representatives of institutions and establishments
furnishing education or vocational training to eligible Veterans or
persons enrolled under chapter 31 of Title 38 (Training and
Rehabilitation for Veterans with Service-Connected Disabilities) while
removing those providing training to Veterans or persons enrolled under
chapter 32 of that title (Post-Vietnam Era Veterans' Educational
Assistance).
Further, S. 3282 would require the composition of the Committee, to
the maximum extent practicable, to include:
Veterans who served on active duty and were deployed in
connection with a contingency operation,
at least one Veteran who is a student currently enrolled
in a program of education and receiving assistance for the pursuit of
such program of education under chapters 30, 31, 33, or 35 of Title 38,
at least one representative from the American Council on
Education or an affiliated organization,
at least one representative from an organization that
represents Veterans,
a representative of a State Approving agency, and
at least two school certifying officials from different
regions of the country.
The Committee would be required to seek feedback on the policies of
VA relating to the administration of chapters 30, 31, 33, 35, and 36 of
Title 38 and chapter 1606 of Title 10 from students who are currently
training under such chapters or Veterans seeking to enroll for training
under such chapters.
At least twice each year, the Committee would be required to submit
to VA and Congress a report on the administration of chapters 30, 31,
33, 35, and 36 of Title 38 and chapter 1606 of Title 10, including
recommendations for legislative and administrative action to improve
educational assistance under such chapters.
VA supports this legislation. If reauthorized, VA would be able to
continue to receive recommendations and seek advice from the Members of
the Committee with regard to the administration and proposals to
enhance VA education benefit programs. VA estimates that S. 3282 would
have insignificant costs associated with its enactment.
S. 3308--A BILL TO AMEND TITLE 38, UNITED STATES CODE, TO IMPROVE THE
FURNISHING OF BENEFITS FOR HOMELESS VETERANS WHO ARE WOMEN OR WHO HAVE
DEPENDENTS, AND FOR OTHER PURPOSES
Section 1(a) of S. 3308 would amend 38 U.S.C. Sec. 2012(a) to
permit a grantee receiving per diem payments under VA's Homeless
Providers Grant and Per Diem Program (GPD Program) to use part of those
payments for the care of a dependent of a homeless Veteran who is
receiving services covered by the GPD Program grant. This authority
would be limited to the time period during which the Veteran is
receiving services under the grant.
Section 1(b)(1) of the bill would amend 38 U.S.C. Sec. 2061(c) to
require the Secretary to ensure that the total amount of grants awarded
in any year under VA's Grant Program for Homeless Veterans with Special
Needs is not less than 15 percent of the total amount of grants awarded
under the GPD Program under 38 U.S.C. Sec. 2011. This would ensure a
level of minimum funding for grants targeted to assist homeless
populations with special needs, such as women, including those with
minor dependents, frail elderly, etc. Section 1(b)(2) would amend 38
U.S.C. Sec. 2061 to authorize for appropriation such sums as may be
necessary for the purposes of this program for FY 2013 and each fiscal
year thereafter. The law currently authorizes for appropriation $5
million to conduct the program through FY 2012.
VA supports the intent of section 1(a) of S. 3308. We feel that
this authority is needed to fully reach the entire homeless population.
However, full implementation of the legislation would require
additional funding to avoid diminished services for homeless Veterans.
At the current level of funding VA would be unable to provide grants to
current grant recipients as well as Veterans with dependants.
VA does not support Section 1(b) for two reasons. First, it fails
to take into account that entities receiving grants under 38 U.S.C.
Sec. 2011 become eligible, subject to the availability of
appropriations, to receive per diem payments subsequently under 38
U.S.C. Sec. 2012. This means that VA may award per diem payments to
current grant recipients in lieu of awarding new grants under section
2011. Indeed, VA conducted its last capital grant Notice of Funding
Availability in FY 2010. Since then, VA has offered a Special Needs
grant round pursuant to 38 U.S.C. Sec. 2061 and a GPD ``Per Diem Only''
grant round pursuant to 38 U.S.C. Sec. 2012 (see also 38 CFR part
61.33).
Second, funding for Special Needs Grant Program is not a separate,
line-item budget item. Funds designated for this program are included
in the general allocation for the entire GPD program and come out of
VA's Medical Services account. With competing priorities for Medical
Service dollars, VHA currently funds the GPD Programs at the levels
that are authorized to be appropriated to for these programs. Were the
mandate in section 1(b) enacted, it would dramatically disrupt GPD
Program operations and force the closure of current GPD projects. To
illustrate, within the GPD Program's current budget of approximately
$224 million for FY 2012, VA expects to support approximately 15,000
operational GPD beds with per diem payments in the amount of
approximately $164 million (80 percent bed occupancy rate), and support
GPD Liaison positions in the amount of approximately $29 million.
Additionally, there are approximately 1,900 capital beds in development
from past capital grant rounds. VA estimates these capital beds could
require an additional $21 million in per diem grant support. Were the
requirements of section 1(b)(1) in place, VA would be required to spend
at least $33 million on GPD Special Needs grants. This would be a
dramatic increase in Special Needs funding--far above the current
mandated spending level of $5 million. Such an increase would have to
be absorbed from the GPD Program budget, and, to do that, the GPD
Program would be forced to close existing and proven GPD projects.
This concern is heightened by the fact that under existing law the
total amount authorized for appropriation for the GPD program will drop
from $250 million in FY 2013 to $150 million in FY 2014 and every
fiscal year thereafter. For FY 2012, approximately $164 million is
slated to cover per diem payments to approximately 15,000 Veteran beds.
In FY 2014, the required funding for per diem payments will exceed the
amounts authorized to be appropriated for the GPD's programs. VA will
then be forced to close GPD projects or reduce per diem rates for all
beds to remain within those authorization limits. In other words,
without a corresponding provision in 38 U.S.C. Sec. 2013 to authorize
appropriations in such sums as are needed to carry out the purposes of
the GPD for FY 2014 and thereafter, the effect of the mandate in
section 1(b)(2) will be meaningless.
VA estimates the costs associated with enactment of S. 3308 to be
$25.5 million for FY 2013, $137.3 million over 5 years, and $302.5
million over 10 years.
S. 3309--HOMELESS VETERANS IMPROVEMENT ACT OF 2012
S. 3309 is a comprehensive bill to continue and improve VA's
provision of benefits to homeless Veterans and their families. Key
provisions of the bill are targeted at addressing specific problems
identified in recent reports by VA's Office of Inspector General and
the Government Accountability Office, e.g., current barriers to access
to care and services faced by both homeless women Veterans and homeless
Veterans with children, the need for infrastructure improvements to
ensure the privacy and security of women Veterans receiving services
under VA or VA-sponsored programs, etc.
Section 2 of S. 3309 would amend current law to prohibit the
Secretary from making a grant for a project under VA's Homeless
Providers GPD Program unless the applicant also agrees in its grant
application to meet the physical privacy, safety, and security needs of
homeless Veterans receiving services through the project.
VA supports Section 2. This new requirement would help reinforce
the GPD Program's inspection efforts and also ensure that GPD grantees
comply with VA's ongoing efforts to ensure the privacy, safety, and
security needs of Veterans participating in the GPD Program. We note as
a practical matter that current GPD grantees would be required to
absorb the costs of making these improvements as VA lacks authority to
offer grants to existing GPD providers to renovate or remodel existing
GPD facilities. (38 CFR part 61.10.3) To help current grantees recover
these unanticipated costs, VA would need authority similar to that
specified in 38 U.S.C. Sec. 2012(c), wherein all GPD grantees were
required to comply with the Life Safety Code. In section 2012(c),
Congress authorized a five-year period during which VA offered grants
to GPD grantees to assist the grantees in meeting the new requirements
of the Life Safety Code. Regardless, future grant rounds for new
grantees would incorporate this requirement as part of the application
process.
VA does not support Section 3 of S. 3309, which would amend current
law to require the Secretary, when awarding grants under the GPD
Program, to assist eligible entities not only in establishing, but also
in maintaining programs to furnish services for homeless Veterans
(i.e., outreach services; rehabilitative services; vocational
counseling and training; and transitional housing assistance). VA does
not support this legislative measure because it would likely result in
substantial costs that are not contemplated in the GPD Program's budget
or in long-term financial planning for the GPD Program. VA believes
that most, if not all, GPD projects would request grant funding for
repairs and/or remodeling, but for the reasons previously explained, it
is unlikely there would be sufficient funds available to cover repairs
and/or remodeling of grantees' facilities.
The GPD Program was, in part, conceived to help save the Federal
Government such costs, especially given the fact that such services can
generally be obtained at lower cost in the community. Were VA to
provide grants to cover the costs of maintaining grantees'
infrastructures, the overall cost-effectiveness of the GPD Program
would be reduced, and, more importantly, fewer funds would be available
for the provision of direct services to homeless Veterans. As an
administrative matter, VA would have to amend its GPD regulations
before such maintenance grants could be awarded.
VA estimates the cost of Section 3 of S. 3309 to be $29.0 million
in FY 2013; $68.4 million over 5 years; and $115.5 million over
10 years.
Section 4 of the bill would amend 38 U.S.C. Sec. 2044(e) to require
that, of the amounts required to be made available for conduct of VA's
Financial Assistance Program for Supportive Services for Very Low-
Income Veteran Families in Permanent Housing (referred to below as the
``SSVF'' Grant Program), at least 1 percent of such funding must be
made available for the furnishing of legal services to assist Veteran
families with issues that interfere with their ability to obtain or
retain housing or supportive services.
VA does not support Section 4 because it duplicates existing
authority. Grants awarded under the SSVF Program already require
grantees to assist participants with obtaining legal services for
issues that interfere with their ability to obtain or retain permanent
housing or supportive services. See 38 CFR Sec. 62.33(g), implementing
38 U.S.C. Sec. 2044(b)(1)(D)(vii). Some grantees have identified
creative no-cost options for providing such legal services, relying on
area law school clinics and local bar associations' pro bono
initiatives. Such a spending-minimum for legal services would likely
discourage grantees from cultivating local networks of legal service
providers who will provide participants services at no cost. Beyond
discouraging or providing a disincentive for the development of no-cost
options for providing legal services, VA is also concerned that this
provision would not be an efficient use of resources inasmuch as the
mandated level of funding could well exceed the grantee's actual costs
of obtaining legal services for participants. Yet, even in such cases,
grantees would still have to slate the mandated-minimum amount for this
purpose, using funds that could otherwise be expended to furnish other
needed supportive services to participants.
Our non-support for section 4 is not meant to discount the central
role that legal services play in preventing and ending homelessness
among Veterans. Garnering adequate resources or partnerships for the
provision of legal services to homeless Veterans and those who are at
risk of becoming homeless is absolutely key to this effort. Veterans
accessing services in our homeless health care programs often have
multiple unmet legal needs ranging from criminal matters (e.g.,
unresolved warrants) to civil matters (e.g., child support arrears and
landlord-tenant disputes). While SSVF grants can be targeted at helping
address their participants' legal needs, those participants constitute
only part of the homeless Veteran population in need of such services.
We are heartened by the growing level of interest among lawyers and law
students in serving homeless Veterans, as evidenced by an increasing
number of Veteran-focused law school clinics and pro bono initiatives.
Still, far more legal resources are needed to build a national practice
community of attorneys who have the expertise and dedication needed to
effectively serve this population. Outside of awarding grants under
section 2044, VA's ability to help non-profits provide or coordinate
the provision of legal services to homeless Veterans is hamstrung by
limits on our legal authority. We are currently exploring ways to
leverage other existing Federal resources to deliver legal services to
both homeless and at-risk Veterans, and we would be happy to discuss
these efforts with the Committee.
VA estimates the cost of Section 4 of S. 3309 to be $3 million in
FY 2013; $15 million over 5 years; and $30 million over 10 years.
Section 5(a) of S. 3309 would amend 38 U.S.C. Sec. 2012(a) to
permit per diem payments made by the Secretary to grantees under VA's
GPD Program to include payments for furnishing care for a dependent of
a homeless Veteran, but only while the Veteran is receiving services
from the grantee under such grant.
Section 5(a) of S. 3309 is identical to section 1(a) of S. 3308,
discussed above. VA supports this section, but we refer you to our
earlier comments, which identify some concerns we have with its
enactment. VA estimates the cost of $25.5 million for FY 2013; $137.3
million over 5 years; and $302.5 million over 10 years.
Section 5(b)(1) of S. 3309 would require the Secretary to make
funds available for per diem payments under VA's GPD Program to grant
recipients or eligible entities that are considered to be ``non-
conforming.'' Non-conforming recipients or entities fall into three
categories: (1) those that meet each of the transitional and supportive
services criteria prescribed by the Secretary and furnish services to
homeless individuals of which not less than 75 percent are Veterans;
(2) those that meet at least one but not all of criteria prescribed by
the Secretary and furnish services to homeless individuals of which not
less than 75 percent are Veterans; and (3) those that meet at least one
but not all of the criteria prescribed by the Secretary and furnish
services to homeless individuals of which less than 75 percent are
Veterans. Currently, the Secretary's authority to make per diem
payments to these non-conforming recipients and entities is
discretionary. Section 5(b)(2) of the bill would require the Secretary
to prescribe such regulations as may be necessary to implement this
change.
VA does not support Section 5(b). The number of eligible conforming
entities seeking to receive GPD funds already far exceeds the resources
of the GPD Program.
For example, from 1994 through 2010, VA received 3,252 applications
from conforming eligible entities for grant funding under the GPD
Program. These applications included capital grant funding, per diem
only funding, and GPD special needs funding. Out of the 3,252
applications from conforming eligible entities, VA could only fund
1,115 of these applications. Similarly, from 1994 through 2010, VA
received applications requesting almost $1.4 billion in capital grant
funding, but VA could only fund approximately $197 million in GPD
capital grants. It is highly unlikely that funding will ever be
available for nonconforming entities, rendering this mandate
ineffectual and generating false expectations on the part of non-
conforming entities who would seek such assistance. We are more
concerned that changing the discretionary language in 38 U.S.C.
Sec. 2012(d)(1) to mandatory language would remove needed discretion
and produce the undesired result of non-conforming entities receiving
grants over conforming entities solely because of this requirement.
There are no additional costs associated with section 5 because
costs would come from those funds already slated to be awarded under
the GPD.
Section 6(a) would authorize the Secretary, subject to the
availability of appropriations, to award grants to cover the
operational expenses of grant recipients' comprehensive service centers
that are not otherwise covered by per diem payments made under the GPD
Program. Section 6(b) would limit the aggregate amount of all such
grants awarded in any Fiscal Year to $500,000. Section 6(c) would
require the Secretary to promulgate regulations not later than one year
after the date of the Act's enactment to carry out this new authority.
VA does not support Section 6 of S. 3309. VA does not believe this
measure would be an effective use of VA's resources and the GPD
Program's budget. VA funds would likely be put to better use funding
traditional outreach in the community or Community Resource and
Referral Centers (CRRCs). Historically, it has been difficult for
service centers to remain viable for several reasons. VA's statutory
authority is limited to paying ``per diem'' to service center
providers, and the service centers have difficulty in providing the
federally-required information under Office of Management and Budget
(OMB) Circulars and other Federal standards needed to accurately
reflect the services they provide, to determine in a timely manner the
eligibility of the individuals receiving those services, and to
determine the amount of time actually spent with the individuals
served. Given GPD grantees' difficulties in accounting for services
provided in service centers, VA does not believe service centers are an
effective outreach model for VA homeless programs and services,
especially given VA has more effective and proven methods of reaching
the homeless Veteran population. For instance, VA excels at traditional
outreach in the community and is introducing CRRCs throughout the
country. VA estimates the cost associated with enactment of section 6
could be $500,000 per any fiscal year these operational grants are
awarded. VA is unable, however, to estimate costs with greater
specificity given the disparate operational needs of each GPD service
center.
Section 7 of S. 3309 would extend dental benefits under 38 U.S.C.
Sec. 2062 to a Veteran enrolled in VA's health care system who is also
receiving for a period of 60 consecutive days assistance under section
8(o) of the United States Housing Act of 1937 (commonly referred to as
``Section 8 vouchers.''). It would also amend current law to permit the
Secretary to disregard breaks in the continuity of assistance or care
for which the Veteran is not responsible. VA supports the intent of
section 7 of S. 3309, but must condition this support on assurance of
the additional resources that would be required were this provision
enacted.
VA recognizes the need for dental care and supports the improvement
of oral health and well-being for Veterans experiencing homelessness.
Indeed, increasing access to dental care for Department of Housing and
Urban Development VA Supportive Housing (HUD-VASH) Veterans is an
important step in VA's Plan to End Veteran Homelessness. Severe dental
disease plagues the majority of Veterans experiencing homelessness,
particularly the chronically homeless Veterans participating in HUD-
VASH. Severe dental disease seriously impacts physical health as well
as self esteem and mental health.
Under Directive 2007-039, homeless Veterans participating in the
GPD Program, Domiciliary Residential Rehabilitation Program, Health
Care for Homeless Veterans (HCHV) contract residential treatment
program, Community Residential Care Program, and Compensated Work
Therapy-Transitional Residence (CWT-TR) program are eligible for a one-
time course of focused dental care. (38 U.S.C. Sec. 1712(a)(1)(H); 38
U.S.C. Sec. 2062). Section 7 would expand dental eligibility to
Veterans participating in the HUD-VASH Program Veterans.
While VA is committed to ensuring eligible Veterans receive
patient-centered, cost-effective, evidence-based care, we acknowledge
that current resources are inadequate to provide these dental benefits
to a new cohort of Veterans and to accommodate the related increase in
workload. An expansion of the eligible dental population without a
corresponding expansion of resources would severely limit VA's ability
to deliver dental care to Veterans already receiving VA dental care
benefits.
Finally, as a technical matter, the language proposed for section
2062 refers in error to subsection ''(a)'' when it should instead
reference subsection ''(b).'' That is, it should be amended in relevant
part to read: ''(b) Eligible Veterans.'' VA further notes that while
Section 7 of S. 3309 would amend the current structure of 38 U.S.C.
Sec. 2062, the only substantive change would be the inclusion of HUD-
VASH Veterans.
VA estimates that there would be significant costs in the first
years of operation as thousands of HUD-VASH Veterans become eligible
for dental care. However, after the first few years of operation, the
cost of providing dental care to Veterans in HUD-VASH would drop
dramatically because the dental needs of this population would be
satisfied or stabilized. VA would avoid new costs because VA expects a
10 percent turnover in HUD-VASH vouchers in each fiscal year.
Specifically, VA estimates the total cost associated with enactment of
section 7 for FY 2013 to be $75.9 million; $123.0 million over a five-
year period, and $182.3 million over a 10-year period. (These estimates
are comprised of the separate amounts estimated for direct patient care
as well as projected increases in administrative costs.) VA's cost
estimate for this provision only focused on HUD-VASH vouchers and
Veterans participating in the HUD-VASH program. It is possible that
Veterans eligible for VA health care reside in Section 8 housing that
is unaffiliated with the HUD-VASH program. As presently drafted,
Section 7 could further increase the cost of this bill.
Section 8 of S. 3309 includes a series of extensions to reauthorize
VA's benefits programs for homeless Veterans. VA supports Section 8 and
notes that, if enacted, these extensions would not result in any
additional costs beyond those contemplated in VA's FY 2013 budget
request. Each provision of Section 8 is discussed below in greater
detail.
Section 8(a) would authorize to be appropriated $250,000,000 for FY
2013 and $150,000,000 for FY 2014 and each fiscal year thereafter for
the conduct of VA's GPD Program.
VA supports Section 8(a). Under current law, the amount authorized
to be appropriated for the GPD Program for FY 2013 will be reduced from
$250,000,000 to $150,000,000 and it remains the same for each
subsequent fiscal year. We support section 8(a) to the extent that it
would retain the program's current level of authorization for FY 2013.
We have concerns, however, about the terms that would drop the
authorization level to $150,000,000 for FY 2014 and each fiscal year
thereafter. Such a decrease would be highly problematic. GPD
expenditures will far exceed the amount authorized to be appropriated
for the program for FY 2014 and in following fiscal years. VA would
require additional funding to support the existing projects at
anticipated per diem and occupancy rates in FY 2014 and beyond.
Otherwise, VA would be forced to either cut per diem payments to GPD
community providers or summarily terminate operational GPD projects
presently serving homeless Veterans.
Section 8(b) would authorize to be appropriated $50,000,000 for FY
2013, for the conduct of the U.S. Department of Labor's (DOL) Homeless
Veterans Reintegration Programs. We defer to the views of the Secretary
of Labor on this provision.
Section 8(c) would extend VA's general treatment and rehabilitation
authority (codified at 38 U.S.C. Sec. 2031(a)) for seriously and
mentally ill Veterans from December 31, 2012 to December 31, 2014. VA
supports this legislative measure, which would reauthorize the VA's
Health Care for Homeless Veterans Program (consisting of VA's premier
outreach program and a program offering contract therapeutic housing).
Section 8(d) would extend VA's operation of comprehensive service
centers for homeless Veterans (under 38 U.S.C. Sec. 2033) from
December 31, 2012 to December 31, 2014. VA supports section 8(d), which
would re-authorize VA's Community Resource and Referral Centers.
Section 8(e) would extend, through December 31, 2013, the
Secretary's authority under 38 U.S.C. Sec. 2041 to sell, lease, or
donate properties to nonprofit organizations that provide shelter to
homeless Veterans. Under current law, the authority will expire on
December 31, 2012. VA supports the extension, as it will help VA meet
its goal of ending Veteran homelessness by 2015. We note, however, that
the five-year extension that the Administration proposed would better
enable VA to achieve our goal. While any extension of authority under
38 U.S.C. Sec. 2041 would result in a reduction in property sales
proceeds, neither a one-year, nor a five-year extension would result
any significant loan subsidy costs.
Section 8(f) would require VA to make available (from amounts
approPriated for Medical Services) $300,000,000 for FY 2013 to carry
out the Department's Financial Assistance Program (required by 38
U.S.C. Sec. 2044). VA supports section 8(f), which would re-authorize
appropriations for the SSVF Program, VA's premier prevention and rapid
re-housing program. VA has already budgeted $300 million for the SSVF
Program in FY 2014.
Section 8(g) would extend VA's Grant Program for Homeless Veterans
with Special Needs through 2015. VA supports this measure.
Section 8(h) would extend VA's Advisory Committee on Homeless
Veterans from December 31, 2012, to December 31, 2014. VA supports this
provision.
S. 3313--WOMEN VETERANS AND OTHER HEALTH CARE IMPROVEMENTS ACT OF 2012
Section 2 of the bill would add a new section 7330B to Title 38,
entitled ``Facilitation of reproduction and infertility research.''
This new section would require the Secretary of VA to ``facilitate
research conducted collaboratively by the Secretary of Defense and the
Director of the National Institutes of Health'' to improve VA's ability
to meet the long-term reproductive health care needs of Veterans with
service-connected genitourinary disabilities or conditions incurred or
aggravated in line of duty that affect the Veterans' ability to
reproduce, such as spinal cord injury. The Secretary of VA would be
required to ensure that information produced by research facilitated
under section 73308 that may be useful for other activities of the
Veterans Health Administration (VHA) is disseminated throughout VHA. No
later than three years after enactment, VA would be required to report
to Congress on the research activities conducted under section 7330B.
VA supports section 2 of S. 3313. Generally, VA supports
implementing research findings for the benefit of Veterans. VA's goal
is to restore the capabilities of Veterans with disabilities to the
greatest extent possible. We utilize new research into various
conditions to improve the quality of care we provide. Of note, rather
than requiring VA to conduct research, this section would require VA to
facilitate research that is conducted collaboratively by the Secretary
of Defense and the Director of the National Institutes of Health. It is
not clear how the term ``facilitate'' would be defined, which could
raise privacy and security issues with respect to identifiable Veteran
information. Given the ambiguity over the meaning of this term, VA is
unable to provide a cost estimate at this time. If facilitation
requires fairly minor involvement (coordination, distribution, etc.),
VA expects the costs of this provision would be nominal; however, if
facilitation is intended to mean direct funding, proposal reviews, and
additional staff, costs would be greater.
Section 3 of S. 3313 would include fertility counseling and
treatment, including assisted reproductive technology, among those
things that are considered to be ``medical services'' under chapter 17
of title 38, U.S.C., as provided in 38 U.S.C. Sec. 1701(6).
VA supports the intent of section 3 of S. 3313, but must condition
this support on assurance of the additional resources that would be
required were this provision enacted. The provision of Assisted
Reproductive Technologies (including any existing or future
reproductive technology that involves the handling of eggs or sperm) is
in keeping with VA's goal to restore the capabilities of Veterans with
disabilities to the greatest extent possible and to improve the quality
of Veterans' lives. For many Veterans, having children is an important
and essential aspect of life, and those who desire but are unable to
have children of their own commonly experience feelings of depression,
grief, inadequacy, poor adjustment, and poor quality of life.
VA estimates the cost of providing these new benefits to all
Veterans would be $59 million in FY 2013, $37 million in FY 2014, $232
million over 5 years, and $529 million over 10 years. The cost estimate
is higher in the first year than in subsequent years because VA assumes
that existing demand would result in immediate utilization of this
benefit, but that demand would decline after these services were
provided.
Section 4 would add a new section 1787 to Title 38 that would
require VA to furnish fertility counseling and treatment, including
assisted reproductive technology, to a spouse or surrogate of a
severely wounded enrolled Veteran who has an infertility condition
incurred or aggravated in line of duty, if the spouse and the Veteran
apply jointly for such counseling and treatment through a process
prescribed by VA. This section would authorize VA to ``coordinate
fertility counseling and treatment'' for other spouses and surrogates
of other Veterans. Section 4 would require VA to prescribe regulations
to carry out section 1787 no later than 1 year after enactment.
VA supports section 4 in part, but must condition this support on
assurance of the additional resources that would be required were this
provision enacted. While VA supports providing infertility services
including Assisted Reproductive Technology (ART) to severely wounded
Veterans described in section 4 and their spouses or partners, VA does
not support coverage of surrogates. The additional coverage of
surrogates is inconsistent with coverage provided by the Department of
Defense (DOD), Medicaid, Medicare, and several private insurers and
health systems. Current DOD policy addressing assisted reproductive
services for severely injured Servicemembers specifically excludes
coverage of surrogates. Moreover, the complex legal, medical and policy
arrangements of surrogacy vary from state to state due to inconsistent
local regulations. VA acknowledges that surrogacy may offer the only
opportunity for Veterans and their partners to have a biological child.
However, there may be other options to consider when exploring how best
to compensate these Veterans for their loss and to facilitate
procreation.
VA recommends clarification of the phrase, ``a severely wounded
veteran who has an infertility condition incurred or aggravated in line
of duty in the active military, naval, or air service'' in subsection
(a) of proposed section 1787 in section 4. The current language is
unclear as to whether this benefit would be available to the spouses
and surrogates of enrolled Veterans that have suffered loss or loss or
use of creative organs, or if the eligible population would be more
limited based on certain conditions of such Veterans (e.g. those with
SCI, polytrauma, genitourinary injuries). VA also recommends
clarification of the terms ``fertility counseling and treatment'' and
``assisted reproductive technology.'' In addition, the meaning and
scope of the coordination contemplated under proposed section 1787(b)
(which would authorize VA to ``coordinate fertility counseling and
treatment'' for the spouses and surrogates of other Veterans not
described in section 1787(a)) is unclear, and could potentially account
for spouses and surrogates of all other Veterans. VA recommends that
this be clarified as well.
VA recommends that this legislation be consistent with DOD's 2012,
``Policy for Assisted Reproductive Services for the Benefit of
Seriously or Severely Ill/Injured (Category II or Ill) Active Duty
Servicemembers.'' As such we recommend this legislation account for
both severe injury and illness. VA cannot separate the costs of illness
and injury. In the context of reproductive health, the distinction
between illness and injury often is not a clearly defined boundary.
VA also recommends the language of the bill be modified to account
for different types of family arrangements, so that benefits are not
limited to only spouses of Veterans described in proposed section 1787
(e.g. to include both spouses and partners of Veterans).
The bill does not state whether maternity services would be covered
for a female spouse of a Veteran once infertility treatment is provided
and pregnancy is established. These benefits typically would be
provided in the private sector following successful fertility
treatment. If the Committee intends that these benefits be included, we
recommend that be made clear in the bill language.
VA also notes that the timeline to implement regulations for this
program within one year of enactment is unrealistic given the
complexity of issues involved.
VA's cost estimates for care provided under this section do not
account for maternity services for a female partner or spouse of a
Veteran with infertility because the bill does not state that maternity
services would be covered for a female partner or spouse of a Veteran
once infertility treatment is provided and pregnancy is established.
Potential costs for surrogates are also not reflected in this analysis
because VA has no reliable way to predict how many surrogates would be
utilized and cannot project the costs to cover the full range of legal
and medical issues arising from surrogacy. This analysis accounts for
the following infertility services, and includes the costs of providing
in vitro fertilization to the proposed eligible population: advice/
office visits, testing, drug therapy, surgery or treatment for blocked
tubes, tubotubal anastomosis (reversal of tubal ligation), vasovasotomy
(reversal of vasectomy), varicocele repair (repair of varicose veins
around scrotum), artificial insemination (AI)/intrauterine insemination
(lUI), assisted reproductive technologies (ART), and ART with donated
egg/sperm, ART with frozen embryo, and ART with host uterus. VA's cost
estimates also assume there is pent-up demand for these services, so
first year costs are expected to be significantly higher as Veterans
and their families would immediately utilize these treatment options.
The estimates reflect only the cost of services and do not reflect any
potential costs associated with additional enrollment or additional
utilization. VA's cost estimate is based on the assumption that the
benefits under section 4 would be extended to the spouses of Veterans
with SCI, polytrauma, or genitourinary injuries, or other creative
organ loss. VA is unable to differentiate between creative organ loss
that is a result of injury and that which is a result of illness.
Therefore, this analysis includes spouses and partners of Veterans with
creative organ loss which could be a result of illness or injury.
VA estimates the total cost to provide care under section 4 for
spouses and partners of severely injured Veterans (those with
polytrauma, genitourinary injuries, and spinal cord injuries, as well
as creative organ loss, which could result from both injury or illness)
to be approximately $77 million in FY 2013, $36 million in FY 2014,
$252 million over 5 years, and $590 million over 10 years. As with
section 3, VA anticipates a greater cost in FY 2013 as existing demand
for these services is addressed.
Section 5 would require VA to enhance the capabilities of the VA
Women Veterans Call Center (WVCC) in responding to requests by women
Veterans for assistance with accessing VA health care and benefits, as
well as in referring such Veterans to community resources to obtain
assistance with services not furnished by VA.
VA supports section 5 of S. 3313, and VA believes the most
effective means of implementing this section would be to establish an
inbound calling system specifically for women Veterans. By building on
capabilities within the WVCC, an incoming call center would allow women
Veterans to call the WVCC, and VA to connect them to resources, assist
with specific concerns, and provide information on services and
benefits. Many Veterans call VA daily requesting more details on how to
enroll, how to find their DD-214, and what benefits they have earned.
WVCC can directly connect women Veterans to Health Eligibility Center
employees for enrollment information and discussion of benefits
available to them. Calls could also be transferred to the appropriate
medical center to assist eligible Veterans with obtaining a health care
appointment. Once a woman Veteran is connected to VA health care
services, the Women Veterans Program Manager could also assist her in
finding community resources that may not be provided by VA.
VA estimates section 5 would cost $1.2 million in FY 2013, $6.4
million over 5 years, and $14.1 million over 10 years.
Section 6 of S. 3313 would expand the locations and duration of the
pilot program required by section 203 of Public Law 111-163. Section
203 required VA to carry out a pilot program to evaluate the
feasibility and advisability of providing reintegration and
readjustment services in group retreat settings to women Veterans
recently separated from service after a prolonged deployment. Section
6(a) would increase the number of locations at which VA is required to
carry out the pilot program from three to fourteen locations. Section
6(b) would extend the duration of the pilot from 2 years to 4 years.
VA supports section 6 of S. 3313. VA is currently in the final year
of the original 2-year pilot program, authorized by section 203 of
Public Law 111-163. These retreats under the pilot program focus on
building trust and developing peer support for the participants in a
therapeutic environment. In FY 2011, VA provided three retreats to
women Veterans with three more retreats scheduled for FY 2012. VA could
benefit from additional retreats as a greater number of women Veterans
will be able to participate. These additional participants will also
provide more data for VA to make a determination as the appropriateness
of these retreats during the final reporting phase. Initial reports
provided after the completed retreats show favorable results with
supplying participants with tools needed to make a successful
reintegration into civilian life.
While VA supports section 6, we note that there may not actually be
fourteen distinct geographic locations that offer the level of service
the program requires. Therefore, we recommend that section 6(a) be
amended to require VA to carry out the pilot program in up to fourteen
locations. VA would continue to look for new locations to hold these
retreats if section 6 were enacted, but previously used facilities may
need to be reused due to the shortage of potentially qualifying
locations based on the retreat requirements, specifically the need for
specialized locations to complete outdoor team building exercises and
other conditions.
Because VA will have completed retreats at six locations by the end
of FY 2012, section 6 would require VA to schedule retreats at an
additional eight locations before entering the final reporting phase.
VA estimates that the cost of implementing this pilot program at an
additional eight locations for an additional 2 years of the pilot
program would cost $335,640 in FY 2013 and $348,000 in FY 2014, for a
total of $683,640.
Section 7(a) would modify the duration of the pilot program
required by section 205 of Public Law 111-163. Section 205 required VA
to carry out a 2-year pilot program at no fewer than three VISNs to
furnish child care services to eligible Veterans as a means of
improving access to mental health care and other health care services.
Section 7(a) would extend the duration of the pilot such that ''[a]
child care center that is established as part of the pilot program may
operate until the date that is 2 years after the date on which the
pilot program is established in the third Veterans Integrated Service
Network.''
VA supports section (7)(a). Currently, VA has two operational sites
for the pilot program required by section 205 of Public Law 111-163:
the first site established in Buffalo in October 2011, and the second
site established in Northport in April 2012. The third identified site,
in American Lake, WA, began offering services in the community in
August 2012, and is expected to open its program on its VA campus in
late 2012. This amendment would extend the authorization to execute
currently planned programs and consequently would result in no
additional cost to VA.
Section 7(b) would require VA to carry out a pilot program to
assess the feasibility and advisability of providing assistance to
qualified Veterans to obtain child care during the period such Veterans
are receiving readjustment counseling and related mental health
services at a Vet Center. The pilot program would be carried out in at
least three Readjustment Counseling Service Regions selected by VA, for
a 2-year period beginning when the last pilot location established
under this section is initiated. VA would be required to report to
Congress on the pilot program not later than 180 days after completion
of the pilot program, which would include findings and conclusions, as
well as recommendations for continuation or expansion of the pilot
program. Paragraph (8) of section 7(b) would authorize the
appropriation of $1,000,000 for each FY 2014 and FY 2015 to carry out
the pilot program. This section would define ``Vet Center'' as ``a
center for readjustment counseling and related mental health services
for veterans under section 1712A of title 38, United States Code.''
VA supports section 7(b). Some Veterans who use Vet Center
services, especially those who have served in either Iraq or
Afghanistan, have voiced concerns that the lack of available child care
has impacted their ability to consistently use Vet Center services. Vet
Center staff members are constantly searching for new initiatives that
have the potential to increase Veteran access to services. This pilot
program could help to identify the scope of these concerns within the
Vet Center program and determine the effectiveness of potential
interventions. However, we have identified some concerns about
confidentiality under the proposed pilot program, as VA's Vet Centers
currently maintain a separate set of records to preserve Veteran
information. There is a possibility that Veterans participating in the
program would need to consent to a verification process that could lead
to a child care provider knowing that the Veteran is using Vet Center
services. The pilot program could allow us to determine whether this
has an impact on utilization of Readjustment Counseling Services.
VA is not able to provide an accurate cost estimate for section
7(b), as VA has no experience in predicting the potential use of such
child care programs by Veterans who use Vet Center services. It is not
viable to use cost estimates from the VA Child Care Pilot Program
required by section 205 of Public Law 111-163, as this pilot is
providing additional services through onsite child care and Vet Centers
do not have space to accommodate such additional services. Further,
usage comparisons with this pilot are not viable, as Vet Centers
provide services during non-traditional hours, including after normal
business hours and on weekends when requested by the Veteran. Depending
upon how the program is executed, the $1 million that would be
authorized to be appropriated under paragraph (8) of section 7(b) may
not be adequate to support a pilot program offering child care services
at three Vet Center locations.
S. 3316--A BILL TO REQUIRE THE SECRETARY OF LABOR TO CARRY OUT A PILOT
PROGRAM ON PROVIDING VETERANS WITH ACCESS AT ONE-STOP CENTERS TO
INTERNET WEB SITES TO FACILITATE ONLINE JOB SEARCHES, AND FOR OTHER
PURPOSES.
Section 1 of S. 3316 would require the Secretary of Labor to
commence a pilot program to assess the feasibility and advisability of
providing Veterans seeking employment with access to computing
facilities to facilitate the access of such Veterans to Internet Web
sites. The bill requires commencement of the pilot program not later
than 90 days after the date of the enactment of this Act. VA defers to
the DOL on section 1 of the bill.
Section 2 of this bill would repeal 38 U.S.C. Sec. 7324, which
requires the Secretary of VA to submit to Congress an annual report on
the use of authorities to enhance retention of experienced nurses. VA
supports this proposal. This reporting requirement has been provided
annually to Congress since 2002. The Veterans Health Administration
(VHA) is very interested in retaining experienced nurses, and this
report has demonstrated for 10 years how VHA utilizes its authorities
to enhance retention. Given that VHA intends to continue its retention
efforts, as the report has demonstrated over the last 10 years, there
is minimal value in resubmitting the same data, with slight variation,
annually. There would be a cost savings associated with the bill.
Annually, VA spends $4,082 to prepare this report. VA estimates cost
savings of $20,400 over 5 years and $40,820 over 10 years.
S. 3324--GRANTS TO NONPROFIT ORGANIZATIONS FOR THE CONSTRUCTION OF
FACILITIES FOR TEMPORARY LODGING
S. 3324 would authorize VA to award grants to the Fisher House
Foundation, Inc. for the construction, furnishing, and decorating of
Fisher Houses to be used by VA to provide temporary lodging under 38
U.S.C. Sec. 1708(a). This bill would also authorize VA to accept, use,
and dispose of gifts of services or property for purposes of awarding
these grants or for operating and maintaining Fisher Houses. Finally,
the bill would authorize the appropriation of $4,000,000 for FY 2013
and each fiscal year thereafter.
VA Fisher Houses improve access to care for Veterans by providing a
supportive environment for family members and caregivers to stay during
the course of medical treatment. Veterans are more likely to travel
long distances to receive care if their families and caregivers can
accompany them without bearing the burden of costs associated with
hotel lodging. VA supports the Fisher House and other similar
foundations. We note that the bill would set a new precedent in
allowing funding for Fisher House construction, where previously VA
only provided operation and maintenance funding. Further, the bill
limits these grants to only the Fisher House Foundation. Other
community organizations have provided funding for the construction of
temporary lodging at VA medical centers. For example, Lilly Endowment,
Inc., in collaboration with other community organizations, funded a
grant to construct the ``Veterans House,'' which opened in 2011, and is
located on the grounds of the Richard L. Roudebush VA Medical Center in
Indianapolis, Indiana.
VA estimates the cost of this bill to be $4.2 million in the first
year, $20.9 million over 5 years and $41.9 million over 10 years.
S. 3336--A BILL TO AUTHORIZE THE SECRETARY OF VETERANS AFFAIRS TO CARRY
OUT A MAJOR MEDICAL FACILITY PROJECT LEASE FOR A DEPARTMENT OF VETERANS
AFFAIRS OUTPATIENT CLINIC AT EWA PLAIN, OAHU, HAWAII, AND FOR OTHER
PURPOSES
S. 3336 would authorize the Secretary of VA to carry out a major
medical facility project lease for an outpatient clinic at Ewa Plain,
Oahu, in an amount not to exceed $16,453,300.
VA supports the bill, but as written it does not fully describe the
project. Because the outpatient clinic will be co-located with the
Department of Defense, VA suggests modifying the language as set forth
below.
``The Secretary of Veterans Affairs may carry out a major
medical facility lease for a Department of Veterans Affairs
outpatient health care access center, to include a co-located
clinic with the Department of Defense and the co-location of
the Veterans Benefits Administration Honolulu Regional Office
and the Kapolei VA Vet Center, in an amount not to exceed
$16,453,300.''
S. 3340--MENTAL HEALTH ACCESS TO CONTINUED CARE AND ENHANCEMENT OF
SUPPORT SERVICES ACT OF 2012
Title I
With regard to sections 101 through 103 and sections 107 through
113 of S. 3340, VA defers to the views of the Department of Defense
(DOD), as these sections primarily affect DOD programs.
Section 104 of S. 3340 would limit disclosure by DOD medical and
mental health care providers of a mental health condition of a member
of the Armed Forces, treatment of a member for a mental health
condition, or a member's request for treatment of a mental health
condition. Under this section, a DOD medical or mental health care
provider could only make such a disclosure if:
(1) The disclosure is to another covered entity (as defined for
purposes of the Health Insurance Portability and Accountability Act of
1996 (HIPAA)) and is necessary;
(2) The member concerned requests the disclosure;
(3) The member concerned does not meet the minimum standards for
deployment prescribed under section 1 074f(f) of Title 10, United
States Code, at the time of the disclosure, regardless of the
deployment status or plans of the member; or
(4) The disclosure is necessary in an emergency to protect the life
or safety of the member concerned or others.
While VA supports the goal of limiting unnecessary disclosures of
Servicemembers' mental health records, we do not support section 104
because its provisions would complicate and delay the delivery of
benefits to which Veterans are entitled. Currently, the Veterans
Benefits Administration (VBA) is authorized to request and receive
mental health treatment records from DOD without requiring the Veteran
to sign a medical release for such disclosure. However, because VBA is
not a ``covered entity'' under HIPAA, section 104 would require that a
Servicemember or Veteran specifically request that VBA obtain the
protected records. Thus, the provisions of section 104 would add an
additional administrative burden for VBA in adjudicating claims for
mental disorders that would potentially operate to the detriment of
Veterans in need of compensation benefits by delaying the adjudication
of their claims.
There are no mandatory or significant discretionary costs
associated with section 104. However, the proposed provision would
likely delay claims processing for Veterans seeking compensation for
mental health conditions by imposing the additional requirement that VA
obtain from every Veteran claiming compensation for a mental health
condition a specific release of information to forward to DOD. This
additional step could ultimately delay the delivery of benefits, or
possibly result in a denial of benefits otherwise warranted if the
Veteran failed to provide the necessary authorization.
Section 105 would require DOD and VA to enter into an MOU governing
the sharing of examination results and other records retained under
DOD's medical tracking system for members of the Armed Forces deployed
overseas.
VA does not support the proposed provision. Current agreements
between DOD and VA already permit the sharing of information contained
within medical tracking systems for members deployed overseas. The
current agreements enable VA to procure such records for purposes of VA
health care and benefits claims. For example, DOD and VHA share
information from DOD's Pre-and Post-Deployment Health Assessment
surveys and the Post-Deployment Health Reassessments surveys by
utilizing the Federal Health Information Exchange (FHIE) and
Bidirectional Health Information Exchange systems. DOD sends data on
separated Servicemembers to VA on a monthly basis, and weekly for
individuals referred to VA for care or evaluation. Because VA and DOD
already share this information pursuant to an MOU governing health
information sharing, this provision is unnecessary. It is unclear
whether this provision would require an additional MOU to replace or
supplement the existing memorandum covering the same subject. There
would be no costs associated with enactment of this provision.
Section 106 would require DOD and VA to enter into an MOU providing
for participation of members of the Armed Forces in VA peer support
counseling programs and would require VA to provide training to
Servicemembers who will perform peer support counseling duties under
those programs. VA has no objection to this section of S. 3340. VA
already is undertaking actions consistent with the objective of section
106 without the use of a memorandum of understanding. VA currently has
a peer support specialist position in development for which active duty
Servicemembers would be eligible to apply. All VA peer support
counselors receive training. In addition to the formal peer support
training program, a volunteer position description has also been
developed expressly to provide volunteer support to those Veterans in
the suicide prevention program. While VA does not consider these
volunteers to be ``peer specialists'' and would not expect or want
these volunteers to provide counseling services, there are a variety of
ways that they can provide support to fellow Veterans, such as
companionship. VA encourages and supports this engagement through the
suicide prevention volunteer program. VA estimates the cost of this
provision would be $32.4 million for FY 2013; $167.5 million over
5 years; and $349.8 million over 10 years.
Title II
Section 201(a) would require that VA, no later than December 31,
2013, develop and implement a comprehensive set of measures to assess
mental health care services furnished by VA. These measures must
provide an accurate and comprehensive assessment of the timeliness of
the furnishing of VA mental health care, the satisfaction of patients
who receive VA mental health care services, the capacity of VA to
furnish mental health care, the availability and furnishing of
evidence-based therapies by VA. Section 201(b) would require VA, not
later than December 31, 2013, to develop and implement guidelines for
the staffing of general and specialty mental health care services,
including at community-based outpatient clinics. Such guidelines must
include productivity standards for providers of mental health care.
VA has no objections to Section 201(a), although it is partially
duplicative of current processes in place by the VHA Office of Mental
Health Operations (OMHO) and Office of Mental Health Services (OMHS).
OMHO and OMHS have partnered to develope four separate work groups to
address access measurement in response to the recent review by the
Office of the Inspector General. VHA leadership has put forth both
temporary and long-term proposals addressing access measurement. VHA is
currently reviewing patient satisfaction using the Survey of Healthcare
Experiences of Patients survey tool, and conducting meetings with
Veterans at every OMHO site visit scheduled this year and on a
recurring 3-year basis to provide feedback from Veterans on mental
health services. VHA has also developed a specific survey to obtain
Veteran feedback about mental health care and will be implementing the
survey in FY 2013. Capacity to furnish mental health care is measured
by the Comprehensive Mental Health Information System (MHIS), which
allows VHA to review the amount of mental health services provided per
unique Veteran at a facility and compare results across facilities.
Likewise, VHA is able to partially monitor the availability and
furnishing of evidence-based psychotherapies (EBP) using the
Comprehensive MHIS, which provides an overall measure for psychotherapy
implementation as well as specific metrics related to the provision of
such services for Veterans with PTSD, Depression, Substance Use
Disorders , and Serious Mental Illness (SMI). VHA anticipates the
implementation of the templates for the EBP notes in FY 2013 will
provide more specific information for analysis.
VA has no objections to section 201(b), OMHO is partnering with
OMHS to further develop the mental health staffing model. A pilot is
currently underway in (Veterans Integrated Service Networks (VISN) 1,
4, and 22, the results of which will help further guide implementation
to all VISNs in FY 2013. Productivity standards for mental health
providers have been drafted and are being reviewed internally by VHA
before final approval. There are no additional costs involved for these
subsections if efforts are covered by current VHA staff.
Section 201(c) would require VA seek to enter into a contract with
the National Academy of Sciences to create a study committee to consult
with VA on VA's development and implementation of the measures and
guidelines required by subsections (a) and (b); and to conduct an
assessment and provide an analysis and recommendations on the state of
VA's mental health services. The contract must require the study
committee to assess certain issues, conduct surveys, and make
recommendations to the Secretary on certain issues. Any subcommittee
that assists the study committee must include at least one former VHA
official and two former VHA employees who were providers of mental
health care. The study committee would be required to submit periodic
reports to VA and provide other consultation to VA. Not later than 30
days after receiving a report from the Committee, VA would be required
to submit to the Congressional Veterans' Affairs Committees a report on
VA's plans to implement each recommendation in the report.
Section 201(c) appears to be duplicative of processes already in
place within OMHO. However, VA does not object to the provision because
a contract might be beneficial for consultative purposes to augment
current internal efforts.
VA has no objection to this subsection.VHA has already reviewed
barriers to mental health services using focus groups with mental
health provider staff as well as through OMHO site visits at every
facility this fiscal year. Comprehensive site visits have been
conducted during which OMHO reviewed the implementation of the Uniform
Mental Health Services Handbook at each facility. VHA could further
modify these ongoing site visits to review implementation of early
interventions services for hazardous drinking and relationship problems
for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New
Dawn (OEF/OIF/OND) Veterans, as proposed in section 201(c). A survey of
Veterans and clinical providers is also currently being finalized for
distribution to the field and will include Veterans from OEF/OIF/OND.
Follow-up analyses of both the surveys and the site visits will be
submitted to upper management detailing overall concerns. Individual
facilities are submitting action plans based on each site visit report.
These actions plans are monitored by OMHO and a follow-up action plan
will be developed based on the survey summary. It should be noted that
site visit teams are also comprised of facility mental health providers
and leaders. A compiled report can be made regularly to the Secretary
for distribution to Congress as desired.
Section 201(d) would require VA to make available to the public on
a VA Internet Web site the measures and guidelines developed and
implemented under this section and an assessment of the VA's
performance using such measures and guidelines. VA would be required to
update the measures, guidelines, and assessment made available to the
public not less frequently than quarterly.
VA has no objection to this provision. VHA could publish its
measures and guidelines along with an assessment of VA's performance
that is based on these metrics. This would be placed on an Internet Web
site for public awareness. However, it should be noted that such
assessments cannot always be updated quarterly, as some metrics may be
updated at various points of the year.
Section 201(e) would require VA to submit to the Congressional
Committees on Veterans' Affairs a report on the Secretary's progress in
developing and implementing the measures and guidelines required by
section 201 no later than June 30, 2013, and no less frequently than
twice each year thereafter. This subsection specifies what the report
must include.
VA has no objection to providing reports to the Senate Veterans'
Affairs Committee (SVAC) and House Veterans' Affairs Committee (HVAC)
to report on progress on the implementation of the measures and
guidelines from above. However, to reduce the burden of report
preparation, we recommend this provision be modified to require reports
annually or as needed.
Section 201(f) would require VA to submit to the Congressional
Committees on Veterans' Affairs a report on the Secretary's planned
implementation of such measures and guidelines not later than 30 days
before the date on which the Secretary begins implementing the measures
and guidelines required by this section. This subsection sets forth the
required elements of this report.
VA has no objection to this provision. While VHA already has
measures in place, OMHO could submit a report to the Secretary that
outlines descriptions of each measure and current vacancies. Prior to
submitting an assessment of how many additional positions may be needed
to meet demand for services, VHA would need to complete the staffing
model pilot and incorporate revisions to the staffing model based on
the outcome of the pilot.
For those subsections of section 201 with costs, VA estimates the
cost of Section 201 provisions to be $2.3 million in FY 2013; $7.7
million over 5 years; and $9.1 million over 10 years.
Section 202 would limit the individuals who can receive
readjustment counseling from VA, including at Vet Centers, to the
following:
(1) Individuals (Veterans and members of the Armed Forces) who
served on active duty in a theater of combat operations or an area at a
time during which hostilities occurred in that area.
(2) Individuals (Veterans and members of the Armed Forces) who
provided direct emergency medical or mental health care, or mortuary
services to the causalities of combat operations or hostilities, but
who at the time were located outside the theater of combat operations
or area of hostilities.
(3) Individuals (Veterans and member of the Armed Forces) who
engaged in combat with an enemy of the United States or against an
opposing military force in a theater of combat operations or an area at
a time during which hostilities occurred in that area by remotely
controlling an unmanned aerial vehicle, notwithstanding whether the
physical location of such Veteran or member during such combat was
within such theater of combat operations or area.
(4) Individuals who previously received readjustment counseling.
(5) Individuals who are family members of a member of the Armed
Forces who is serving on active duty in a theater of combat operations
or in an area at a time during which hostilities are occurring in that
area.
(6) Individuals who are family members of a Veteran or member of
the Armed Forces described above.
With respect to individuals described in (1) through (4) above, VA
would be authorized to provide counseling to assist in readjusting to
civilian life. For individuals described in (5) and (6) who are family
members of a member who is deployed in a theater of combat operations
or an area at a time during which hostilities are occurring in that
area, VA may provide counseling during such deployment to assist them
in coping with the deployment. For individuals who are family members
of a member or Veteran who is readjusting to civilian life, VA may
provide counseling to them to the degree that counseling furnished to
them is found to aid in the readjustment of the Veteran or member to
civilian life.
Section 202 also would permit licensed and certified mental health
care providers to determine that mental health services are needed to
facilitate a Veteran's successful readjustment to civilian life.
Currently, the law only permits physicians or psychologists to do this.
Section 202 would define the term ``Vet Center'' as a facility
which is operated by VA for the provision of services under this
section and which is situated apart from VA general health care
facilities.
Section 202 would define the term ``family member'' to mean an
individual who is a member of the family of the Veteran or member of
the Armed Forces, including a parent, a spouse, a child, a step-family
member, or an extended family member; or an individual who lives with
the Veteran or member of the Armed Forces, but is not a member of the
family of the Veteran or member of the Armed Forces.
Finally, section 202 would authorize VA to provide for and
facilitate the participation of VA employees who provide services under
this section in recreational programs that are designed to encourage
the readjustment of Veterans eligible for counseling under this
section; and operated by organizations named in or approved by VA to
prepare, present, and prosecute claims for Veterans' benefits.
VA supports this section, which would expand readjustment
counseling services to two new cohorts: (1) Medical, Mental Health, and
Mortuary Professionals who deal with the casualties of war; and (2)
Servicemembers and Veterans who served in positions within unmanned
aerial vehicle crews. Both of these groups represent individuals that
may not have necessarily deployed to combat theaters or areas of
hostilities though still experience firsthand the reality of war and
have their own unique readjustment to civilian life.
There would be no cost associated with this section. These two
cohorts represent a relatively small number of Veterans and
Servicemembers. Furthermore, VA will be augmenting Vet Center staff
around Active Duty military bases, where many of these individuals are
stationed, as a part of the implementation of Section 401, Public Law
111-163 which expands Vet Center eligibility to active duty
Servicemembers who served in OEF/OIF/OND.
Section 203 would authorize VA, subject to the availability of
appropriations, to furnish mental health care to immediate family
members of members of the Armed Forces who are deployed in connection
with a contingency operation through VA medical facilities, !elemental
health modalities, and such community, nonprofit, private, and other
third parties as the Secretary considers appropriate. Family members
would not be eligible for VA payments for beneficiary travel as part of
this care.
VA does not support this provision. These services are currently
provided to family members of deployed Servicemembers by TRICARE or at
a DOD medical facility. It is unclear what additional services would be
offered by VA that are not already provided by TRICARE or DOD.
VA estimates the cost of the provision to be $1.1 billion in FY
2013; $7.6 billion over 5 years; and $19 billion over 10 years.
Section 204 would amend Subchapter 1 of Chapter 73 of title 38 of
the United States Code, to add a new section 7309, which would
restructure the Readjustment Counseling Service (RCS) as a distinct
organization within VHA, and add a new position of Chief Officer with
direct authority over RCS staff and assets, including Vet Centers, who
would report directly to the Under Secretary for Health. It would
establish qualifications standards for Chief Officer, including, in
part, combat Veteran status, psychological doctorates and internships
approved by the American Psychological Association (APA), and minimum
amount of required experience in administering and providing direct
counseling or outreach services. This new section would fund the
activities of RCS, including Vet Centers, through VHA's Medical Care
appropriations, but prohibit allocation of the funds through the
Veterans Equitable Resource Allocation system. Section 7309 also would
require an annual report to Congress on the activities of RCS,
including each Vet Center's workload, additional treatment capacity,
and ratio between FTE employees and individuals served, and detailed
analysis of demand and unmet need for readjustment counseling services
and the plan for meeting such need.
VA does not support this section, which would reorganize RCS within
VHA. RCS is an independent organizational unit within VHA that provides
unique services in a safe and confidential environment not provided at
VA medical center facilities. Its current organizational placement
under the Deputy Under Secretary for Policy and Services allows RCS to
interact with all other clinical programs at the national level, while
maintaining independence at the operational level. This alignment
provides a conduit for coordination and collaboration where services
are similar (e.g. policy development for mental health services that
are common to both RCS and other facilities); it also supports the
alignment of patient needs when primary care or specialty services are
identified.
Section 204 would also establish the statutory qualifications in
the new section 7309 for the Chief Officer position. These include
combat Veteran status, psychological doctorates and internships
approved by the APA, and minimum years of experience in administrating
or providing direct counseling and outreach services. Qualification
requirements for VA's organizational Chief Officers are generally not
set forth in statute. For example, Title 38 does not recognize specific
professional associations for other health care professionals. In
addition, the APA would have the sole authority to determine
satisfactory doctorates and internships. This would conflict with the
Secretary's authority under 38 U.S.C. Sec. 7402(b)(8) to determine, by
policy, whether a particular psychological doctorate or internship is
``satisfactory,'' and would require a statutory amendment before VA
could accept doctorates or internships from other psychological
professional associations. Finally, new section 7309 would establish
the minimum amount of experience required to qualify for the Chief
Officer position. There is no evidence to support that any set time
makes a person more or less qualified to apply for the position. These
provisions could limit VA's ability to recruit and appoint qualified
candidates and result in an unintentional limitation on the sources of
qualified individuals.
There are no costs associated with this section.
Section 205 would require the Secretary to establish a national
program of outreach to societies, community organizations and
government entities in order to recruit qualified mental health
providers on a part-time, without compensation basis under 38 U.S.C.
Sec. 7405. Section 205 would enable VA to partner with or assist in
developing a community entity, including through use of a sharing
agreement under 38 U.S.C. Sec. 8153 that provides strategic
coordination to the societies, community organizations, and government
entities in order to maximize the availability and effective delivery
of their mental health services to Veterans. In carrying out the
national outreach program, VA would train mental health professionals
on military and service specific culture, combat experience, and other
factors unique to Veterans who served in OEF/OIF/OND.
This section would require VA to participate in outreach to recruit
Without Compensation (WOC) Mental Health providers to provide mental
health services on VA's behalf. VA currently has provisions for woe
Employees that require mandatory credentialing and privileging
procedures to assure competency and safety. VHA wants to ensure it has
the ability to set recruitment targets and approve only those
individuals who are qualified to provide mental health services. This
summer VHA will release an accredited Military Culture Training program
that will be available to all community providers, including those who
provide care in the community for Veterans and Servicemembers.
We do not believe that this legislation is needed and we do not
support the widespread recruitment of WOC mental health providers who
are not credentialed and privileged to provide services under our
guidelines. However, VA supports the goal of conducting outreach to
mental health providers who are appropriately qualified to treat our
Nation's Veterans. VA is well positioned to set the appropriate
recruitment and training guidelines that will maintain the integrity
and safety of VA mental health care.
VA estimates costs of $32.4 million for FY 2013; $167.5 million
over 5 years; and $349.8 million over 10 years. Other costs may be
needed, e.g., to run EES training programs for such WOC employees, but
those cannot be estimated at this time.
Section 206 would amend 38 U.S.C. Sec. 7411 to authorize
reimbursement to full-time board-certified physicians and dentists for
certification, recertification, or continuing professional education
(CME) expenses up to $1,000 per year or, in the case of full-time
psychiatrists, up to $4,000 per year.
VA does not support this section, which would create an inequity
among other professionals subject to similar continuing education and
certification obligations.
VA estimates costs for the provision at $24.6 million in FY 2013;
$132 million over 5 years; and $292 million over 10 years.
Section 207 of S. 3340 would require (as opposed to merely
authorize) the Secretary to establish and carry out the peer support
counseling program as provided for in 38 U.S.C. Sec. 1720F(j). Section
207 would also require that the training provided to peer counselors
include the training carried out under a contract with a national not-
for-profit mental health organization for Veterans of OEF and OIF to
provide peer outreach and peer support services. This program would
need to commence at each VA medical center no later than 270 days after
enactment of the Act.
VA does not support this provision. Currently, peer services are
being provided at VA medical centers. In addition, the President
recently signed an Executive Order to improve access to mental health
services for Veterans, Servicemembers and military families. The Order
requires VA to hire and train 800 peer-to-peer counselors to empower
Veterans to support other Veterans and help to meet mental health care
needs by December 31, 2013. Toward this end, new peers will be hired
this fiscal year and throughout the coming fiscal year to enable VHA to
provide these services at all VA medical centers and very large
community-based outpatient clinics (CBOC). VA has developed the
national training program and is currently soliciting bids for
implementation. It is expected that an award will be made this summer
and training will begin this fall.
VA estimates that this provision will cost $27.8 million in FY
2013; $249.4 million over 5 years; and $567.3 million over 10 years.
______
Response to Posthearing Questions Submitted by Hon. Patty Murray to
Madhulika Agarwal, M.D., M.P.H., Deputy Under Secretary for Health for
Policy and Services, U.S. Department of Veterans Affairs
Question 1. Last Congress, we created a pilot program to provide
child care at several VA medical centers for veterans who were coming
in for health care services. I understand that the first site opened in
October 2011, but that the third site is not open for business yet.
Please provide any preliminary assessment of the program, or lessons
learned from the implementation to date.
Response. In October 2011, the Department of Veterans Affairs (VA)
began carrying out a 2-year pilot program to provide child care
services to eligible Veterans at the Buffalo VA Medical Center (VAMC),
and expanded this program to the Northport VAMC in April 2012. The
third selected site, at American Lake, WA, a Division of the VA Puget
Sound Health Care System, is scheduled to open in early fiscal YEAR
(FY) 13. Preliminary information from this program reveals that
Veterans are overwhelmingly supportive of the program and report that
it has made health care more accessible for them. In FY 2012, VA
projects it will spend a little more than $1 million to support the
program. Data from the Buffalo program covers 10 months (October 2011-
July 2012), and Veteran utilization has steadily increased. Buffalo
cared for 108 children in the month of July. The overall monthly
average for the number of children cared for is 61. The program
operates 5 days a week at both the Buffalo and Northport VAMCs. The
Northport VAMC has 3 full months of data available (May 2012-
July 2012), and has experienced high utilization since opening,
providing care to 130 children in the month of July. The overall
monthly average for the number of children cared for is 92.
We have identified contracting and construction issues as
challenges to timely implementation. For example, the Buffalo VAMC
operated under a monthly purchase order until VA awarded a contract on
June 22, 2012. Other delays with construction and contracting have
pushed back the opening of the American Lake site until early FY 2013.
VA officials have learned several valuable lessons from this pilot.
Perhaps most important is that an implementation team comprised of
individuals from General Counsel, Contracting, Public Affairs, and
other offices is essential to timely implementation. The requirement
for an integrated implementation team will be added as experience has
indicated significant delays occurred as each office dealt with issues
such as outreach and contracting sequentially rather than concurrently.
We also receive valuable feedback from Veterans concerning hours of
operation, logistics, implementation, and other elements of the program
via our approved satisfaction survey. Suggestions for improvement are
carefully considered and implemented as appropriate. As the pilot
progresses, we anticipate other lessons learned will be more readily
identified, and we will include this information in our report to
Congress after the completion of the pilot program.
VA has determined that its authority to execute the pilot program
will expire on October 2, 2013, 2 years after the first pilot site
opened in Buffalo. Because not all facilities began providing these
services at the same time, under the current authority, Northport and
American Lake will not be able to operate for a full 2 years. Section
7(a) of S. 3313, the Women Veterans and Other Health Care Improvements
Act of 2012 which currently resides in the Committee, would provide a
technical amendment authorizing the program to run for a period of 2
years beginning on the date the third site is activated. If such an
amendment were made, VA would expand the pilot to additional locations
in FY 2013 to obtain more, valuable information on the costs and
benefits. These sites would be selected based upon interest by facility
leadership, availability of resources, need for child care services
among the Veteran population, and other relevant factors. These
additional locations would provide VA with more data, thereby allowing
VA to provide a better recommendation to Congress on whether the pilot
should be continued or expanded.
Question 2. The Mental Health ACCESS Act of 2012 would make a range
of improvements to mental health services for our servicemembers and
veterans. Among its other provisions, this bill would expand the
availability of mental health services for family members of veterans
and deployed servicemembers. Please discuss the importance of veterans
having good, stable family support when they return home from
deployments, and the extent to which VA can help accomplish this goal.
Response. Family members of Veterans with emotional symptoms and
problems that arise during their military service or post-deployment
face many challenges as they strive to be a significant source of
strength and support for their Servicemember or Veteran family member.
A recent study found that 86 percent of Veterans with Post Traumatic
Stress Disorder (PTSD) view their symptoms as a source of family stress
(Batten et al., 2009). In the case of PTSD, symptoms of emotional
numbing, including difficulties experiencing and expressing positive
and negative feelings, can hinder the ability of the Veteran with PTSD
to feel close or connected to family members (Riggs et al, 1998). Also,
symptoms such as irritability, being easily startled, and having
trouble concentrating or sleeping can contribute to conflict within the
family (Taft et al., 2007). Other issues that can contribute to
relationship and family issues include difficulty with trusting others,
lowering of self-esteem, and problems with power and control.
Family members are an extremely important source of support for
Veterans as they heal. The ability to reconnect and reestablish strong
bonds with loved ones is a critical part of the post-deployment
adjustment and the recovery process. The ultimate goal of family
support is creating and sustaining mutually-satisfying relationships
that bolster the Veteran's successful community adjustment. Research
shows that more than three-fourths of Veterans with PTSD are interested
in more family involvement in treatment (Batten et al., 2009).
Furthermore, the success of treatment for PTSD can be increased if
family members provide the Veteran with social and emotional support.
VA has the ability to provide a number of services, including
several couple- and family-based programs to help families develop the
skills and attitudes to support recovery. VA offers a telephone
hotline, Coaching into Care, for family members to learn effective
strategies to encourage the Veteran to begin or reinitiate VA Services.
Many VA facilities sponsor ``The Support and Family Education (SAFE)
Program,'' which is an 18-session educational workshop for families of
Veterans living with PTSD or serious mental illness. Families may
attend as many sessions as needed. SAFE topics include Communication
Tips for Family Members, Problem-Solving Skills for Families, and
Skills for Managing Stress Effectively as a Family Member. VA also
offers Veteran-Centered Brief Family Consultation (VCBFC), in which the
family meets with a mental health professional as needed to resolve
specific issues related to the Veteran's treatment and recovery. This
intervention is designed to be brief; it usually consists of between
one and five sessions for each consultation. Finally, VA offers more
intensive couples counseling to help Veterans and their loved ones have
more satisfying relationships.
Recently, VA was authorized through section 304 of Public Law 111-
163 to provide services to family members up to 3 years after
deployment to receive readjustment counseling and mental health
services to assist the family member in readjusting after deployment.
These services are available through Vet Centers, as well as at an
increasing number of VA medical centers as new peer support specialists
are hired. Mental health services for family members can be arranged
with community organizations as needed.
References
Batten, S. V., Drapalski, A. L., Decker, M. L., DeViva, J. C., Morris,
L. J., Mann, M. A., & Dixon, L. B. (2009). Veteran interest
in family involvement in PTSD treatment. Psychological
Services, 6(3), 184-189.
Riggs, D. S., Byrne, C. A., Weathers, F. W., & Litz, B. T. (1998). The
quality of the intimate relationships of male Vietnam
veterans: problems associated with Post Traumatic Stress
Disorder. Journal of Traumatic Stress, 11(1), 87-101. doi:
10.1023/A:1024409200155.
Taft, C. T., Street, A. E., Marshall, A. D., Dowdall, D. J., & Riggs,
D. S. (2007). Posttraumatic stress disorder, anger, and
partner abuse among Vietnam combat veterans. [Research
Support, U.S. Gov't, Non-P.H.S.]. J Fam Psychol, 21(2),
270-277. doi: 10.1037/0893-3200.21.2.270
Question 3. A veteran is lost to suicide every 80 minutes, and so
far this year, one servicemember commits suicide per day. One of the
keys to effective suicide prevention is ensuring there is timely access
to care. Often veterans only seek care when they are on the verge of
crisis. If VA turns them away because they are too busy, we have lost
the opportunity to help that individual. Concerns remain whether there
are enough providers in the system.
How can VA use authorities like those provided in the Mental Health
ACCESS Act, along with existing hiring and retention authorities, to
recruit and retain top mental health providers?
Response. In direct support of the Mental Health Hiring Initiative
(MHHI), the Veterans Health Administration (VHA) Workforce Management
and Consulting (WMC) Office, in partnership with the VHA Human
Resources (HR) and Office of Mental Health (OMH), has developed and
implemented a systematic process to recruit, hire, and retain top
mental health providers.
WMC created multiple task forces that target the recruitment and
staffing efforts to bring these new employees into VA as effectively
and efficiently as possible. The Recruitment and Marketing Task Force
provides oversight of the national recruitment and marketing strategies
for MHHI.
Recruitment & Marketing Task Force
Key processes include use of a skilled national team of
professional health recruiters, targeted advertising and outreach,
aggressive recruitment from a pipeline of qualified candidates to
leverage against mission critical mental health vacancies, and
provision of consultative services to Veterans Integrated Service
Networks (VISN) and VA stakeholders.
The National Recruitment Program (NRP) provides VHA with an in-
house team of highly skilled professional recruiters employing private
sector best practices to fill VA's most mission critical clinical
occupations. As of July 16, 2012, the NRP has provided dedicated
recruitment support to 251 mental health positions at the specific
request of VISN/VAMC leadership (primarily psychiatry and psychology).
This team of recruiters has helped hiring managers identify and select
over 100 psychiatrists. One example of their efforts was recruitment at
the American Psychiatric Association (APA) event held May 5-8, 2012, in
Philadelphia, PA, which resulted in identifying 7 psychiatrists who
have received offers, and all are projected to be on board by
September 30, 2012.
The Marketing and Advertising task group has implemented an
aggressive, multi-faceted, sustained national marketing and outreach
campaign to include maximum visibility to rural and highly rural
markets. Completed milestones include:
Spotlight advertisement renewed on USAJobs Web site as of
June 18, 2012. An earlier run resulted in over 8,000 ``click-throughs''
to www.VAcareers.va.gov.
Online banner advertisement currently being run on seven
professional mental health association homepages.
Eleven Web banners currently running through the Joining
Forces partnership and its APA-affiliated networks.
VA has taken these efforts over the past several months and in
previous years to partner with professional associations, societies,
and other health care organizations for the purpose of recruiting
additional mental health providers.
Hiring and Tracking Task Force
The Hiring and Tracking Task Force provides oversight for MHHI.
This team moves the hiring process forward expeditiously in a focused
manner and addresses any issues or concerns immediately while resolving
road blocks to fill each position promptly. This task force provides
daily oversight on the tracking status of each position and
consultative services to VISN Human Resource officers (HRO), OMH, and
VHA recruiters, as needed. This task force tracks the daily progress of
the 1,900 new hires as well as the 2,815 existing vacancies. The task
force conducts daily conference calls with the field H.R. community to
ensure engagement and accountability. Hiring Task Force members
collaborate with VISN HROs to ensure efficiency and flexibility by
implementing specific workflows to enhance timelines:
Recruitment and Retention Incentives
VHA promotes maximized flexibility with, and availability of,
recruitment and retention incentives (relocation, home buy-out, signing
bonuses, student loan repayment programs, etc.) to better attract the
best qualified candidates. VHA collaborates with the Office of Human
Resource Management to reassess current salary tables for psychiatrists
to make these positions more competitive with private industry and DOD.
Provider retention remains a top strategic priority for VHA in its
commitment to maintaining quality services to Veterans. These
incentives permit the staffing and retention of difficult-to-fill
positions with high quality candidates who possess unique skills and
competencies. VA clinical education programs are a crucial resource for
VA's employment pipeline. With over 100,000 trainees rotating through
VA facilities annually, we have a vigorous developmental cohort from
which to recruit new staff in 40 or more disciplines. We know, for
example, that roughly 70 percent of current VA optometrists,
physicians, and psychologists participated in VA training programs
prior to their employment in VA. VA is still reviewing the provisions
of the Mental Health ACCESS Act to determine how those provisions might
complement these efforts.
Question 4. I understand the Department has reviewed each VISN
office and is proposing to reduce the number of staff.
a. How are you posing to change which functions will be performed
by the network offices?
Response. VA recognizes the need to improve the consistent and
efficient use of staffing resources in each VISN office and to ensure
that staffing is aligned with mission and function. To this end, a
workgroup comprised of a small group of VISN directors was chartered in
the fall of 2011 to conduct a review of each VISN office to establish
definitions of core and non-core staff functions, identify targeted
staffing levels, develop an implementation timeline and plan to align
VISN staffing levels, and develop a monitoring mechanism to assure
achievement of target staffing levels. As part of the VISN staffing
alignment process, each VISN was asked to review its organizational
chart and staffing reports, and identify which functions are performed
by whom, which functions are core to the mission of the VISN office,
and describe the basis for consolidating certain functions. The input
provided by the VISNs was evaluated by the workgroup. The workgroup
identified a core set of staff for all VISNs and that plan has now been
approved by the Under Secretary of Health. VHA staff briefed staffs on
the House and Senate Committees on Veterans' Affairs on July 17, 2012.
b. What do you believe is an appropriate number of medical centers
for a network office to oversee?
Response. VISN boundaries were developed originally based on
patient-referral patterns, including aggregations of patients and
facilities that would be needed to support a continuum of primary,
secondary, and tertiary care, and to a lesser extent, to be consistent
with jurisdictional boundaries such as state lines. Every VISN
composition is unique, and the complexity levels of the VA medical
centers, size of patient populations, geographies and regional aspects
vary widely. There is no prescribed number of appropriate medical
centers for a Network Office to oversee. However, currently the maximum
number of health care systems in any one VISN is 11, and that number
does represent the upper limit that would be advisable.
c. When was the last time the Department reviewed the network
boundaries to see if they are still the most appropriate way to
organize the health care system?
Response. The current VISN boundaries were first drawn in 1995 as
part of VHA's ``Vision for Change'' plan for reorganizing the Veterans
Health Administration, which called for the dissolution of the
hierarchical central office, regional office and network structure, in
favor of 22 VISNs with 5-11 medical centers and various other VA
assets. One of the sub-objectives of the VISN boundaries of 1995 was to
achieve a basic budgetary and planning unit for delivery of Veterans
health care, and a means of pooling resources. The last time VA
reviewed the number of VISNs was in 2002, and merged VISNs 13 and 14 to
form VISN 23. When the VISNs were originally formed, there were no
medical foster homes, no ambulatory surgery centers, and hundreds fewer
community-based outpatient clinics, community living centers (nursing
homes), and domiciliaries. VA has subsequently gathered more data on
long-term care and mental health services, as well as for some
inpatient services, because sufficient information was not available at
the time regarding demand for these services and other factors.
Question 5. VA currently has discretionary authority to pay
beneficiary travel for some individual who are not otherwise covered
specifically by law. Given how difficult it can be for veterans who are
blind or have the serious injuries outlined in S. 1755, it would seem
these veterans could use this assistance. How many of these veterans
received beneficiary travel benefits from VA under the existing
authority?
Response. VA does not track beneficiary travel payments by patient
diagnosis. However, historical data indicates that approximately 33
percent of VHA users collect travel benefits. Assuming the same benefit
use rate for the three groups identified in S. 1755, VA estimates the
following beneficiary travel usage based upon workload for FY 2011.
------------------------------------------------------------------------
Beneficiary
Condition VHA Users Travel Users
------------------------------------------------------------------------
Spinal Cord Injury (SCI).................. 20,724 6,839
Amputee................................... 7,088 2,339
Blind..................................... 39,956 13,185
-----------------------------
Total................................... 67,768 22,363
------------------------------------------------------------------------
Question 6. The Department recently set a goal to increase access
to mental health care services through telehealth consultations, and is
working to improve veterans' access to services in rural areas. As you
know, bandwidth capacity in rural areas can be severely limited. Some
medical centers have to prioritize clinical services when networks are
slow in order to protect critical hospital functions. One particularly
vulnerable service is these remote mental health care services are
interrupted. What is VA's plan to ensure each medical center and clinic
involved in the clinic-based telehealth program is properly equipped
and will have enough bandwidth to conduct video consultations?
Response. In anticipation of using telehealth to expand Veterans
access to mental health services (telemental health) and other
specialty care services, VA ensured the necessary support structures
are in place as part of its FY 2011-2012 Expansion Initiative. The
Telehealth Expansion Initiative began in June 2011, and resulted in the
completion of major purchases in all VISNs of clinical
videoconferencing equipment and associated telehealth peripherals and
equipment; and the hiring of Telehealth Program Managers in each VISN
and Telehealth Coordinators at every VAMC. In FY 2012, funding support
continued for these positions and VISNs were provided additional
funding to recruit 1,144 Telehealth Clinical Technicians (TCTs) to
assist clinicians with delivery of telehealth based care, where the
patient and the provider are separated geographically.
As of 3rd quarter FY 2012, this VA initiative has:
Provided more than 3,200 clinical videoconferencing units
for telehealth to all VAMCs and their associated sites of care.
Ensured these sites of care have the necessary
telecommunications capability (``bandwidth''), namely being able to
provide two concurrent clinical video telehealth (CVT) consultations at
384 kilobits/second, in place by September 2012.
Recruited and trained a 1,012 telehealth clinical
technicians (TCT) to assist clinicians in VA medical centers and
community-based outpatient clinics to provide care via telehealth, and
to offer the first line of support in the event of technical problems
with equipment as of June 2012.
Established a national telehealth help desk that provides
immediate access to technical assistance for clinicians and TCTs at all
VA sites of care with expertise to resolve technical problems that TCTs
cannot address on-site.
As a result of this preparatory work VA has the technology
infrastructure and technical support to meet its goals for increased
access to mental health care services through telehealth consultations.
______
Response to Posthearing Questions Submitted by Hon. Scott Brown to
Madhulika Agarwal, M.D., M.P.H., Deputy Under Secretary for Health for
Policy and Services, U.S. Veterans Health Administration
Question 1. Please describe the relationship that currently exists
between VA and the Fisher House Foundation.
Response. Fisher Houses are housing facilities located at, or in
proximity to, a VA medical facility; are available for residential use
on a temporary basis by patients of that facility and their family
members; and are constructed by and donated to the Secretary by the
Zachary and Elizabeth M. Fisher Armed Services Foundation.
VA has 21 operational Fisher Houses with planned expansion to 38 VA
Fisher Houses over the next several years. In 2011, over 11,797
families and caregivers utilized VA Fisher Houses in order to be close
to a Veteran or Active Duty Servicemember during the course of medical
treatment.
VA Fisher Houses improve access to care for Veterans and Active
Duty Servicemembers by providing a supportive environment for family
members and caregivers to stay during their course of medical
treatment. Veterans and Active Duty Servicemembers are more likely to
travel long distances to receive care if their families and caregivers
can accompany them without bearing the burden of costs associated with
hotel lodging. Once donated to VA, it is the expectation of the Fisher
House Foundation that VA Fisher Houses are maintained in pristine
condition, and funding is available to support the costs of
refurbishing, redecorating, and replacing major appliances in VA Fisher
Houses. The corresponding VA medical center is also responsible for
funding all Fisher House operations.
Question 2. In the opinion of VA leadership, how many VA medical
centers or campuses require a Fisher House, and which sites are the
most critical?
Response. VA has a formal process to identify and prioritize VA
medical centers for Fisher House construction. First, VA initiates a
formal call for Fisher House applications.
Applications are evaluated and prioritized based upon the following
criteria:
The availability of services in specialty areas such as
Polytrauma, Spinal Cord Injury, Blind Rehabilitation, Transplant,
Inpatient Palliative Care and Hospice Programs, and Oncology Programs;
VA medical centers serving a large post-9/11 Active Duty
population;
VA medical centers serving large rural catchment areas;
and
The availability of land to construct a VA Fisher House on
or within close proximity to a VA medical center.
The following are locations with an identified need for a Fisher
House:
Michael E. DeBakey VA Medical Center, (second house)--
Houston, Texas
North Florida /South Georgia Veterans Healthcare System--
Gainesville, Florida
Tennessee Valley Healthcare System Murfreesboro Campus--
Murfreesboro, Tennessee
Clement J. Zablocki Veterans Affairs Medical Center--
Milwaukee, Wisconsin
Louis Stokes VA Medical Center--Cleveland, Ohio
VA Long Beach Healthcare System--Long Beach, California
VA Connecticut Healthcare System--West Haven, Connecticut
VA Eastern Colorado Healthcare System--Denver, Colorado
(new medical center)
Orlando VA Medical Center--Orlando, Florida
Omaha-VA Nebraska/Western Iowa Healthcare System--Omaha,
Nebraska
VA Maine Healthcare System--Togus, Maine
VA Caribbean Healthcare System--San Juan, Puerto Rico
New Mexico VA Healthcare System--Albuquerque, New Mexico
Portland VA Medical Center--Portland, Oregon
Southern Arizona VA Healthcare System--Tucson, Arizona
VA continues to assess on a regular basis the need for additional
Fisher Houses, and many VA medical centers have expressed interest in
future Fisher House construction.
Question 3. For those existing VA medical centers and campuses
without a Fisher house, what is the VA currently doing to provide
families with comparable lodging?
Response. VA medical centers provide alternative resources to
accommodate families requiring temporary lodging assistance. These
resources may include providing lodging at a temporary lodging facility
located at a VA health care facility (generally referred to as a
``Hoptel''), or a temporary, non-VA lodging facility, such as a hotel
or motel, funded by a VA health care facility. VA medical centers also
have relationships with community Hospital Hospitality organizations,
such as Ronald McDonald House, to assist with temporary lodging
accommodations for family members as needed.
Question 4. In the absence of legislation, what can VA do within
existing authorities to fund the Fisher House construction on the
grounds of medical centers and campuses?
Response. The construction of VA Fisher Houses is a joint venture
between the Department of Veterans Affairs and the Fisher House
Foundation. Existing statutory authority (38 U.S.C. Sec. 1708) defines
the term ``Fisher House'' as a housing facility that is located at, or
in proximity to, a Department medical facility; is available for
residential use on a temporary basis by patients of that facility and
others described in 38 U.S.C. Sec. 1708(b)(2); and is constructed by,
and donated to the Secretary by, the Zachary and Elizabeth M. Fisher
Armed Services Foundation. Current statutory authority does not
authorize VA to fund Fisher House construction.
Question 5. In 2011 GAO released a report entitled, Homeless Women
Veterans: Actions Needed to Ensure Safe and Appropriate Housing. In
that report, GAO found that VA and HUD lacked information regarding the
characteristic and needs of homeless women veterans at the national,
state, and local levels. What is the VA currently doing to get a handle
on this problem, especially as it relates to understanding the unique
needs of homeless women veterans with children?
Response. Established in 2009 by Department of Veteran Affairs
Secretary, the National Center on Homelessness among Veterans (the
Center), is a multi-site initiative within VISN 4 and 8, with
leadership offices located at the Philadelphia VAMC. As a key component
of VA's National Homeless Programs Office, the Center and its academic
affiliates play a critical role in piloting new innovations and
developing the empirical knowledge needed to improve the care and
quality of life for Veterans who are homeless or at-risk for
homelessness. The Center's goal is to improve services to homeless
Veterans by developing, promoting, and enhancing policy, clinical care
research, and education. The Center is also designed to be a national
resource for both VA and community partners, improving the quality and
timeliness of services delivered to homeless Veterans and their
families. The Center is developing a comprehensive Homeless Registry, a
data warehouse that tracks and monitors homeless program expansion,
operation, and treatment outcomes. The Homeless Registry allows ``real-
time'' access to data by VA providers, program administrators, VAMC
staff, as well as VISN and VHA Central Office leadership to facilitate
performance monitoring and decisionmaking.
The registry enhances VHA's capacity to utilize longitudinal
programmatic and Veteran-specific data to better evaluate how programs
function and how the system as a whole is progressing to end Veteran
homelessness. The registry has the capacity to provide individualized
reports on Veteran characteristics by geographic regions. This new
capacity facilitates VHA's ability to target resources (program funding
and grant funding) to where the need is greatest. Examples include
gender specific, age, and service era data that inform decisions
related to Supportive Services for Veteran Families (SSVF) and
Department of Housing and Urban Development-Department of Veterans
Affairs Supportive Housing (HUD-VASH) programs as well as Grant and Per
Diem (GPD).
VHA has also realigned its data collection about homeless programs
to be more consistent with those in HUD's Homeless Management
Information System (HMIS) standards. VA bed capacity is now entered
into the HMIS bed inventory section to achieve coordinated and complete
data collection of VA resources in HMIS. VA and HUD have collaborated
on a single reporting mechanism of Veteran homelessness in the Veterans
Annual Homelessness Assessment Report (Vet AHAR). These modifications
promote greater consistency in reporting prevalence of Veteran
homelessness both inside and outside of VA.
In June 2012, the Homeless Data Cube became available through the
VHA Support Service Center (VSSC). The Homeless Data Cube provides data
on VA Homeless Services, data analysis, and reporting. The data in the
cube goes back to 2006 through the present and utilizes a variety of
data sources. The Homeless Data Cube contains descriptive and
demographic data on homeless Veterans, including gender, Operation
Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/
OIF/OND) status, etc. The Homeless Data Cube also contains utilization
and outcome data on homeless and at-risk Veterans served within VA.
Finally, the data can be analyzed by program, location (including
national, facility, VISN and state), and fiscal year.
Since 1993, VA has collaborated with local communities across the
United States in Project Community Homelessness Assessment, Local
Education, and Networking Groups (CHALENG) for Veterans. The mission of
CHALENG is to bring together Veterans, representatives from VAMCs and
Veterans Benefits Administration regional offices, community providers
and advocates, local officials, and other concerned citizens to
identify the needs of homeless Veterans and then work to meet those
needs through planning and cooperative action. In 2011, the CHALENG
Veterans survey provided gender specific information, and in 2012, the
community partner survey will include gender specific questions to
increase awareness of women and their families' unique needs.
VA is working with the US Interagency Council on Homelessness,
national Veterans Service Organizations, and Federal, state, local and
community partners that serve homeless and formerly homeless women
Veterans and children to capture the needs of homeless women Veterans.
Chairman Murray. Thank you very much. We really appreciate
the VA's testimony today. I just have a couple of questions I
am going to ask and then I will submit the rest for the record
because we want to make sure we have time to get to the second
panel today, and I know there are a number of Committee Members
here who want to ask you questions as well.
Let me just begin. The witnesses on the next panel are
going to talk about VA's fertility treatment options for
seriously injured veterans. Their testimony, when taken
collectively, is resoundingly clear. VA's fertility treatment
options fall short for our veterans with very severe injuries.
Unlike the Department of Defense, the VA is prohibited by
regulation from offering IVF. I wanted to ask you today, is the
VA considering lifting the ban?
Dr. Agarwal.
Dr. Agarwal. Thank you for the question, Madam Chairman.
Consistent with VA's goals to improve health and quality-
of-life for veterans, we do offer certain infertility
treatments and diagnostic tests including genetic counseling.
However, regulation in 1999 did exclude IVF services from
VA's defined medical benefits package. DOD in April this year
has defined and clarified implementation guidance on provision
of IVF services for certain categories of servicemembers, and
the VA is reviewing its regulatory options and your Women's
Health Bill, which was introduced on June 19, and we will work
with you and your staff to bring about what needs to happen.
Chairman Murray. Well, the VA cannot offer much in the way
of care for spouses. What does that mean for couples who need
extra assistance conceiving a child because of the war injury?
Dr. Agarwal. Thank you again for this question, Madam.
Congress has generally restricted eligibility of health care
services in VA to spouses. There are some rare exceptions such
as in CHAMPVA.
S. 3313 is aimed at expanding that authority to include
infertility management for spouses under some circumstances
when the veterans injury has precluded their ability to
procreate naturally. We do not have our position on this yet
but are reviewing it and again look forward to working with you
and the Committee.
Chairman Murray. I appreciate it. On our second panel we
are going to have some compelling testimony. I hope that the
Members of our Committee are able to hear what I have been
hearing as well on this.
I also wanted to just mention the Mental Health ACCESS Act
of 2012, which I have introduced. I want to stress we need
comments back from the VA very urgently on this. This is going
to expand the availability of mental health services for family
members of veterans and deployed servicemembers.
As we talked about, the VA currently has very limited
authority to provide service to family members. So, I would
appreciate your comments back on that as soon as you can as
well.
With that, let me turn it over to Senator Burr for any
questions he has.
Senator Burr. I thank the Chairman.
Mr. Secretary Schoenhard, VA's written testimony states
that the VHA has, and I quote, already reviewed each VISN
headquarters, is in the process of working with each to
streamline operations, create efficiencies internal to each
VISN and to realign resources.
Has General Shinseki been briefed on what that realignment
is going to look like?
Mr. Schoenhard. Ranking Member Burr, yes, he had been
briefed, and we are still in the process of discussion and
evaluation.
Senator Burr. When does the Secretary plan to approve those
recommendations?
Mr. Schoenhard. Sir, we should be having this accomplished
here in the coming weeks. We look forward to briefing you and
your staff.
Senator Burr. Will we be briefed before the Secretary signs
off on it or after the Secretary signs off on it?
Mr. Schoenhard. Sir, I think we would brief you after the
Secretary signs off.
Senator Burr. Does the Committee play any part in this
process?
Mr. Schoenhard. Sir, we would very much appreciate the
opportunity to brief you and the members of your staff and any
Members of the Committee regarding our work.
Senator Burr. Before or after the Secretary signs off?
Mr. Schoenhard. Sir, I think we would like to further
evaluate and review our work and then sit with you, Sir.
Senator Burr. In the 17 years since Dr. Kaiser created the
VISNs, there has been a significant growth in the number of
VISN headquarters staff. The original plan called for 220 full-
time workers, full-time employees. Yet, the current staff is at
1,340.
Do you anticipate the staff level in VISN reorganization to
be cut?
Mr. Schoenhard. Sir, we do. Let me just, if I can, just
back up and say we have done a systemic review of the function
of the VISN, and I think that you will be seeing reductions in
our staff as a result of this effort.
Senator Burr. Well, I just was taken a little bit aback by
the Under Secretary's comments that my legislation was too
prescriptive. I am not sure how you can set up an
administrative structure without it being prescriptive.
Mr. Schoenhard. Yes, sir.
Senator Burr. You have got to design what it is over, what
its mission is, and hopefully what the staffing is; and that
is, in fact, what I put in my legislation.
Is that what your review is going to do?
Mr. Schoenhard. Yes. We have looked at the core function of
a VISN, the core staff required to accomplish that mission, and
I think that our focus has been with the end in mind what is it
that a VISN should do as the main operating vehicle for
accountability and leadership to address all of the concerns we
have heard this morning regarding care to rural veterans, care
and mental health and the rest, to do that in a way that is
population health based, is based on the veterans in that
location with sufficient span of control to accomplish that
mission and to serve veterans.
Senator Burr. I look forward to the opportunity for you and
I to get together.
Mr. Schoenhard. Yes, sir.
Senator Burr. Sooner rather than later.
Mr. Schoenhard. Yes, sir.
Senator Burr. Mr. Murphy, you addressed the Second
Amendment issue. If individuals, let me ask you this. How many
veterans' names have been turned over to NICS? How many are
currently on that list?
Mr. Murphy. I do not have the details on the number of
names that are currently on their list. I can tell you the
details around the number of requests for relief or removal
from the list.
Senator Burr. How many names have been requested to be
relieved?
Mr. Murphy. 185, Senator.
Senator Burr. How many have been granted?
Mr. Murphy. A total of 19.
Senator Burr. That is out of 127,000 names that have been
turned over on the NICS list?
Mr. Murphy. Correct. I am assuming your numbers are
correct. I do not have those in front of me.
Senator Burr. Trust me, they are.
Mr. Murphy. OK.
Senator Burr. If individuals seek relief from the NICS
reporting requirements, does the VA assist them in coming up
with the evidence needed to show whether they are dangerous?
Mr. Murphy. Yes, Senator, we do.
Senator Burr. What do you do?
Mr. Murphy. The Duty to Assist Act requires us to fully
develop the case. This is not a light matter in the Veterans
Administration. This is a fully adjudicated, fully developed
claim with a full decision letter, with an explanation of how
the decision was arrived at with all supporting evidence and
documentation provided to them.
Senator Burr. Are there any veterans that are determined
incapable to handle their own personal finances whose name is
not put on the NICS list?
Mr. Murphy. Let me make sure I understand the question. Are
there veterans who----
Senator Burr. You have somebody that has determined that a
veteran cannot write a check. So, they cannot handle their
finances. They have now assigned to a spouse to be in charge of
the finances.
Is there anybody that that has happened to that that
veteran was not then listed on the NICS list?
Mr. Murphy. I can say that they are not supposed to be. I
am not saying that through administrative process for errors
that it had not occurred.
Senator Burr. My understanding, and I will get you to go
back and clarify this if I am wrong, every veteran who is
relieved of their financial or deemed that they cannot handle
their own finances is automatically put on the list.
Mr. Murphy. They are placed on the list by the Veterans
Administration. Yes.
Senator Burr. So, what are the qualifications of the VA
employees who make the decisions about whether veterans and
their families should be stripped of their Second Amendment?
What training do these people go through?
Mr. Murphy. I do not believe we have an option in this,
Senator. We are directed----
Senator Burr. You have VA employees that are making a
decision on whether somebody is capable of doing their own
personal finances. That determination that they are not capable
of doing that strips them of their Second Amendment right. It
is very simple.
What training does that VA employee go through to be
qualified to make a determination that would strip somebody of
their constitutional rights?
Mr. Murphy. Our employees, our adjudicators are trained in
determining whether or not that veteran is capable of making
the financial determinations they have with the funds that the
Veterans' Administration provides to that individual.
As a result of that decision, they are placed on the NICS
list. It is not a determination whether the individual is
capable of handling firearms or not. It is, can they manage
their personal finances or not.
Senator Burr. I know. But when they go on the NICS list,
they are now deprived of firearm ownership.
Mr. Murphy. That is correct.
Senator Burr. OK. So, a determination that they cannot
handle their personal finances strips them of their Second
Amendment right and also, the way that it is written, it
forbids any firearm to be handled by anybody in the household.
So, you, in essence, strip the spouse of the Second
Amendment right. You strip children of the Second Amendment
right because you have determined that a veteran cannot handle
their own personal finances.
Are we in agreement?
Mr. Murphy. We are.
Senator Burr. OK. I do not want to make this too
simplistic. But if a veteran cannot sign their name to a check
and the VA determines that their spouse should be assigned the
financial responsibilities because you are transferring money
into an account, do we agree that that would trigger their
listing on the NICS list and they would lose their Second
Amendment right as well as everybody else in the household?
Mr. Murphy. That is one I need to ask Mr. Hipolit to verify
for me because I am unaware of the requirement for other
members of the household's restriction to own firearms.
Mr. Hipolit. Yes, that is correct as well. I was also
personally not aware of the household restriction. I know that
if VA determines that the person is incapable of handling their
financial affairs, that does get them on the NICS list.
Senator Burr. But you would agree, Mr. Hipolit, that a
determination that they cannot handle their finances has a wide
definition to it?
Mr. Hipolit. I would say that if VA determines that they
are unable to handle their finances, that does qualify them to
get on the NICS list and their names are referred for the list.
Senator Burr. That is not necessarily a mental
determination. It could be a physical determination, correct?
If they are not capable of handling their finances.
Mr. Hipolit. If they had a physical disability that
impaired their ability to handle their financial affairs.
Senator Burr. So, they are automatically classified as
dangerous?
Mr. Hipolit. Our determination is just whether they can
handle their financial affairs and then that automatically
triggers the requirements to refer their names.
Senator Burr. So, would you agree that the purpose of the
NICS list which is to take guns away from dangerous people and
the threshold that VA currently uses to determine who goes on
the NICS list are potentially two very different things?
Mr. Hipolit. I think that the law enforcement agencies
determined who should be put on the NICS list, and they
determined that person is found to be----
Senator Burr. But they do not in the case of veterans. In
the case of veterans, the only person that determines whether
they go on the NICS list is the VA, and it is determined based
upon are they capable of handling their own personal finances.
Mr. Hipolit. Well, the law that requires us to make the
referral is a regulation from the----
Senator Burr. And you are the only agency in the Federal
Government that across-the-board sends every person that is not
qualified to handle their personal finances to the NICS list?
Are you aware of that?
Mr. Hipolit. That is not my understanding. It is my
understanding that other agencies refer people as well.
Senator Burr. Other agencies refer people but they have a
different threshold for the ones that they refer. I think they
might use the definition of dangerous, and what I have heard
you say is dangerous does not come into play. Mental capacity
does not come into play. Capability of handling your own
personal finances is the only threshold, and when they hit
that, they are automatically put on the NICS list.
Mr. Hipolit. From the VA standpoint, if they are determined
not to be able to handle their financial affairs, we have to
refer them for the NICS list.
Senator Burr. I hate to dig in on this. I just want to
point out to you that the threshold is very, very different at
VA. There are many veterans, spouses, and family members who
are deprived of their Second Amendment rights to own firearms
based upon an arbitrary decision by somebody at VA that they
cannot handle their own personal finances.
These people are all of a sudden labeled as dangerous when,
in fact, the decisions may have been a physical disability that
did not permit them to handle their own finances. I hope this
is something the Committee will look at. I am actually shocked
that the Veterans' Affairs Committee is not outraged at the way
this is being implemented. 127,000 of our country's veterans
are stripped of a constitutional right. Some probably should.
Many of those 127,000 should have never had their right taken
away.
I thank the Chair.
Chairman Murray. Senator Boozman.
Senator Boozman. Just really quickly to follow up. So, the
process is that they are deemed where they need help in
handling their finances.
How do they become aware that they are on the list? Do you
send him a letter, explaining again that all the guns in the
house need to go out and all that?
I guess what I am saying is do the people who are actually
on the list know that they are on the list----
Mr. Murphy. It is actually more extensive than that,
Senator.
Senator Boozman [continuing]. And the ramifications of what
has happened to them.
Mr. Murphy. There is a decision made and with the
appointing of a fiduciary comes a VA employee actually visiting
the veteran's home, talking with the veteran, explaining to the
veteran, and ensuring that they are in a safe environment for
that veteran to be living.
Mr. Hipolit. Under the NICS Improvements Act, there was a
notification requirement put in. Before VA declares somebody
incompetent, we have to make them aware that that would affect
their ability to possess and buy a firearm. So, there is a
notification requirement.
Senator Boozman. Of the 18 that were reversed, how long did
it take to go through the process?
Mr. Murphy. The number of days to complete is 187.
Senator Boozman. 187 days?
Mr. Murphy. Yes, sir.
In that, there are some requirements to allow veterans time
notices with time to respond, multiple 60-day periods. So, in
order to provide due process to the veteran to fully develop
their rights under this in the appeals process 187 days.
Senator Boozman. Did you say 18 had been reversed?
Mr. Murphy. It is 19, Senator.
Senator Boozman. 19.
Mr. Murphy. Yes, sir.
Senator Boozman. So, the average of those was 187 days?
Mr. Murphy. Correct, to get reversed.
Senator Boozman. What was the longest?
Mr. Murphy. I do not have the details on the spread. If you
would like, I would be more than happy to provide those for
you.
Senator Boozman. What would you guess?
Mr. Murphy. The 187 days average includes some of the
veterans for us just starting this process. So, what I would
say that that number would be higher than what the average if I
just looked over the last few cases that went through.
So, the first few veterans that went through going through
a new process took a little bit longer time and pushed it
beyond that 187 days. But I believe that the next time I appear
before you, if you asked me this question, it is going to be
some number below that 187.
Senator Boozman. Thank you, Madam Chair.
Chairman Murray. Thank you. Senator Burr, do you have a
question?
Senator Burr. Madam Chairman, just one follow-up question
to Mr. Murphy because you said that you were under duty to
assist.
Mr. Murphy. That is correct, Senator.
Senator Burr. I have got this memo from the Department of
Veterans Affairs, dated November 22, 2010, and it says that the
duty to assist as demonstrated in an order and examinations for
securing private medical records do not apply in this program.
Mr. Murphy. Well, Senator, then I was in error.
Senator Burr. OK. I just wanted to make sure we were on the
same sheet. Thank you.
Mr. Murphy. I did bring three documents today. I understand
how important this is to you, so what it is is our Fast Letter,
the specific instructions to the field for the relief process.
In addition to that, I have two redacted decision letters: one
that was granting the relief; and one that was denying the
relief. If you would like to see those, Senator, I would make
those available to you.
Senator Burr. Let me just ask the Chair if she would make
them available for the record?
Chairman Murray. I will do that.
[The letters referred to follows:]
Senator Boozman. Madam Chair, can I just ask one other
thing quickly?
Chairman Murray. Yes, Senator Boozman.
Senator Boozman. In regard to Senator Ayotte, you know,
with her bill and the cemetery issue in the Philippines, can
you all comment about that?
I guess, you know, one of the things that we are so proud
of when you go overseas and you see the--we are the only Nation
in the world that really does that, you know, that takes such
good care of our veterans. That really distinguishes us instead
of the mass graves and this and that. We have done such a
tremendous job. Tell me about, you know, rectifying that or if
you feel like we need to rectify it, specifically what the
problem is, how we got into this situation.
Mr. Murphy. That is a bill, well, the picture is shown
there and VA's understanding of exactly the condition of that
specific cemetery, that is a bill that falls clearly under the
American Battle Monuments Commission, and we have to defer to
their input on that bill.
Mr. Hipolit. I would add that the National Cemetery
Administration maintains cemeteries within the United States
and the Commonwealth of Puerto Rico. We do not have overseas
cemeteries. The American Battle Monuments Commission
traditionally maintain the overseas cemeteries.
Senator Boozman. So, is this particular cemetery in a
Catch-22 situation where it does not have anybody who has
claimed it because I suspect if it fell under their--if they
felt like it fell under their jurisdiction, they would be
taking care of it.
Mr. Hipolit. I cannot speak for them, but I think as of
this time no Federal agency has responsibility for that
cemetery.
Senator Boozman. Can we say that you all are committed to
helping to work that out where there is a claiming of the
cemetery so we can do the appropriate thing?
Mr. Hipolit. Our position is that we need to defer to the
American Battle Monuments Commission because that would be more
within their jurisdiction then within VA's. I can see that
those pictures were quite moving of the current condition of
the cemetery, and I can fully understand the concern over it.
Senator Boozman. Good. Thank you very much.
Chairman Murray. Thank you very much.
With that, I would like to thank this panel. I do have
additional questions I will submit for the record because I
want to leave time for our second panel today. So, thank you
again very much.
Dr. Agarwal. Thank you.
Chairman Murray. With that, I like to call up our second
panel; and as we are changing out positions here, I am going to
introduce them.
We are going to be joined today by Tracy Keil. She is the
wife of a paralyzed veteran, as well as Dr. Mark Thomas Edney,
who is an Operation Iraqi Freedom veteran and a urologist who
is representing the American Urological Association.
Speaking on behalf of VetsFirst today is Vice President of
Veterans Policy, Heather Ansley. Rounding out this panel is Joy
Ilem. She is the Deputy National Legislative Director of the
Disabled American Veterans.
Before I turn to the testimony from this panel, I also want
to take a moment to thank retired Staff Sergeant Andrew
Robinson for joining us today. He is in the audience.
Andrew was injured in 2006 when a roadside bomb threw him
from the truck that he was in. Like Tracy, who we will be
hearing from in just a moment and her husband Matt, Andrew and
his wife Sarah also went through some very challenging times
and had to use in-vitro fertilization to conceive there now 6-
month-old twins I understand.
Andrew, I want to thank you for your service to the
country, and thank you for driving down to be here with us
today for this important legislative hearing.
All of your statements will be entered into the record, and
I really do appreciate all of your testimony today.
Ms. Keil, I am going to start with you and thank you so
much for your courage in coming speaking to our Committee
today. So we will begin with you.
STATEMENT OF TRACY KEIL, CAREGIVER AND
SPOUSE OF AN OIF VETERAN
Ms. Keil. Good afternoon, Chairman Murray, Ranking Member
Burr, Members of the Committee. Thank you for inviting me to
share my family's experiences with you today.
My husband, Staff Sergeant Matthew Keil, was shot in the
neck while on patrol in Ramadi, Iraq, February 24, 2007, just 6
weeks after we were married.
The bullet went through the right side of his neck, hit his
vertebral artery, went to his spinal cord, and exited his left
shoulder blade. Matt instantly became a quadriplegic.
When I first saw him 3 days after he was injured, I was in
shock. They explained to me that he had a Christopher Reeves-
type injury. He was on a ventilator for the rest of his life,
and he would never move his arms or legs.
Matt and I looked at each other in the hospital room at
Walter Reed, and he asked me if I still loved him. I told him,
baby, you are stuck with me. At that moment, we knew that we
would be OK if we stayed in it together.
I knew that we just needed to work really hard to get Matt
off his ventilator and increase his life expectancy so that we
could live out our dreams.
Ultimately, we moved to Craig Hospital in Denver to be
closer to our families. Four weeks to the day of arriving at
Craig Hospital, Matt was officially off his ventilator, and we
could truly concentrate on him doing physical rehabilitation.
Matt was able to regain 10 percent function of his left arm
but not his hand. He was feeling good and getting used to his
new normal of being a wheelchair and asking for help for
everything. It was while we were at Craig Hospital that we
started talking about having a family.
The Craig doctors talked to us about in-vitro
fertilization, letting us know that that would be most likely
the only way we could conceive. We started to get really
excited that even though so much had been taken away from Matt
physically that we could still have the future that we always
dreamed up.
We had our whole lives ahead of us. Matt was just 24 when
he was injured, and I was 28. We were very fortunate that he
survived his injuries that day, and we made a promise to each
other on our wedding day, for better or for worse, in sickness
and in health; and we meant every word and we still do today.
It is a challenge for my husband and I every day, but we
knew we still wanted a family. I remember back when he was in
rehab at Craig and all we could talk about was when we were
going to be adjusted to our new normal and when we will be
ready to have children. We always knew since the day we met
that we wanted to have kids.
In 2008, we moved into a fully accessible home built for us
by Homes For Our Troops, and we started filling like things
were falling back into place in our lives. We felt like we were
getting back on track to where we were before he was injured.
However, his injury ultimately, unfortunately, prevents him
from having children naturally. In mid-2008, I started asking
the VA what services they could offer my husband and I to
assist us with fertility. I remember hitting roadblocks at
every turn, and I decided to take things into my own hands.
At one point, I was leading 12 women whose husbands were
injured, writing letters, and making phone calls, and trying to
get anyone to listen to us that we really needed help.
Fertility treatments are very expensive; and since I had
left my full-time job, we were still trying to adjust living on
one income. I felt helpless and hopeless that our dreams of
having a family may never come true.
The VA did finally say that they would cover the sperm
withdrawal from my husband and that costs around $1,000 and
that they would store it for us at no charge. However, they
could not offer me anything.
It is very difficult to put into words the emotions that I
felt when I found out there was no help available for us from
the VA or TRICARE. I felt very defeated, sad, disappointed and,
in some ways, I felt helpless.
I researched everything I could about how to get TRICARE to
cover some of the costs, but they could not because it was a
direct result of my husband's injuries and that fell under the
VA. The VA said they had no programs in place for this sort of
thing. I even started asking nonprofits to assist with the cost
and they could not help due to the other immediate needs of
injured servicemembers.
In January 2010, my husband and I decided that we needed to
move forward with our plans to start a family and we began our
journey of fertility treatments. We selected a doctor in the
private sector that has been a leader in IVF. We were fortunate
that the best fertility doctor in the world is right in our
town.
Having a doctor located near our home was helpful because I
had to go every other day and then daily near the time of the
transfer. This made it very easy for my husband to be there
with me every step of the way.
I was on several medications that I took every day along
with injections into my stomach three times a day. I would go
to the doctor every other day for blood draws to check my
hormone levels and make sure everything was progressing
normally.
Each time I would be at the fertility clinic I was charged
anywhere from $250 to $650. TRICARE did not cover any of these
costs of anything related to the fertility treatments because I
did not have any fertility issues myself. Everything was a
direct result of my husband's injuries.
We are fortunate that Matt and I got pregnant on our first
try with IVF. We welcomed our twins Matthew and Faith November
9, 2010. As you can see from the attached photographs, they are
happy, healthy, and they love riding around with their dad.
As a couple who had already sacrificed so much for our
country, I do not believe we should also have to give up on our
dream of having a family. Fertility treatments are not a
guarantee of having children, but it does give us hope.
It gives us hope that we can have a normal life just like
everyone else. Part of living the American dream for us was
having a home to raise our children and, of course, having the
children to fill our home.
Now we have both, and while it is incredibly difficult to
raise children while your husband is in a wheelchair, it is
possible. We are living proof that anything is possible.
This is exactly the way our family is supposed to be. I
strongly believe that my husband is supposed to be in a
wheelchair. I cannot tell you why but this is the life that we
are supposed to be living, and it is what it is supposed to
look like. We are happy. We are healthy, and we are living out
our dreams.
Now that my husband is retired, we are able to raise our
children together as stay-at-home parents. We are a team and my
only wish is that other families could find this happiness. One
of the things I love the most about having children now is that
their dad is just their dad. They do not see the wheelchair.
They make him feel like the man he was before he was injured,
and they complete our life together and the kids have helped
fulfill our dreams that we had when we got married and started
our life together.
I would like to emphasize this statement. Wartime changes a
family. It should not take away the ability to have one.
I hope that hearing our story today has helped you
understand the importance of offering fertility treatments to
injured veterans who have lost the ability to reproduce
naturally.
I have always wanted more than anything for my husband to
feel whole again. There is no magical cure for spinal cord
injury. There is nothing out there that will help him walk
again or move his arms.
However, Congress, the VA, and the American people have
said countless times that they want to do everything they can
to support him and other wounded warriors. This is your chance
to honor his sacrifice and others like him. Having a family is
exactly what he needed to feel whole again.
Please help us make these changes so that other families
can share in this experience, and I also ask that you turn to
the last page of my written statement and look at the photos I
have provided. This is the face of a truly recovered injured
veteran.
Thank you for your time and I look forward to your
questions.
[The prepared statement of Ms. Keil follows:]
Prepared Statement of Tracy Keil, Caregiver and Spouse of OIF Veteran
Good Afternoon. Chairman Murray, Ranking Member Burr, Members of
the Committee, thank you for inviting me to share my family's
experience with you today.
My husband, Matt, was shot in the neck while on patrol in Ramadi,
Iraq, on February 24, 2007, just 6 weeks after we were married. The
bullet went through the right side of his neck, hit his vertebral
artery, went through his spinal cord and exited through his left
shoulder blade. Matt instantly became a quadriplegic. When I first saw
him 3 days after he was injured I was in shock, they explained to me
that he had a ``Christopher Reeve type injury.'' He would be on a
ventilator for the rest of his life, and would never move his arms or
legs.
Matt and I looked at each other in his hospital room at Walter Reed
and he asked me if I still loved him? I said ``baby you're stuck with
me!'' at that moment we knew that we would be OK if we stayed in this
together. I knew that we just needed to work really hard to get Matt
off his ventilator to increase his life expectancy. Ultimately we moved
to Craig Hospital in Denver to be closer to family support.
Four weeks to the day of arriving at Craig Hospital in Denver, Matt
was officially off of his ventilator and we could truly concentrate on
him doing physical rehabilitation. Matt had regained about 10% function
of his left arm but not his hand. He was feeling good and getting used
to his new normal of being in a wheelchair and asking for help for
everything.
It was while we were at Craig hospital that we started talking
about having a family. Craig doctors talked to us about invitro
fertilization and recommended some doctors for us to speak to when we
were ready to start a family. We started to get really excited that
even though so much had been taken away from Matt physically that we
could still have the future we always dreamed of.
My husband is the most amazing man I have ever met. He is strong,
honest and loyal, and he wanted us to both have everything we always
wanted before his injury and we agreed that this injury wasn't the end,
it was the beginning of a new life, and we were in this together.
We had our whole lives ahead of us. Matt was just 24 when he was
injured and I was 28. We are very fortunate that he survived his
injuries that day and we made a promise to each other on our wedding
day ``For better or worse, in sickness and in health.'' I meant every
word and still do today. It is a challenge for my husband and me every
day, but we knew we still wanted to start a family. I remember back
when he was in rehabilitation at Craig Hospital it's all we could talk
about was when we were going to be adjusted to our new normal and when
would we be ready to have children. We always knew we had wanted
children.
In 2008 we moved into a fully handicap accessible home built for us
by Homes For Our Troops. We were starting to feel like things were
falling into place in our lives. We felt like we were starting to get
back on track to where we were before Matt was injured.
His injury unfortunately prevents him from having children
naturally. In mid 2008 I started asking the VA what services they could
offer my husband and I to assist us with fertility. I can remember
hitting road blocks at every turn. I decided to take things into my own
hands and write letters and make phone calls to try and get anyone to
listen to us that we needed help. Fertility treatments are very
expensive and since I had left my full time job we were still adjusting
to living on one income.
I felt helpless and hopeless and thought that our dreams of having
a family may never come true. The VA finally said that they would cover
the sperm withdrawal from my husband * * * that costs $1,000 and that
they would store the sperm for us at no charge.
It was very difficult when I found out there was no help available
for us from the VA or TRICARE. I felt very defeated, sad, disappointed
and in some ways I felt helpless. I researched everything I could about
how to get TRICARE to cover some of the costs but they couldn't because
it was a direct result of my husbands' injury and that fell under the
VA. The VA said that they had no programs in place for this sort of
thing. I even started asking non profits to assist with the cost and
they couldn't help due to the other immediate needs of injured
servicemembers.
I am very pleased that this issue is being addressed because it is
necessary for the success of the families. We shouldn't have to
struggle with how we are going to pay for costly fertility treatments
when they are a direct result of a combat injury. We already have so
many adjustments to make to all of our hopes and dreams and plans. We
should never have to contemplate whether or not to even have children
because of how expensive fertility treatments can be. I have always
wanted more than anything for my husband to feel whole again. There is
no magical cure for a spinal cord injury, there is nothing out there
that will help him walk again or move his arms. What we do have though
is a strong voice. We can help other families just like ours so they
don't have to go through what we went through.
In January 2010 my husband and I decided that we needed to move
forward with our plans to start a family and we began our journey of
fertility treatments. We selected a doctor in the private sector that
has been a leader in IVF. Having a doctor located near our home was
very important for us because I had to go to the doctor every other day
and then daily near the time of the transfer. This made it very easy
for my husband to be there with me every step of the way. I was on
several medications that I took 3 times a day along with giving myself
hormone injections into my stomach three times a day for several weeks.
I would go back to the doctor every other day for blood draws to check
my hormone levels to make sure everything was progressing normally.
TRICARE did not cover any of the costs of anything related to the
fertility treatments because I did not have any fertility issues,
everything was a direct result of my husbands' injury.
Matt and I were very fortunate that we got pregnant on our first
try with IVF. We welcomed our twins Matthew and Faith on November 9,
2010.
Fertility treatments are not a guarantee of having children, but it
gives us hope. It gives us hope that we can have a normal life just
like everyone else. Part of living the American Dream for us was having
a home to raise our children * * * and of course having the children to
fill our home. Now we have both and while it is incredibly difficult to
raise children while your husband is in a wheelchair it is possible. We
are living proof of anything is possible.
To be honest, not walking is the easy part. The hard part is that
it affected every single aspect of our lives. Matt requires assistance
with almost everything. As his caregiver, I feed him, bathe him, dress
him, get him in and out of bed, I am the sole driver in our household,
I even assist him with changing the channel on the TV. He has lost
almost all independence. The day we had our children something changed
in both of us. This is exactly what we had always wanted, our dreams
had arrived. While it may be challenging to care for my husband and my
children, this is exactly what our family is supposed to be. I strongly
believe that my husband is supposed to be in a wheelchair, I can't tell
you why, but this is what our life is supposed to look like. We are
happy, we are healthy and we are living out our dreams. Now that my
husband is medically retired we have the ability to raise our children
together as stay home parents. We are a team and my only wish is that
other families could find this happiness.
Since having our children I see my husband light up again, I see
him happy, fulfilled. He is truly living the American Dream. I cannot
imagine where we would be if we didn't save money knowing we would need
to do IVF in the future.
One of the things I love the most about having children now is that
their dad is just their dad. They don't see the wheelchair. They will
be kind to people with disabilities and more understanding. All of the
injured veterans who have children are helping share with others that
people with disabilities are just like everyone else, they just do
things a little differently. My husband is a shining example of a
wonderful father who loves his children and we would have done anything
possible to have them.
They make him feel like the man he was before he was injured, they
complete our life together and the kids have helped fulfill our
American dream. The VA, Congress and the American People have said
countless times that they want to do everything they can to support my
husband or make him feel whole again and this is your chance. Having a
family is exactly what we needed to feel whole again. Please help us
make these changes so that other families can share in this experience.
If the VA does decide to begin offering fertility treatments I
think it's important to note that this is a very personal issue.
Selecting a doctor to perform these treatments was very personal for my
family and we didn't want to use ``just anybody.'' We wanted to go to
the best. I think it would be wonderful to let the private sector help
these men and women start their families and do their part to help
injured servicemembers. This way if the families choose, they can go to
a private sector doctor to have these services performed. I know that
it is a challenge for my family to drive to the VA on a daily basis for
treatments. Sometimes families can find something closer to their homes
to make things easier. We have to remember that we are talking about
the most severely injured veterans that encounter fertility issues due
to their injuries, so doing whatever is easiest for the family is
extremely important.
Fertility is an area where we need experts in the field with
extensive experience. Those doctors are already set up in private
practices across the country. I think it would be very beneficial to
the families to fee base the fertility specialist of their choice.
There is also the option of capping the benefit at a certain amount of
money or a certain amount of rounds of fertility treatments. As family
of a severely injured veteran, I do not expect taxpayers to pay for
every single thing we could ever wish for, so putting a limit on the
fertility amounts is certainly understandable and expected.
There are about 600 men and women who have returned home with
damage to their reproductive ability. Today I ask you to please support
these brave servicemembers in their dream to have families. I am here
today to say that this injury took away so much of my husband
physically that he cannot get back, but we could not let this injury
take away our dream of a family. Having children meant that we were
back to where we were before he was injured. It brought a sense of
accomplishment and fulfilled our dreams of a family. In some ways it
made my husband feel whole again.
I hope that hearing our story today has helped you understand the
importance of offering fertility treatments to injured veterans who
have lost the ability to reproduce naturally. What happened to them is
by no fault of their own. Wartime changes a family, it shouldn't take
away the ability to have one.
Thank you for your time.
Chairman Murray. Ms. Keil, thank you so very much for your
courage in speaking out for so many others. I have been looking
at the pictures. They are actually in front of me. I am sorry
the audience cannot see them. They are absolutely adorable.
And you are right. That is truly compelling. So, thank you
very much for being here today.
Dr. Edney, we will turn to you.
STATEMENT OF MARK THOMAS EDNEY, M.D., OIF VETERAN, MEMBER,
LEGISLATIVE AFFAIRS COMMITTEE OF THE AMERICAN UROLOGICAL
ASSOCIATION
Dr. Edney. Chairman Murray, Ranking Member Burr, Members of
the Committee, honored guests, fellow servicemembers, I thank
the Committee on Veterans' Affairs for inviting me to testify.
My name is Mark Edney. I am a Urologist, a physician who
treats genitourinary disease and injury. I am also an Army
Reservist.
It is an honor and privilege to be able to testify before
the Senate Committee on Veterans' Affairs in support of Senate
3313. My testimony has the support of many organizations
dedicated to this issue, including the American Urological
Association, The Men's Reproductive Health Alliance, the
American Fertility Association, and the Men's Health Network,
and others, many of whom are represented in the room today.
I am a husband and the father of three children, ages 10,
7, and 5 years. In my 10 years of reserve service, I have been
called back to duty three times: first to Walter Reed Army
Medical Center in 2004, next a combat tour with the 399th
Combat Support Hospital in Mosul, Iraq in 2006, and finally a
tour at Tripler Army Medical Center in Hawaii in 2009.
I have seen and treated genitourinary injury in the theater
of operations, and I have also participated in its chronic
management in our largest military medical centers.
It is important to understand the breadth of the types of
injuries that can occur that threaten fertility. The most
common mechanism of injury to the genitourinary organs in
theater right now is blast effect from improvised explosive
devices and also from gunshot wounds.
The most common types of male genitourinary injuries are
testicular rupture, penile shaft, urethral and bladder injury.
Blast injuries to the phallus often result in erectile
dysfunction or render it otherwise incapable of intercourse.
Urethral injuries often result in scar tissue, preventing
the release of semen. Shrapnel often penetrates the perineum,
the area that includes the sexual organs and the rectum.
Even with proper current protective gear, the perineum is
exposed. In these instances, the external sexual organs may be
preserved, but injury can occur to the pelvic portion of the
tissue cylinders responsible for normal function.
Damage can also occur to the nerve and vascular supply
responsible for normal function. Damage anywhere in the sperm
delivery system may result in the absence of sperm in the
semen.
There are a range of female injuries that can result from
fertility problems. Blast injury can occur to the perineum and
the vaginal vault which precludes intercourse. Shrapnel or
bullet penetration of the pelvis can injure the ovaries,
inhibiting egg development and delivery. Damage to the
fallopian tubes easily results in a lack of ability to transmit
the egg to the uterus.
Overall genitourinary injuries comprise five to 10 percent
of wounds suffered in battle, but they can be some of the most
psychologically debilitating.
Spinal cord and Traumatic Brain Injury are two major
classes of non-neurologic injury that can also impede utility
through sexual dysfunction in men.
There are also non-ballistic threats to women's
reproductive health in theater. A recent survey of female
soldiers revealed that there can be a lack of confidence of the
unit level health care providers with respect to competence in
women's health issues and concerns around confidentiality
leading to avoidance of care seeking.
There are underappreciated psycho-social issues with female
family separation that can have both psychological and
physiological effects that lead to sexual dysfunction and
fertility issues.
The issue of military sexual trauma which can have a
profound impact on sexual function and fertility continues to
be addressed military-wide through the sexual harassment,
assault response and prevention program.
To support these issues, S. 3313 has critical provisions
that improve female--the female veterans call center and expand
the counseling of women upon separation from the military.
Given the many ways that injured soldiers can return to
their home units, their civilian life, and their families with
fertility-threatened injuries, the question becomes how are we
willing to help them.
Though genitourinary is not publicly visible, it is no less
physically or psychologically debilitating than loss of limb or
other overtly disfiguring injury. Professionals who specialize
in fertility will attest to the intense psychological pain and
suffering endured by infertile couples who will go to great
financial and emotional extremes in order to conceive a child.
S. 3313 contains powerful provisions that provide access to
advanced reproductive technologies for fertility impaired
soldiers, their spouses, and surrogates.
Intrauterine insemination or IUI and in-vitro fertilization
or IVF are the advanced reproductive techniques that S. 3313
makes available.
IUI is the deposition to process sperm into the uterine
canal to then finish the normal cycle of fertilization. It is
used when female anatomy is intact at and above the cervix but
when any number of the injuries I have mentioned preclude
delivery of sperm to the uterine cavity.
IVF is employed when the injury or combination of injuries
precludes the normal meeting of sperm and egg. Fertilization is
achieved in the laboratory. Then the fertilized eggs is then
replanted back into the uterus for normal gestation.
If the uterus has been rendered incapable of sustaining a
pregnancy, a surrogate can be engaged for the pregnancy of the
natural parents fertilized egg.
It is noteworthy that the substantial cost of an IVF cycle
in the private sector where battle injury infertile VA couples
now must turn is on the order of $20-30,000 per cycle with
success rates of 20 to 40 percent per cycle. Multiple cycles
are often necessary.
The expertise and technology exists within the VA and the
DOD for a fraction of the cost. We just need S. 3313 to unlock
it for these most deserving Americans.
There is a desperate need to establish a research database
of soldiers with genitourinary injury to better study the
continuum of care from prevention to initial management to
reconstruction and to fertility treatment and outcomes.
Senator Murray's bill takes a critical step in calling for
the Department of Defense and the NIH to conduct collaborative
research to address the long-term reproductive health care
needs of veterans with service-connected reproductive injuries.
Also to this end, I want to bring to the Committee's
attention H.R. 1612, which has been reintroduced this session
with the sponsorship of Congressman Brett Guthrie and 25
cosponsors in the House.
The bill, promulgated by the American Urological
Association, sets up a national commission on uro-trauma. The
16-member commission, which is a collaboration of the
Departments of Defense, Veterans Affairs, and Health and Human
Services, will be a sunset commission with defined objectives.
They are in summary, one, to study the current state of
knowledge from prevention to initial management to chronic
therapy. Two, to identify public and private resources that can
be brought to bear for fertility-impaired soldiers. Three, to
identify care enhancing programs of potential benefit to the
genitourinary injured soldier.
The bill is described in more detail in my written
testimony, and I would be happy to discuss it further with any
Members of the Committee who might be interested in supporting
it.
We as a Nation have done better recently at addressing the
physical disability that results from war injury.
Appropriately, hundreds of millions of dollars have been
dedicated to the research and development of prosthetics to
return soldiers with loss of limb to a higher degree of
physical ability. We are getting better at detecting and
addressing the psychological wounds of war from PTSD and
dramatic brain injury.
There is an important group who have been left behind.
Those suffering the publicly invisible but intensely
emotionally painful loss of fertility as the result of
genitourinary injury.
Let us together show these finest Americans that we are
willing to go beyond our current efforts of physical and
emotional support. Let us use the expertise and tools that we
have in place today to restore their fertility so that they may
1 day look into the eyes of their own children and see the
family history, the pride, and hope for the future that so many
of the rest of us have been blessed to know.
We owe these brave Americans no less for the sacrifices
they have made for our great Nation.
I thank the Committee again for the privilege and honor of
being asked to testify.
[The prepared statement of Dr. Edney follows:]
Prepared Statement of Mark T. Edney, M.D., F.A.C.S., Army Reservist,
Operation Iraqi Freedom Veteran and Member, Legislative Affairs
Committee, American Urological Association
Chairman Murray, Ranking Member Burr, Members of the Committee,
honored guests, fellow servicemembers, I thank the Committee on
Veterans' Affairs for inviting me to testify.
It's an honor and privilege to testify before the Senate Committee
on Veterans Affairs in support of Senate Bill 3313. This Bill provides
critically needed support for soldiers within the Department of
Veterans Affairs who have suffered fertility-impairing trauma in
battle. My comments have the support of many organizations that have
tangibly dedicated themselves to the care, rehabilitation, and
restoration of fertility to soldiers who have suffered urogenital and
other forms of trauma that threaten fertility. These organizations
include the American Urological Association, The Men's Reproductive
Health Alliance, the American Fertility Association, and the Men's
Health Network. This is by no means an exhaustive list of the
professional organizations and patient advocacy groups with a vested
interest in this subject, many of whom are represented in the room
today.
I am a Urologist, a specialist who treats genitourinary disease and
injury, in private practice in Salisbury, MD. I am a husband and the
father of three children 10, 7, and 5 years old. I am also an Army
Reservist of 10 years. I have been called to active duty 3 times: first
to Walter Reed Army Medical Center in 2004, one tour with the 399th
Combat Support Hospital in Mosul, Iraq in the winter of 2006, and
finally a tour at Tripler Army Medical Center in 2009. I have seen and
treated genitourinary trauma in the theater of operations and have
participated in its chronic management at our largest military medical
centers stateside.
To begin, a brief review of the mechanics of natural human
fertilization may be helpful. The testicle produces two elements
essential to fertility: sperm and testosterone. After going through the
stages of maturation, sperm leave the testicle through a series of
tubes (the epididymis and vas deferens) and wait temporarily in the
section of vas deferens that enters the prostate gland (ejaculatory
duct). When ejaculation occurs, the supporting fluid (semen), is
released from the seminal vesicles, sperm is released from the
ejaculatory ducts (emission), and the mixture is propelled forward to
be deposited in the vagina. Sperm then begin their journey across the
cervix, into the body of the uterus. Eventually a very small percentage
of the original populations make it to the fallopian tube to meet the
egg which upon penetration of a single spermatozoon, is then
fertilized. The fertilized egg (zygote) then implants in the wall of
the uterus for the remainder of gestation.
Normal female physiology is as follows: Eggs mature in the ovaries
and once per cycle, an egg (oocyte) is released into the fallopian tube
and begins its migration toward the body of the uterus. If it
encounters a sperm on the way and becomes fertilized, the resulting
zygote (fertilized egg) implants into the wall of the uterus and
gestation ensues. If not, the oocyte is expelled and the process
repeats on a monthly basis.
It's important to understand the breadth of types of injuries that
result in threats to fertility. The most common mechanism of injury to
the genitourinary organs in Operation Iraqi Freedom and Operation
Enduring Freedom is blast effect from improvised explosive devices
(IEDs), followed by gunshot wounds. The most common types of male
genitourinary injuries, sometimes seen in isolation, but commonly in
combination are: testicular rupture (unilateral or bilateral), penile
shaft/pendulous urethral injury, posterior urethral injury, and bladder
injury. Spinal cord injury and Traumatic Brain Injury are two major
classes of non-urological injury that can impede fertility through
ejaculatory dysfunction. If testicular rupture injuries present within
a few hours as most do with current evacuation systems, salvage is
possible with rates of up to 74% reported recently. Bilateral
testicular loss is a devastating injury that obviously precludes future
fertility.
Blast injuries to the phallus often result in either erectile
dysfunction or otherwise render it mechanically incapable of
intercourse to achieve a natural pregnancy. Urethral injuries of either
the pendulous or posterior aspect often result in stricture (scar
tissue) formation that renders ejaculation either impaired or
impossible. Schrapnel often penetrates the perineum, the area that
includes the sexual organs and rectum. The perineum, even with proper
use of the current protective gear, is unprotected. In these instances,
the external sexual organs may be preserved but injury can occur to the
portion of the erectile bodies (the tissue cylinders in the penis
responsible for erection) that attach to the pubic bones or to the
nerve and vascular supply responsible for erectile function. Even if
the testicles are uninvolved or salvaged after a schrapnel injury,
damage to the ductal system anywhere from epididymis to ejaculatory
duct may result in lack of sperm delivery to the ejaculate.
There is a groin-protective garment that is issued to soldiers as
they are deployed. It is a triangular shaped shield that attaches to
the front of the Improved Outer Tactical Vest (IOTV). Its design and
location, however, are felt by many soldiers to be cumbersome and to
inhibit mobility and so it is not worn by many. There is a critical
need to invest in the research and development of protective gear for
the genital organs that is effective and practical for the tactical
environment.
Blast or gunshot wounds to the female pelvis can also result in a
variety of fertility-impairing injuries. Trauma to the perineum and
vagina can easily result in an altered vaginal vault that renders
intercourse impossible. Additionally, penetrating schrapnel injury to
the female pelvis can disrupt the ovaries, fallopian tubes, body of the
uterus or the vaginal vault. Fallopian tube injuries can preclude the
normal passage of the egg and therefore prevent fertilization. Uterine
injury can result in a uterus incapable of sustaining a pregnancy which
then opens the issue of surrogacy.
Women also experience non-ballistic risks to maintenance of
reproductive health while in theater. A recent white paper developed by
the Army's Women's Health Assessment Team identified several barriers
to optimal genitourinary health for female soldiers in theater. These
included lack of secure facilities for women to attend to personal
hygiene. There is in some instances a lack of confidence in unit-level
health care provides with respect to competence in women's health
issues and concerns around confidentiality leading to avoidance of
care-seeking. There are underappreciated psycho-social issues with
female family separation that can have both psychological and
physiological effects that lead to sexual dysfunction and fertility
issues. The issues of military sexual trauma, which can have profound
impact on sexual function and fertility, continue to be addressed
military-wide through the Sexual Harassment/Assault Response and
Prevention (SHARP) program. S. 3313 seeks to meet these needs in two
critical ways. First, by increasing the number of retreat-style
counseling opportunities for returning female soldiers, and second, by
improving the functionality of the female veterans' call center.
Given the many ways that injured soldiers can return to their home
units or civilian life and their families with fertility-threatening
injuries, the question becomes how are we willing to help them? Though
genitourinary trauma is not publicly visible it is no less physically
or psychologically debilitating than loss of limb or other overtly
disfiguring injury. Procreation is one of the most fundamental of human
instincts.
The range of male and female injuries described above can all
result in the inability for couples to achieve a pregnancy in standard
fashion. That's where advanced reproductive technology is brought to
bear and where S. 3313 will have an immediate and profound impact for
fertility-impaired soldiers, and their spouses. The advanced techniques
are specifically intrauterine insemination (IUI) and in-vitro
fertilization (IVF). IUI involves processing sperm that have been
obtained either from the ejaculate or harvested from the testicle or
epididymis, and implanting them directly into the uterus to complete
the remainder of the natural fertilization process. In-vitro
fertilization (IVF) is the process by which sperm and egg are united in
a controlled laboratory environment and post-fertilization the zygote
is placed in the uterus for implantation. IUI is employed when female
anatomy is intact and functional from the cervix up, but either a male
or female injury precludes depositing a requisite number of sperm into
the vagina. As IUI is less technology and labor intensive, it is also
less expensive per cycle. IVF is employed when a male and or female
injury precludes the natural union of sperm and egg in the fallopian
tube for any number of the reasons mentioned above. In cases where the
uterus has been rendered incapable of sustaining a pregnancy, a
surrogate can be engaged to carry the fertilized egg for the natural
parents. More labor intensive than IUI, IVF also costs more but it is
important to note that the cost per cycle of IVF in government
facilities is tens of thousands of dollars less than in the private
world, where VA couples are now forced to seek care at $20-30,000
dollars per cycle. The per-cycle success rate depends on a variety of
factors including age. Pregnancy rates range between 20 and 45% per
cycle and live birth rates range between 10% and 30% per cycle.
An important provision of S. 3313 provides treatment to the spouse
of the injured soldier. It's important to understand the concept of
sub-fertility. It is possible that a soldier with a fertility impairing
injury, given a normally functioning partner, could still conceive
naturally. Should the partner, however, have a condition resulting in
sub-fertility (low sperm count, low sperm volume for men or hormonal
cycle variables or minor anatomic variation for women), the partner
under S. 3313 would be eligible for treatment.
Currently the Department of Defense as of April 2012 (DOD
instruction 1300.24) provides for advanced fertility treatment for
soldiers who have suffered genitourinary injury. This DOD policy is a
start but as currently written only covers those soldiers with the most
severe general injury status who may be infertile. There are soldiers
in the DOD who may have suffered isolated genitourinary injury and
despite their infertility may remain functional in their MOS and this
class of soldiers is not covered for infertility care under current
policy. It's important that the Department of Veterans Affairs create
policy based on ``infertility injury'' and not a more general injury
scale so as to capture every soldier who has been rendered infertile
from battle injury. Every soldier with battle injury infertility
deserves access to advanced reproductive technology.
There is a desperate need, not only within the Department of
Veterans Affairs but including the Departments of Defense and Health
and Human Services to fund a longitudinal, prospective database of
soldiers with genitourinary injury to better study the continuum of
care from prevention, to initial management in theater, to
reconstruction at higher levels of care to fertility treatment and
outcomes. S. 3313 takes a critical step in calling for the Dept of
Defense and NIH to conduct collaborative research to address long-term
reproductive health care needs of veterans with service-connected GU/
reproductive injuries. Also to this end, I want to bring to the
Committee's attention H.R. 1612 which has been re-introduced this
session with the sponsorship of Congressman Brett Guthrie along with 25
co-sponsors in the House. The Bill, promulgated by the American
Urological Association, seeks to establish a National Commission on
Urotrauma. The 16 member Commission, a collaboration of the Departments
of Defense, Veterans Affairs, and Health and Human Services, will be a
sunset Commission with defined objectives as follows: 1) To conduct a
comprehensive study of the present state of knowledge of the incidence,
duration, and morbidity of, and mortality rates resulting from
urotrauma and of the social and economic impact of such conditions; 2)
To evaluate the public and private facilities and resources (including
trained personnel and research activities) for the prevention,
diagnosis, and treatment of, and research in such conditions; and 3) To
identify programs (including biological, behavioral, environmental, and
social programs) in which, and the means by which, improvement in the
management of urotrauma can be accomplished. The Bill has been scored
at a nominal cost and the offset has been identified. I would be happy
to discuss the Bill further with any Members of the Committee who would
like to learn more and perhaps support it.
There is a wealth of expertise and the infrastructure is in place
within the Department of Veterans Affairs and Department of Defense to
provide soldiers with fertility-impairing injuries comprehensive
management so that they may have their own children. S. 3313 unlocks
that capability for soldier in the VA system to protect them from the
$20-30,000 per cycle fees in the private sector where they now by
necessity seek treatment. This is a wrong that S. 3313 rights. We as a
nation have done better recently at addressing the physical disability
that results from war injury. Appropriately, hundreds of millions of
dollars have been dedicated to the research and development of
prosthetics to return soldiers with loss of limb to a higher degree of
physical ability. We are getting better at detecting and addressing the
psychological wounds of war from PTSD and Traumatic Brain Injury.
There's an important group who have been left behind: those suffering
the publicly-invisible but intensely emotionally painful loss of
fertility as a result of genitourinary injury. Let's together show
these finest of Americans that we are willing to go beyond our current
efforts of physical and emotional support. Let us use the expertise and
tools that we have in place today to restore their fertility so that
they may one day look into the eyes of their own children and see the
family history, pride, and hope for the future that so many of the rest
of us have been blessed to know. We owe these brave Americans no less
for the sacrifices they have made for our great Nation.
Chairman Murray. Thank you very much, Dr. Edney.
With that, let us now turn to Ms. Ansley please.
STATEMENT OF HEATHER ANSLEY, M.S.W., VICE PRESIDENT OF VETERANS
POLICY, VETSFIRST
Ms. Ansley. Thank you. Chairman Murray, Ranking Member
Burr, and distinguished Members of the Committee, thank you for
inviting VetsFirst to share our views and recommendations
regarding the legislation that is the subject of this morning's
hearing.
My oral testimony will focus on our support for the Mental
Health ACCESS Act of 2012. First, however, I would like to take
a moment to highlight our support for some of the other bills
included in today's hearing that are of particular interest to
our members.
Specifically, we support S. 3313, which has been discussed
already today. S. 1838, regarding service dog training, and
S. 1755 concerning coverage for rehabilitation services for
certain veterans.
Each of these bills is critically important to allowing
disabled veterans to live in their communities full, healthy
lives. Our comments on these and other bills before the
Committee are included in our written testimony.
The chair of the VetsFirst Committee who was on the Hill
with me yesterday spent 16 months at the Bronx VA in the late
1960s after acquiring a spinal cord injury and he recently told
me that during those 16 months he had one visit with a
psychologist.
The visit ended rather abruptly when he told the
psychologist that he was thinking about returning to grad
school. The psychologist shut the folder and wished him well.
Thirty-six years later, after becoming a quadriplegic, he
finally sought the mental health counseling that he needed to
deal with the emotional and mental consequences that any type
of serious injury brings.
Although the services of the Bronx VA have greatly improved
since that time, we want to make sure that another generation
of veterans do not have problems accessing VA mental health
care.
Through VetsFirst work with the Consortium for Citizens
with Disabilities, CCD, which is a coalition of over 100
national consumer, service-provider, and professional
organizations that advocate on behalf of people with
disabilities, we are working to expand our efforts and working
with members of the disability community, the veterans
community, and mental health communities to engage in efforts
to address these concerns.
To expand our efforts, we are working with the Mental
Health Liaison Group, MHLG, which is a coalition comprised of
national behavioral health organization's that represents
consumers, family members, advocates, professionals, and
providers and advocates on behalf of people with until health
or substance use issues.
We highlighted our concerns about wait times for
appointments and asserted our belief that clinicians might need
to be given the time and resources to provide patients with
evidence-based therapy in a letter that we sent to VA earlier
this year.
We have also expressed that VA should leverage the full
range of certified mental health professionals that are
available. We are pleased that VA has reached out toward us
regarding our concerns, and we welcome the opportunity to
continue working with VA and appreciate the outreach to both
CCD and MHLG including the Vietnam Veterans of America, the
American Foundation for Suicide Prevention, Mental Health
America, and VetsFirst, who are the members of the coalitions
that are leading this outreach effort with VA.
The remainder of my comments on the Mental Health ACCESS
Act of 2012 reflect the views of VetsFirst and my comments
addressed only Title II which directly concerns VA.
Access to quality mental health care is critical in
ensuring that veterans are able to successfully reintegrate
into their communities. We appreciate the requirement in this
legislation for a VA to develop a measure of access to health
care that will evaluate the timeliness, satisfaction, capacity,
and availability of furnishing evidence-based therapies.
We also support the requirement that VA develop a
comprehensive staffing model that will include productivity
standards. Requiring the VA to work with the National Academy
of Sciences to create a study committee to advise in the
development of these guidelines and measures will provide a
heightened level of expertise. The mandates for transparency
that require posting this information online will increase
accountability.
To increase access, we also support expanding eligibility
for Vet Centers services which is a positive step for
servicemembers, families, and veterans.
As we all know, Vet Centers are vital links to care for
many who might not otherwise seek services. The role that Vet
Centers plays an important role in the delivery of this care.
We support this legislation expansion of eligibility as long as
Vet Centers are properly resourced to meet the needs that they
are designed to address.
Although VA must have sufficient resources to meet the
mental health needs of our Nation's veterans, we also believe
that the scope of the need requires VA to link with community
resources.
We support the requirement for VA to carry out a national
program of outreach to connect with community mental health
resources which represents a good opportunity to mobilize
qualified providers in a concerted effort to organize
clinicians who meets VA requirements and that will help to
expand service capacity.
In addition to community resources, peer support counselors
are also an important component of the mental health delivery
system. The counselors serve as a useful vector for helping
individuals to seek more formal types of care and that
establishing one of these programs at each VA medical center
will ensure the availability of these services to as many
veterans as possible.
Again, thank you for the opportunity to share VetsFirst's
views on this legislation. This concludes my testimony and I
will be pleased to answer any questions that you may have.
[The prepared statement of Ms. Ansley follows:]
Prepared Statement of Heather L. Ansley, Esq., M.S.W., Vice President
of Veterans Policy, VetsFirst, a program of United Spinal Association
Chairman Murray, Ranking Member Burr, and other Distinguished
Members of the Committee, Thank you for the opportunity to testify
regarding VetsFirst's views on the bills under consideration today.
VetsFirst represents the culmination of 60 years of service to
veterans and their families. United Spinal Association, through its
veterans service program, VetsFirst, provides representation for
veterans, their dependents and survivors in their pursuit of Department
of Veterans Affairs (VA) benefits and health care before VA and in the
Federal courts. Today, United Spinal Association is not only a VA-
recognized national veterans service organization, but is also a leader
in advocacy for all people with disabilities.
women veterans and other health care improvements act of 2012 (s. 3313)
After a decade of war, many severely disabled veterans who have
experienced trauma related to improvised explosive devices and other
conditions of warfare may experience infertility. For many veterans,
the ability to start or grow their families represents an important
part of moving forward with their lives. Unfortunately, the current
services available from VA in many cases do not reflect the needs of
these veterans and their families.
Presently, VA provides male veterans who have spinal cord injuries
with fertility services for retrieving, storing, and preparing sperm
for use for assisted reproductive technology. These services are
available to male veterans who are service-connected and also for those
who have access to VA health care but whose disabilities are not
related to their military service. Although VA provides these services
for male veterans who have spinal cord injuries, there is no provision
to provide the assisted reproductive technologies needed for
fertilization.
The Women Veterans and Other Health Care Improvements Act takes
important steps toward assisting veterans, their spouses, and
surrogates in holistically addressing infertility. VetsFirst supports
the addition of fertility counseling and treatment, including treatment
using assisted reproductive technology to the definition of medical
services. We are also pleased that this legislation not only expands
the definition of medical services to include these treatments, but
also provides them to veterans' spouses or surrogates. We are
disappointed, however, that these services are not required for
veterans who are not service-connected.
We appreciate the requirement for the promulgation of regulations
to implement these new statutory requirements. To provide a level of
certainty to veterans and their spouses, it will be important for VA to
develop a non-inclusive list of the types of technologies that will be
provided (at a minimum) by VA. It must also be clear to veterans and
their spouses or surrogates whether VA will provide services related to
subsequent costs of pregnancy and post-partum care.
This legislation also requires VA to facilitate collaborative
research with the Department of Defense (DOD) and the National
Institutes of Health which will help VA to address the long-term
reproductive health needs of veterans. This research will be critical
in addressing the unique infertility issues of veterans with combat-
related injuries. We are also pleased that the legislation requires
that the research be disseminated within the Veterans Health
Administration to guide treatment practices.
VetsFirst also supports efforts in the legislation to improve
access to VA services for women veterans. Women make up an increasing
percentage of the veteran population. Consequently, VA must improve
efforts to address the unique needs and concerns of women veterans.
Otherwise, women may be hesitant to take advantage of their benefits.
MENTAL HEALTH ACCESS TO CONTINUED CARE AND ENHANCEMENT OF SUPPORT
SERVICES (ACCESS) ACT OF 2012
The need to access high quality VA mental health services when
needed is critically important for our Nation's veterans and their
families. After a decade of war, the number of veterans who need mental
health services due to Post Traumatic Stress Disorder and other wounds
related to their service has greatly increased. Veterans from previous
wars also continue to need mental health care services which allow them
to be vital contributors to their communities and families.
The difficulty of some veterans in accessing VA mental health care
services in a timely manner has been detailed in numerous hearings
before this Committee over the last year. The report from VA's Office
of Inspector General regarding access to mental health care that was
released on April 23, 2012, highlighted concerns about appointment
times and the lack of accurate performance data. Aside from the
statistics, we are acutely aware of the sheer human toll of war as
reflected by the number of servicemembers and veterans who are
committing suicide on a daily basis.
As an organization that is both a veterans service organization and
a disability organization, we are very concerned about the ability of
veterans to have timely access to evidence-based therapies. Through our
work with the Consortium for Citizens with Disabilities (CCD),
VetsFirst is working with members of the disability, veterans, and
mental health communities to engage in efforts to address these
concerns. Specifically, representatives of the CCD Veterans and
Military Families Task Force and the Mental Health Liaison Group (MHLG)
have been meeting regularly to better determine how we might work with
VA to improve access to mental health services for our Nation's
veterans.
CCD is a coalition of over 100 national consumer, service provider,
and professional organizations which advocates on behalf of people with
disabilities and chronic conditions and their families.
The MHLG is a coalition comprised of national behavioral health
organizations representing consumers, family members, advocates,
professionals, and providers which advocates on behalf of individuals
with, or at risk of, a mental health or substance use condition,
including servicemembers, veterans, and their families.
On April 5, the CCD Veterans and Military Families Task Force and
MHLG sent a letter signed by 41 member organizations to VA expressing
our concerns about the delay in veterans receiving VA mental health
services. In this letter, which is included with our testimony, member
organizations highlighted our concerns about wait times for
appointments. We also asserted our belief that clinicians must be given
the time and resources to provide veterans with evidence-based
therapies that represent the best practices for addressing veterans'
specific needs. Last, we asserted that VA should leverage the full
range of certified mental health professionals, including psychiatric
social workers and licensed professional counselors, to increase access
to these best practice therapies.
We are pleased to report that VA reached out to us regarding our
concerns, and we look forward to growing our partnership to ensure that
our Nation's veterans have access to needed mental health services. We
welcome the opportunity to continue working with VA and appreciate the
outreach to CCD and MHLG, including Vietnam Veterans of America, the
American Foundation for Suicide Prevention, Mental Health America, and
VetsFirst who are the member organizations leading the outreach effort.
The remainder of VetsFirst's comments on the Mental Health ACCESS
Act of 2012 reflect our individual views. For purposes of our
testimony, we are limiting our comments to Title II--Department of
Veterans Affair Matters.
Access to quality mental health care is critical in ensuring that
veterans are able to successfully reintegrate into their communities.
To ensure that access standards are being met, VA must develop
comprehensive measures that accurately determine whether proper access
to services is being provided. We appreciate the requirement in this
legislation for VA to develop a measure of access to health care that
will evaluate timeliness, satisfaction, capacity, and availability and
furnishing of evidence-based therapies by VA. We also support the
requirement that VA develop a comprehensive staffing model that will
include productivity standards.
The development of access measures and staffing guidelines for
mental health care is crucial to meeting the mental health care needs
of veterans. Requiring VA to contract with the National Academy of
Sciences to create a study committee to advise in the development of
these guidelines and measures will provide a heightened level of
expertise. We also support the requirement for the study committee to
assess the mental health needs of our newest veterans. The mandates for
transparency through reporting and posting the measures and guidelines
online will help to facilitate accountability.
Expanding access to Vet Centers is a positive step in efforts to
address the mental health care for veterans, servicemembers, and their
families. Vet Centers are a critical link to care for many veterans who
might not otherwise seek services. The role that Vet Centers play in
the delivery of this care is crucial. Thus, the services and supports
provided by Vet Centers must be available when needed by these
individuals. We support this legislation's expansion of eligibility for
services as long as Vet Centers are properly resourced because of the
great need for readjustment services by servicemembers and their
families.
We also support the proposed organization of VA's Readjustment
Counseling Service. We appreciate the inclusion of language stating
that, ``The Readjustment Counseling Service is a distinct
organizational element within Veterans Health Administration.'' We are
also pleased that the Chief Officer of the Service will have direct
authority over staff and assets and that its budget request will be
listed separately. The autonomy of the Service contributes to its
successful outcomes and outreach to veterans.
Although VA must have sufficient resources to meet the mental
health needs of our Nation's veterans, the scope of the need requires
VA to fully utilize any available resources that will properly meet
these needs. Requiring VA to carry out a national program of outreach
to connect with community mental health resources represents a good
opportunity to mobilize qualified providers. A concerted effort to
organize clinicians who meet VA requirements will expand the capacity
of VA services. We are also pleased that the legislation requires
training in military culture to ensure that these providers are able to
better meet the needs of veterans.
In addition to community resources, peer support counselors are
also an important component of the mental health delivery system. These
counselors serve as useful vectors for helping individuals to seek more
formal types of mental health care. Requiring that peer support
counseling programs be established at each medical center will ensure
the availability of these services to as many veterans as possible.
We believe that the steps taken in Title II of this legislation
will strengthen VA's ability to serve veterans, servicemembers, and
their families.
To require VA to consider the resources of individuals applying for
pension that were recently disposed of by the individuals for
less than fair market value when determining the eligibility of
such individuals for such pension (S. 3270)
VA's pension program provides benefits for veterans who are low-
income and are either permanently and totally disabled, or age 65 and
older, if they served during a period of war. These benefits are
critical for veterans who have few other resources available to them.
Because these benefits are very important to low-income disabled
veterans, we believe that these benefits must be protected to ensure
that they are fully available when needed. As a result, we do not
condone fraudulent efforts to benefit from the VA's pension program. We
also believe, however, that people should not have to impoverish
themselves just to receive the services that they need whether in VA's
program or any other government benefits program.
The look-back proposed in this legislation seeks to preempt efforts
to transfer assets to make veterans eligible for pension benefits.
Without commenting further on the specific merits of this proposal, we
are concerned that the legislation does not exempt transfer of assets
to special needs trusts. Special needs trusts are designed to
supplement the services and supports received by people with
disabilities through Social Security and Medicaid. The funds in a
special needs trust may be used for expenses such as modifying a home
for accessibility, paying for recreational activities, or purchasing
tickets to visit family. If the funds were made directly available to
the individual, then he or she may lose eligibility for Supplemental
Security Income (SSI) benefits and Medicaid services and supports,
which are income dependent. By placing the funds in a special needs
trust, parents can ensure, for instance, that their disabled children
retain eligibility for these crucial benefits and services.
A good example illustrating the importance of special needs trusts
is found in the current quandary with the DOD survivor benefit plan
(SBP). An SBP annuity allows for retiring servicemembers to make a
portion of their retired pay available to their survivors. However,
Federal law requires that these benefits must be paid to a ``natural
person.'' Thus, if a child with a disability is in receipt of income
dependent services and supports, then the child may lose these benefits
and services because SBP funds cannot be paid to a special needs trust.
Unfortunately, the amount received from the annuity may not be
sufficient to pay for the services lost. Thus, the child not only loses
eligibility for the services but then is unable to pay for them
privately.
In the November 2011 edition of Exceptional Parent Magazine, Kelly
A. Thompson, an attorney, relayed how this dilemma played out for one
adult child with a disability.
``A recent example concerns a 52 year-old man with an
intellectual disability who had lived in a group home for 18
years and attended a day program for individuals with
disabilities. His only income was SSI of $674 per month. His
SSI benefits and Medicaid paid for his programs and services.
However, when his father, a retired Navy officer, died, his
adult son began to receive military SBP in the amount of $2,030
per month. This SBP payment made him ineligible for Medicaid
waiver services. The private pay cost of the programs and
services he was receiving prior to his father's death is $8,600
per month, more than four times his SBP payment. He lost his
group home placement, as well as his day program, and was
transferred to a state ``training center''--a large
institutional setting isolated from the community.'' \1\
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\1\ Kelly A. Thompson, ``The Dilemma for Military Parents of
Children with Disabilities.'' EP Magazine. November 2011.
People with disabilities greatly benefit from access to special
needs trusts. In the Omnibus Budget Reconciliation Act of 1993,
Congress exempted the transfer of assets for the benefit of a person
with a disability under the age of 65 from the look-back provisions of
the Medicaid program. Thus, not only is a person with a disability able
to benefit greatly from a special needs trust but the transfer of
assets to the trust for the benefit of another does not count against
the transferor in the event that he or she subsequently needs Medicaid
assistance. In light of the importance of special needs trust, it is
clear that these benefits should be available for the disabled children
of veterans, without disadvantaging the veteran in receiving VA pension
benefits if needed.
It should also be noted that a person with a disability who is
under the age of 65 may have his or her own assets transferred into a
special needs trust that directly benefits him or her. These types of
trusts may only be established by a parent, grandparent, legal
guardian, or a court and allow the individual to remain eligible for
Medicaid services and supports. Any remaining funds available at death
must be used to pay-back the Medicaid program for services provided.
Any efforts to penalize transfer of assets under the VA's pension
program must provide for appropriate exemptions for transfers to
special needs trusts similar to those available through other Federal
programs also based on financial need.
To require VA to carry out a pilot program on service dog training
therapy (S. 1838)
Service animals provide multi-faceted assistance to people with
disabilities. Specifically, service animals promote community
integration. In addition to performing specific tasks such as pulling a
wheelchair or opening a door, these same service animals can also help
to break down barriers between people with disabilities and society. In
addition to increased social interaction, many people with disabilities
also report experiencing a greater sense of independence.
We support efforts to ensure that properly trained service animals
are available to veterans who can benefit from their assistance. This
legislation provides a unique opportunity to benefit not only veterans
seeking the assistance of a service dog but also provides veterans with
post-deployment mental health concerns or Post Traumatic Stress
Disorder the opportunity to benefit from training these dogs. The dual
nature of this approach has the potential to assist a wide range of
veterans.
To provide coverage under the VA's beneficiary travel program for the
travel of certain disabled veterans for certain special
disabilities rehabilitation (S. 1755)
Veterans who have spinal cord injuries or disorders, vision
impairments, or double or multiple amputations require access to
rehabilitation services that allow them to live as independently as
possible with their disabilities. For those veterans who need these
services but who are not eligible for travel benefits, the ability to
pay for travel to these rehabilitation programs is very difficult. In
addition, few of these services are available locally, particularly in
rural areas.
We strongly support providing travel benefits for catastrophically
disabled non-service-connected veterans who need to travel to receive
in-patient care at special disabilities rehabilitation programs. Every
effort must be made to reduce barriers that limit access to these
services. The long-term savings of ensuring that these veterans are
able to maintain their health and function significantly outweighs the
short-term costs associated with this legislation.
Veteran Voting Support Act of 2011 (S. 1264)
Exercising the right to vote is a fundamental aspect of American
citizenship. For servicemembers and veterans who have served as the
defenders of our Nation's freedoms, the opportunity to register to vote
and exercise that right is particularly meaningful.
The Veteran Voting Support Act seeks to increase access to voter
registration opportunities by requiring VA to provide voter
registration applications and assistance to veterans during specified
interactions with VA. Although we support the efforts of this
legislation to ensure that veterans have increased opportunities to
register to vote, we are concerned by the lack of a meaningful
enforcement mechanism and protections for registrants that are
available through the National Voter Registration Act (NVRA).
The NVRA provides mechanisms, including state designation of
Federal agencies as voter registration agencies, to ensure that
citizens, including veterans, have more opportunities to register to
vote or update a previous registration. Since 2008, at least seven
states have requested that VA agree to designation as a voter
registration agency.
If VA were to be designated as a voter registration agency under
the NVRA, in the event of a violation, either the Department of Justice
(DOJ) or a third party may bring an action requesting enforcement.
Under the Veteran Voting Support Act, however, the only initial remedy
is for the veteran to provide written notice to the facility director
or the Secretary of Veterans Affairs. If the violation is not remedied
within 90 days, the individual may file a written notice of complaint
with DOJ and the Election Assistance Commission. But, there is no
opportunity for third party litigation, which has proven critical in
ensuring that the NVRA is enforced by individual states.
Although the Veteran Voting Support Act parallels the NVRA, other
important aspects of the NVRA would not be available under this
legislation. For example, if a veteran registers to vote through VA
under the mechanism of the Veteran Voting Support Act, then the
veteran's registration will not be official until submitted by VA.
Under the NVRA, the registration would be considered officially
submitted once provided to VA.
Last, we are concerned that the Veteran Voting Support Act does not
require VA to report the number of voter registration applications
submitted to VA. Thus, it will be difficult to determine whether VA is
fully implementing the legislation as required. Ultimately, we believe
that the NVRA provides a better system of voting rights that is more
enforceable than those envisioned under the Veteran Voting Support Act.
Unfortunately, VA has expressed concern that agreeing to state
designation as a voter registration agency would be too costly and
would expand VA's mission at a time when resources are critically
needed to assist veterans of the wars in Iraq and Afghanistan, as well
as meet the needs of veterans of all eras. We believe, however, that
serving as a voter registration agency enhances VA's fulfillment of its
mission to help veterans reintegrate into their communities.
Thus, we would support legislation that is at least modeled on the
requirements of the NVRA.
Thank you for the opportunity to testify concerning VetsFirst's
views on these important pieces of legislation. We remain committed to
working in partnership to ensure that all veterans are able to
reintegrate in to their communities and remain valued, contributing
members of society.
Chairman Murray. Thank you very much.
Ms. Ilem.
STATEMENT OF JOY J. ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR,
DISABLED AMERICAN VETERANS
Ms. Ilem. Chairman Murray and the Members of the Committee,
thank you for inviting DAV to present our views on the bills
under consideration today. I will limit my remarks to five
bills that are of particular interest to DAV and our members.
In accordance with the long-standing resolutions, DAV is
pleased to support S. 1391, a bill that would change the
standard of proof required to establish service connection for
veterans with Post Traumatic Stress Disorder resulting from
military service and mental health conditions related including
PTSD due to military sexual trauma.
We believe the enactment of this bill would provide a
commonsense standard of proof or veterans who have experienced
serious mental and physical trauma but that is often difficult
to verify because of a lack of documentation.
S. 2259 would provide cost-of-living adjustment or COLA in
the rates of compensation for veterans with service-connected
disabilities and the rates of DIC. DAV supports this
legislation. However, consistent with DAV resolution 172, we
oppose rounding down adjusted rates to the lower whole dollar.
We thank the Chairman for her continued efforts on
improving VA services for women veterans and are pleased to
support S. 3313. This bill is focused on improving the
Department's ability to meet the long-term reproductive health
care needs of veterans who have a service-connected condition
that affects the veteran's ability to reproduce.
While DAV has no specific resolution from our membership
related to reproductive and infertility research and
infertility counseling and treatment because it focuses on
service-connected injuries and would be beneficial to many DAV
members and veterans, we have no objection to the passage of
these provisions.
Regarding the remaining sections of the bill, DAV has heard
positive feedback related to counseling services in retreat
settings and the childcare pilot programs established in Public
Law 111-163. We supported the original provisions for these
pilots in according to DVA resolution 185 and are pleased to
support the proposal to expand them in this measure to include
veterans seeking readjustment counseling services at Vet
Centers.
The Mental Health ACCESS Act of 2012 focuses on improving
and enhancing the programs and activities of DOD and VA related
to suicide prevention, resilience, and behavioral health
disorders of members of the Armed Forces, veterans, and their
families.
We appreciate the bill's provisions related to implementing
a comprehensive set of measures to assess timeliness,
satisfaction, and barriers to mental health care, improving
access to services, productivity standards for the providers,
and establishing an IOM study committee with the inclusion of
members that have VA clinical mental health experience.
Of particular interest to DAV is section 204 of the
measure. As intended by Congress in establishing its original
mandate in 1979, the RCS was to be an independent, non-medical,
non-psychiatric model of care for veterans who were in need of
combat related readjustment services but did not necessarily
want to go to traditional mental health clinics in VA.
Today's new combat veterans have made it clear to DAV and
others that date too desire a similar non-stigmatizing
readjustment program to aid them and to have found Vet Centers
to be a welcoming, non-judgmental places to receive that help.
DAV is pleased to support this comprehensive measure in
accordance with DAV resolution 189 and 200 and we appreciate
the Chairman's continued efforts on improving mental health
programs for veterans, members of the Armed Forces, and their
families.
The final bill we would like to comment on is S. 3084, the
VISN Reorganization Act of 2012. This measure would require the
Secretary of the VA to restructure and realign VHAs 21 current
Veterans Integrated Service Networks or VISNs and to set
personnel limits for the VISNs.
DVA has no specific resolution concerning the
organizational alignment of the VISNs and no formal position on
this bill. However, we have urged Congress to examine VISN
staffing and functions by conducting an independent study of
the VISN structure.
In this regard, we appreciate Senator Burr's intention to
address this critical issue in his measure. It appears from
VA's testimony in the previous panel that it is working toward
a VISN reorganization plan; and like this Committee, we look
forward to hearing more about that plan and are hopeful that
the best VISN model to serve our veteran population will be
established.
Madam Chair, that concludes my statement and I am happy to
answer any questions you or Committee Members may have. Thank
you.
[The prepared statement of Ms. Ilem follows:]
Prepared Statement of Joy J. Ilem, Deputy,
National Legislative Director, Disabled American Veterans
Chairman Murray, Ranking Member Burr and Members of the Committee:
On behalf of the Disabled American Veterans (DAV) and our 1.2 million
members, all of whom are wartime disabled veterans, I am pleased to
present our views on the 23 legislative bills and two draft measures
under consideration today.
S. 1264, VETERAN VOTING SUPPORT ACT OF 2011
The Veteran Voting Support Act of 2011 would require the Secretary
of Veterans Affairs to permit facilities of the Department to be
designated as voter registration agencies and expand assistance to
veterans in registering to vote and voting. Section 3 of the bill
directs the Department of Veterans Affairs (VA) to provide mail voter
registration application forms to each veteran who seeks to enroll in
the VA health care system; and is already enrolled in such system when
there is a change in the veteran's enrollment status or when there is a
change in the veteran's address.
It also requires the Secretary to accept completed voter
application forms and transmit them to appropriate state election
officials and requires forms accepted at VA medical centers, community
living centers, community-based outpatient centers, and domiciliaries
be transmitted within ten days of acceptance, unless a completed form
is accepted within five days before the last day for registration to
vote in an election, in which case it must be transmitted within five
days of acceptance.
Section 4 requires each director of a VA community living center,
domiciliary, or medical center to provide assistance in voting by
absentee ballot to resident veterans, and requires such assistance to
include: 1) providing information relating to the opportunity to
request an absentee ballot; 2) making available absentee ballot
applications upon request, as well as assisting in completing such
applications and ballots; and 3) working with local election
administration officials to ensure the proper transmission of the
applications and ballots.
Section 5 requires the Secretary to permit nonpartisan
organizations to provide voter registration information and assistance
at facilities of the VA health care system.
Section 6 prohibits the Secretary from banning any election
administration official, whether state or local, party-affiliated or
non-party affiliated, or elected or appointed, from providing voting
information to veterans at any VA facility. It also directs the
Secretary to provide reasonable access to facilities of the VA health
care system to state and local election officials for the purpose of
providing nonpartisan voter registration services to individuals.
Although DAV has a long-standing resolution encouraging disabled
veterans to register to vote and to vote--and initially provided our
support for S. 1556, the Veteran Voting Support Act of 2009--at this
time we have reconsidered our position on the bill due to concerns
about the overall negative impact this bill would have on the Veterans
Health Administration (VHA) and the fact that VA is currently providing
voter registration to veterans when requested. Currently, VHA Directive
2008-053 defines VA's policy for assisting patients who seek
information on voter registration and voting. Based on the policy, VA
does not solicit voter registration but provides assistance to veterans
who are inpatients under VA's care; residents of VA community living
centers and domiciliaries who want to get registered to vote or vote in
an election. Additionally, state and local election officials, as well
as non-partisan groups are invited into VA health care facilities and
those visits are coordinated to ensure there are no disruptions in
patient care services. Finally, flyers and information on the voting
assistance program are posted throughout facilities and volunteers have
been specifically recruited in the past to help with these efforts.
Based on this policy, it appears that much of the bill would be
duplicative of VA's current efforts and therefore unnecessary.
Likewise, we are confident that the policy and existing Federal
Regulations under title 38, subsection 17.33, ensure veteran patients
the opportunity to exercise their voting privilege.
S. 1391
S. 1391 would change the standard of proof required to establish
service connection for veterans with Post Traumatic Stress Disorder
(PTSD) resulting from military service, and for veterans suffering from
certain mental health conditions, including PTSD, resulting from
military sexual trauma that occurred in service.
Essentially, S. 1391 would eliminate the requirement of an in-
service, verifiable stressor in conjunction with claims for PTSD. Under
this change, VA would now be able to award entitlement to service
connection for PTSD even when there is no official record of such
incurrence or aggravation in service, provided there is a confirmed
diagnosis of PTSD coupled with the veteran's written testimony that the
PTSD is the result of an incident that occurred during military
service, and a medical opinion supporting a nexus between the two.
In November 2010, VA modified its prior standard of proof for PTSD
related to combat veterans by relaxing the evidentiary standards for
establishing in-service stressors if it was related to a veteran's
``fear of hostile military or terroristic activity.'' S. 1391 would
buildupon that same concept and expands it to cover all environments in
which a veteran experiences a stressor that can reasonably result in
PTSD, regardless of whether it occurred in a combat zone, as long as it
occurred when the veteran had been on active duty or active duty for
training. The legislation would also remove the current requirement
that the diagnosis and nexus opinion come only from VA or VA-contracted
mental health professionals, but would instead allow any qualified
mental health professional.
S. 1391 would also allow VA to award entitlement to service
connection for certain mental health conditions, including PTSD,
anxiety and depression, which a veteran claims was incurred or
aggravated by military sexual trauma experienced in service, even in
the absence of any official record of the claimed trauma. Similar to
the evidentiary standard above for PTSD, the veteran must have a
diagnosis of the covered mental health condition together with a
written testimony by the veteran that the claimed trauma was incurred
during military service. Further, the veteran must have a medical
opinion from a mental health professional indicating that the claimed
mental health condition is reasonably related to military sexual
trauma, which would include a physical assault of a sexual nature,
battery of a sexual nature, or sexual harassment while the veteran was
serving on active duty or active duty for training.
DAV supports S. 1391, which is consistent with DAV Resolutions 59
and171. DAV Resolution 171 states that, ``establishing a causal
relationship between injury and later disability can be daunting due to
lack of records or certain human factors that obscure or prevent
documentation of even basic investigation of such incidents after they
occur * * *'' and that, ``* * * an absence of documentation of military
sexual trauma in the personnel or military unit records of injured
individuals prevents or obstructs adjudication of claims for
disabilities for this deserving group of veterans injured during their
service, and may prevent their care by VA once they become veterans * *
*.'' Further, DAV Resolution 59 states that, ``* * * proof of a causal
relationship may often be difficult or impossible * * *'' and that, ``*
* * current law equitably alleviates the onerous burden of establishing
performance of duty or other causal connection as a prerequisite for
service connection * * *.'' Enactment of S. 1391 would provide a
commonsense standard of proof for veterans who have experienced serious
mental and physical traumas in environments that make it difficult to
establish exact causal connections.
S. 1631
S. 1631 would authorize the Secretary of Veterans Affairs to
establish a center for technical assistance for non-Department health
care providers who furnish care to veterans in rural areas. This bill
makes the head of such center the Director of the Rural Veterans Health
Care Technical Assistance Center. It also requires the Secretary, in
selecting the center's location, to give preference to a location that,
among other things, has a high number of veterans in rural and highly
rural areas, and is near one or more entities carrying out programs and
activities relating to health care for rural populations.
The purpose of the center would be to develop and disseminate
information, educational materials, training programs, technical
assistance and materials and other tools to improve access to health
care for veterans living in rural areas. It would also help to
establish and maintain Internet-based information such as best practice
models, research results and other appropriate information.
VHA's Office of Rural Health's (ORH) mission is to improve access
and quality of care for enrolled rural and highly rural veterans by
developing evidence-based policies and innovative practices to support
their unique needs. ORH includes information on its Web site about the
three Veterans Rural Health Resource Centers (VRHRC) that have been
established. The Western Region center in Salt Lake City focuses on
outreach, access issues and the special needs of Native Americans
(American Indian, Alaska Native, Native Hawaiian, Pacific Islander) and
aging veterans. The Central Region center in Iowa City, Iowa focuses on
evaluating rural health programs and piloting new strategies to help
veterans overcome barriers to access and quality. The Eastern Region
center located in Gainesville, Florida focuses on developing models to
deliver specialty care services to rural areas, training VA and non-VA
service providers caring for rural veterans and bringing specialty care
to community-based clinics via tele-health technology.
DAV Resolution No. 203 supports the mission of the VA's Office of
Rural Health and improvements to VA coordinated health care services
for veterans living in rural areas. DAV originally supported S. 1631
when it was introduced in September 2011. It is unclear from the
information we have available to us if any of the VRHRCs are in fact
devoting resources toward the intent of this bill, which is to aid non-
VA providers who furnish care to veterans in rural areas with technical
assistance. We urge the Committee to ask VA to provide specific details
in this regard. In the event that VA is not working toward this goal,
we continue to support this bill and taking other actions to help
medical providers better deliver much-needed health care to veterans in
rural areas.
S. 1705
Introduced by Chairman Murray, this bill would designate the VA
Medical Center in Spokane, Washington, as the ``Mann-Grandstaff
Department of Veterans Affairs Medical Center.'' DAV has no resolution
on this issue and has no national position on this bill.
S. 1707, VETERANS SECOND AMENDMENT PROTECTION ACT
Introduced by Senator Burr, this bill would amend title 38, United
States Code, to clarify the conditions under which certain persons may
be treated as adjudicated mentally incompetent for certain purposes.
DAV has no resolution on this issue and has no position on this bill.
S. 1755
S. 1755 would provide for coverage under VA's beneficiary travel
program disabled veterans with vision impairment, a spinal cord injury,
or multiple amputations for travel related to in-patient care in a
special disabilities rehabilitation program. Currently, VA is
authorized to pay the actual necessary expense of travel (including
lodging and subsistence), or in lieu thereof an allowance based upon
mileage, to eligible veterans traveling to and from a VA medical
facility for examination, treatment, or care. According to title 38,
United States Code, Section 111(b)(1), eligible veterans include those
with a service-connected rating of 30 percent or more; receiving
treatment for a service-connected condition; in receipt of VA pension;
whose income does not exceed the maximum annual VA pension rate, or;
traveling for a scheduled compensation or pension examination.
Notably, the VA Secretary has the discretionary authority under
section 111(b)(2), to make payments for beneficiary travel to or for
any person not currently eligible for travel by such person for
examination, treatment, or care.
DAV has no resolution on this issue and has no position on this
bill. However, we would note that while the intended recipients of this
expanded eligibility criteria would certainly benefit, we would urge
the Committee to consider a more equitable approach rather than one
based on the specific impairments of a disabled veteran. Further, we
ask that if the Committee does favorably consider this measure, it also
take appropriate actions to ensure that sufficient additional funding
be provided to VA to cover the cost of the expanded program.
S. 1799, ACCESS TO APPROPRIATE IMMUNIZATIONS FOR VETERANS ACT OF 2011
This measure would require the Secretary of Veterans Affairs to
make available periodic immunizations against certain infectious
diseases as adjudged necessary by the Secretary of Health and Human
Services through the recommended adult immunization schedule
established by the Advisory Committee on Immunization Practices. The
bill would include such immunizations within the authorized
preventative health services available for VA-enrolled veterans. The
bill would establish publicly reported performance and quality measures
consistent with the required program of immunizations authorized by the
bill. The bill would require annual reports to Congress by the
Secretary confirming the existence, compliance and performance of the
immunization program authorized by the bill.
Although DAV has no adopted resolution from our membership dealing
specifically with this matter of immunizations for infectious diseases,
DAV Resolution No. 193 calls on VA to maintain a comprehensive, high
quality, and fully funded health care system for the Nation's sick and
disabled veterans, specifically including preventative health services.
Preventative health services are an important component of the
maintenance of general health, especially in elderly and disabled
populations with compromised immune systems. If carried out
sufficiently, the intent of this bill could also contribute to
significant cost avoidance in health care by reducing the spread of
infectious diseases and obviating the need for health interventions in
acute illnesses of those without such immunizations. For these reasons,
DAV supports this bill and urges its enactment.
S. 1806
S. 1806 would amend the Internal Revenue Code of 1986 to allow
taxpayers to designate overpayments of tax as contributions to the
homeless veterans assistance fund. DAV has no resolution on this issue
and has no position on this bill.
S. 1838
S. 1838 would require the Secretary of Veterans Affairs to carry
out a pilot program on service dog training therapy. If enacted, this
measure would require the Department to conduct a pilot program to
assess the feasibility and advisability of using service dog training
activities as part of an integrated post-deployment mental health
program. The purpose of the pilot program is for VA to produce
specially trained service dogs for veterans; to determine how
effectively the program would assist veterans with Post Traumatic
Stress Disorder (PTSD) and the feasibility of extending or expanding
the pilot program.
DAV has no resolution on this issue and has no position on this
bill. However, we are looking forward to the receipt of findings from
VA's ongoing research project to determine the efficacy of service dog
usage by veterans challenged by mental illness and post-deployment
mental health conditions related to combat, including PTSD. We
recognize that trained service animals can play an important role in
maintaining functionality and promoting maximum independence and
improved quality of life for persons with disabilities--and that pilot
programs such as the one proposed could be of benefit to certain
veterans. However, we do have a concern about VA's experience with
advanced training methods for the many varieties of highly specialized
service dogs.
S. 1849, RURAL VETERANS HEALTH CARE IMPROVEMENT ACT
S. 1849, the Rural Veterans Health Care Improvement Act, would
require VA to develop a five-year strategic plan for ORH for improving
access to, and the quality of, health care services for veterans in
rural areas.
DAV supports the intention of S. 1849 in accordance with DAV
Resolution No. 203. However, we note that the VA's ORH has made
available its ``Strategic Plan Refresh'' for Fiscal Years 2012-2014
with six specific goals and a number of initiatives to achieve those
goals. The VA's Strategic Plan on rural health care is comprehensive
and seems to cover many of the provisions listed in S. 1849; however,
we would like to see additional information on the use of mobile
clinics and coordination of care for women veterans living in rural
areas. We ask VA to provide an update on the use of mobile clinics in
rural areas and the provisions in the bill that would require a survey
of each VA facility that serves rural and highly rural areas concerning
the provision for and coordination of care for women veterans--
including options for fee-basis care and specialty care. DAV is
interested in hearing VA's testimony on these topics, and in the event
that their current two-year plan does not address those specific
provisions outlined in S. 1849, we would support passage of an amended
version of this bill related to those specific provisions or any others
that are missing from VA's plan.
S. 2045
S. 2045 would require judges of the United States Court of Appeals
for Veterans Claims to reside within 50 miles of the District of
Columbia. DAV has no resolution on this issue and has no position on
this bill.
S. 2244, VETERANS MISSING IN AMERICA ACT OF 2012
This bill would direct the Secretary of Veterans Affairs to
cooperate with veterans service organizations and other groups in
assisting the identification of unclaimed and abandoned human remains.
The VA would also be required to determine if any such remains are
eligible for burial in a national cemetery. The VA would cover the
burial cost if the remains are determined to be that of an eligible
veteran who does not have a next of kin or other person claiming the
remains, and there are no available resources to cover burial and
funeral expenses. In addition, the bill calls on the VA to establish a
public database of the veterans identified in this project. DAV has no
resolution on this issue and has no position on this bill.
S. 2259, VETERANS' COMPENSATION COST-OF-LIVING ADJUSTMENT ACT OF 2012
S. 2259 would provide for a cost-of-living adjustment (COLA),
effective December 1, 2012, in the rates of compensation for veterans
with service-connected disabilities and the rates of dependency and
indemnity compensation for the survivors of certain disabled veterans
based on the Social Security COLA. DAV generally supports this
legislation; however, consistent with DAV Resolution 172, we oppose
rounding down the adjusted rates to the next lower whole dollar.
S. 2320, REMEMBERING AMERICA'S FORGOTTEN VETERANS CEMETERY ACT OF 2012
S. 2320 would direct the American Battle Monuments Commission to
provide for the ongoing maintenance of Clark Veterans Cemetery in the
Republic of the Philippines, and for other purposes. DAV has no
resolution on this issue and has no position on this bill.
S. 3049
S. 3049 would expand the definition of homeless veteran for
purposes of benefits under the laws administered by the Secretary of
Veterans Affairs. DAV has no resolution on this issue and has no
position on this bill.
S. 3052
S. 3052 would require the Secretary of Veterans Affairs to notify
veterans who electronically file claims for benefits that they may be
able to receive assistance from veterans service organizations (VSOs),
and to provide contact information for such VSOs. DAV Resolution 001
states that, ``* * * our first duty as an organization is to assist the
service-connected disabled, their surviving spouses and dependents * *
*,'' and the inclusion of information explaining the availability of
VSO assistance and VSO contact information on electronic claims
applications would likely increase our ability to do exactly that. In
fact, DAV has made this exact request to the Veterans Benefits
Administration as they have been developing a new electronic paperless
claims system, and it is our understanding that just as VSO contact
information is provided to veterans who file paper claims, it will
similarly be provided to those who file electronic claims. As such,
while enactment of statutory language may not be necessary, we are not
opposed to the favorable consideration of this bill.
S. 3084, VISN REORGANIZATION ACT OF 2012
S. 3084, the VISN Reorganization Act of 2012, would require the
Secretary of Veterans Affairs to restructure and realign VHA's 21
current Veterans Integrated Service Networks (VISNs) as well as set
personnel limits for VISNs.
Section 2 of the bill would place a limitation on the number of
VISN management units at 12, down from the current 21, and would lay
out the missions, policies, budgets, procedures and other
responsibilities of these integrated regional VISNs, including
alliances with other agencies, health care organizations and
governments in conducting their work. It would also specify that each
network's VISN headquarters be restricted to not exceed employment of
more than 65 full-time employee equivalents, including contractors, and
would require VA to submit reports to Congress annually on VISN
employment; budget and other benchmarks. This section would also
prescribe a consolidation of the existing 21 VISNs in a specified
pattern and direct the Secretary to choose one of the existing VISN
offices consolidated as sites of the new combined VISN headquarters,
including dealing with leased space in commercial buildings, relocation
of employees and reemployment assistance for those displaced.
Section 3 of the bill would establish four VISN regional support
centers whose main purpose would be to evaluate the effectiveness and
efficiency of the new VISNs, across a number of parameters, with a
preference that these support centers be established in existing VA
medical center locations.
Section 4 of the bill would clarify that this reorganization of
VISNs would not require any change to existing direct care at VA sites,
including medical centers, CBOCs, or Vet Centers.
DAV has no resolution concerning the organizational alignment of
the VHA, or of the VISNs; thus, DAV has no position on this bill.
However, last year, DAV, along with other national VSOs, put forward a
set of nine recommendations to eliminate waste, duplication and
inefficiency within VA, one of which dealt with the size of VISN
bureaucracy versus its original mandate as outlined in VA's ``Vision
for Change'' report that led to the creation of the current VISN
structure.
We would also note that the VA Office of Inspector General recently
completed two reports on VHA's VISNs, with a particular concern about
the size of their staffing. Results of these reviews were inconclusive,
but strongly suggested that VISNs have expanded their permanent
staffing allocations significantly compared to the levels in 1995,
rather than relying on using ``temporary'' task forces and working
groups pulled from medical centers and other facilities as envisioned
in the original plan. In addition, a number of coordinator positions
covering a variety of subjects (OEF/OIF; suicide; quality;
credentialing of professionals; and FRC, etc.) have been imposed by
Congress or VA Central Office over the years, further adding to their
staffing totals. Also, pressures on acquisition, human resources and
financial management have dictated establishment of consolidated
functions for the activities at the VISN level leading to additional
personnel.
In our recommendations, DAV and the other VSOs urged Congress to
examine VISN staffing and functions by contracting with the National
Academy of Sciences, Institution of Medicine (IOM), to conduct an
independent study of the VISNs, including their staffing levels, and to
submit recommendations to Congress about whether and how these
functions should be reorganized. We believe such a study is necessary
before setting specific limitation on either the number of VISNs (12)
or FTEE per VISN (65). Therefore, we recommend that the Committee ask
IOM to conduct such a study, with appropriate protections for the many
benefits the structure has brought to VA health care, before taking any
legislative action to restructure or reorganize VHA's VISN system.
S. 3202, DIGNIFIED BURIAL OF VETERANS ACT OF 2012
S. 3202, the Dignified Burial of Veterans Act of 2012, would
authorize VA to furnish a casket or urn to a deceased veteran when VA
is unable to identify the veteran's next-of-kin and determines that
sufficient resources are not otherwise available to furnish a casket or
urn for burial in a national cemetery. The bill would further require
that VA report back to Congress on the industry standard for urns and
caskets and whether burials at VA's national cemeteries are meeting
that standard. Under current law, VA is not authorized to purchase a
casket or urn for veterans who do not have a next-of-kin to provide
one, or the resources to be buried in an appropriate manner. DAV has no
resolution on this issue and has no position on this bill. However, if
it is to be favorably considered by the Committee, we urge additional
resources be provided to VA to ensure that implementation of this
discretionary authority does not result in a reduction of funding for
other authorized programs.
S. 3206
S. 3206 would extend from 2013 to 2018 the authorization of
appropriations under title 38, United States Code, section 322,
allowing VA pay a monthly assistance allowance to disabled veterans
training or competing for the Paralympic Team. It would similarly
extend the authorization of appropriation under section 521A for VA to
provide assistance to United States Paralympics, Inc.
The DAV has testified previously on sections 521A and 322 before
and after enactment of Public Law 110-389.\1\,\2\ Specifically, while
the intent of Public Law 110-389 is laudable, our concern was and
remains the impact it may have on the National Disabled Veterans Winter
Sports Clinic, which is a rehabilitation event and not a training
ground for future Olympians.\3\
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\1\ Meeting the Needs of Injured Veterans in the Military
Paralympic Program: Hearing before the House Committee on Veterans'
Affairs, 111th Congress. 17 (2009) (testimony of Adrian Atizado)
\2\ Legislative Hearing on H.R. 4255, H.R. 6221, H.R. 6224, H.R.
6225, and H.R. 6272: Hearing before the Subcommittee on Economic
Opportunity of the House Committee on Veterans' Affairs, 111th
Congress. 19 (2008) (testimony of Kerry Baker)
\3\ Section 521A, paragraph (d) of the bill states, amongst other
things, that a program under that section includes a program that
``promotes * * * competition.'' The activities described in that same
section are, among others, instruction, participation, and
``competition in paralympic sports.''
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In addition, the same paragraph allows for individuals with
disabilities who are not veterans or members of the Armed Forces to
participate in sports programs that receive funds originating from VA
grants. As an organization devoted to improving the lives of our
Nation's wartime disabled veterans, we are concerned about any shift of
VA's mission, personnel, and resources away from disabled veterans,
their families and survivors.
Unfortunately, our concern was appropriate based on issues
surrounding the implementation, oversight and accountability for the
first year of the grant program authorized under section 521A. As you
may be aware, VA and U.S. Paralympics, a division of the United States
Olympic Committee (USOC), signed its Memorandum of Understanding at the
beginning of fiscal year 2010, announced the Olympic Opportunity Fund
and subsequently sought proposals. It was in this first year that it
became apparent to DAV there was a lack of VA oversight and
accountability on the implementation of the grant program and grant
recipients, as well as a lack of accountability to ensure adherence by
certain grant recipients to the intent of the law.
We note, however, that a number of improvements have been and
continue to be made since the consolidation of VA's Office of National
Programs and Special Events, which managed VA's National Rehabilitation
Special Events, with the Office of National Veterans Sports Programs
and Special Events, and additional staff and resources were provided to
this office. Furthermore, we look forward to the actions VA will take
to address the findings and recommendations of the Government
Accountability Office's investigation of this grant program.
In an effort to ensure limited VA resources are wisely spent
directly, rather than incidentally, on disabled veterans and disabled
members of the Armed Forces to participate in recreation and sport
activities, we urge this Committee, if this measure is favorably
considered, to include a future mandatory review of this grant program
by the Government Accountability Office (GAO). We also urge this
Committee to conduct oversight of this grant program subsequent to the
release of GAO's upcoming and future reports.
S. 3238
S. 3238 would designate the VA community-based outpatient clinic in
Mansfield, Ohio, as the David F. Winder Department of Veterans Affairs
Community Based Outpatient Clinic. DAV has no resolution on this issue
and has no national position on this bill.
S. 3270
S. 3270 would require the Secretary of Veterans Affairs to consider
the resources of individuals applying for pension that were recently
disposed of by the individuals for less than fair market value when
determining the eligibility of such individuals for such pension. DAV
has no resolution on this issue and has no position on this bill.
S. 3309, HOMELESS VETERANS ASSISTANCE IMPROVEMENT ACT OF 2012
S. 3309, the Homeless Veterans Assistance Improvement Act of 2012,
is a comprehensive bill that focuses on improving services for homeless
veterans.
Sections 2, 3 and 4 of the bill require that recipients of VA
grants for comprehensive service programs for homeless veterans meet
physical privacy, safety, and security needs of such veterans; modify
the authority of the Department to provide capital improvement grants
for comprehensive service programs that assist homeless veterans by not
only establishing but maintaining such programs; and provide funding
for furnishing legal services to very low-income veteran families in
permanent housing.
Section 5 modifies the requirements relating to per diem payments
for services furnished to homeless veterans allowing such payments to
include furnishing care for a dependent of a homeless veteran who is
under the care of that veteran while he or she receives services from
the grant recipient (or entity).
Section 6 authorizes grants by VA to centers that provide services
to homeless veterans to be used for operational expenses. The aggregate
amount of all grants awarded in any fiscal year may not exceed
$500,000.
Section 7 expands the authority of VA to provide dental care to
eligible homeless veterans who are enrolled for care for a period of 60
consecutive days, and who are receiving assistance under section 8(o)
of the United States Housing Act of 1937 (42 U.S.C. 17 1437f(o)); or
receiving care (directly or by contract) in any of the following
settings; a domiciliary; therapeutic residence; community residential
care coordinated by the Secretary; or a setting for which the Secretary
provides funds for a grant and per diem provider.
Section 8 of this measure extends the dates, authorities and
resources affecting homeless veterans for the following programs in
title 38, United States Code:
Comprehensive programs
Homeless veterans reintegration programs
Outreach, care, treatment, rehabilitation and therapeutic
transitional housing for veterans suffering from serious mental illness
Program to expand and improve provision of benefits and
services by VA to homeless veterans
Housing assistance for homeless veterans
Financial assistance for supportive services for very low-
income veteran families in permanent housing
Grant program for homeless veterans with special needs;
and
The Advisory Committee on Homeless Veterans
DAV is pleased to support S. 3309, the Homeless Veterans Assistance
Improvement Act of 2012, as it is in line with DAV Resolution No. 205,
which calls for us to support sustained and sufficient funding to
improve services for homeless veterans. This resolution approved by our
membership also urges Congress to strengthen the capacity of VA's
programs to end homelessness among veterans and to provide health care
and other specialized services for mental health, including dental
care.
S. 3313, WOMEN VETERANS AND OTHER HEALTH CARE IMPROVEMENTS ACT OF 2012
S. 3313, the Women Veterans and Other Health Care Improvements Act
of 2012, contains a number of important enhancements to women veterans
health care programs.
Section 2 of the bill instructs the Secretary of Veterans Affairs
to facilitate reproductive and infertility research conducted
collaboratively by the Secretary of Defense and the Director of the
National Institutes of Health to find ways to meet the long-term
reproductive health care needs of veterans who have a service-connected
genitourinary disability or a condition that was incurred or aggravated
while serving on active duty, such as spinal cord injury, that affects
their ability to reproduce.
The Secretary of Veterans Affairs would ensure that any information
produced by the research deemed useful for other activities of the VHA
be disseminated throughout the VHA. Within three years after the date
of enactment, the Secretary will report to Congress on the research
activities conducted.
Section 3 of the measure clarifies that fertility counseling and
treatments, including treatment using assisted reproductive technology,
are medical services the Secretary may furnish to veterans.
Section 4 of this bill requires the Secretary to furnish
reproductive treatment and care for spouses and surrogates of veterans
by allowing the Secretary to furnish fertility counseling and
treatment, including the use of assisted reproductive technology, to a
spouse or surrogate of a severely wounded veteran who has an
infertility condition incurred or aggravated while on active duty and
who is enrolled in the health care system established under section
1705(a) 25 of title 38, United States Code, if the spouse and the
veteran apply jointly for such counseling and treatment through a
process prescribed by the Secretary.
In the case of a spouse or surrogate of a veteran not described who
is seeking fertility counseling and treatment, the Secretary may refer
such spouse or surrogate to a qualified clinician and would be required
to prescribe regulations to carry this out no later than one year after
enactment.
While DAV has no specific resolution from our membership related to
reproductive and infertility research and fertility counseling and
treatment, this section of the bill is focused on improving the
Departments' ability to meet the long-term reproductive health care
needs of veterans who have a service-connected condition that affects
the veteran's ability to reproduce. For these reasons DAV has no
objection to the passage of these sections of the bill, with the
exception of subsection (b) of section 4 of the measure: DAV has no
position on that particular subsection.
Section 5 of this bill requires that the Secretary of Veterans
Affairs enhance the capabilities of the VA women veterans call center
by responding to requests by women veterans for assistance with
accessing health care and benefits and by referring such veterans to
community resources to obtain assistance with services not furnished by
VA.
Sections 6 and 7 of the bill seek to modify the pilot program of
counseling women veterans newly separated from active duty in retreat
settings by increasing the number of locations from three to fourteen
and by extending the time of the pilot program from two years to four
years; and to modify the duration of the established child care pilot
programs for certain veterans receiving VA health care under Public Law
111-163 to note that the pilot program may operate until the date that
is two years after the date on which the pilot program is established
in the third VISN.
Section 7 of the measure would also require a child care pilot
program in at least three Readjustment Counseling Service Regions for
certain veterans receiving readjustment counseling and related mental
health services. It requests the Secretary of Veterans Affairs to carry
out a pilot program to assess the feasibility and advisability of
providing assistance to qualified veterans to obtain child care so that
such veterans can receive readjustment counseling and related mental
health services.
Child care assistance under this subsection may include: stipends
for the payment of child care offered by licensed child care centers
either directly or through a voucher program; payments to private child
care agencies; collaboration with facilities or programs of other
Federal departments or agencies; or other forms of assistance as the
Secretary considers appropriate. When the child care assistance under
this subsection is provided as a stipend, it must cover the full cost
of such child care.
No later than 180 days after the completion of the pilot program,
the Secretary shall submit to Congress a report on the pilot program.
The report shall include the findings and conclusions of the Secretary
as a result of the pilot program, and shall include such
recommendations for the continuation or expansion of the pilot program
as the Secretary considers appropriate. There is authorized to be
appropriated to the Secretary of Veterans Affairs to carry out the
pilot program $1,000,000 for each of fiscal years 2014 and 2015.
We thank the Chairman for her continued efforts on improving VA's
women veterans heath programs and services and are pleased to support
this draft measure. DAV has heard positive feedback related to the
pilot program of counseling women veterans newly separated from active
duty in retreat settings and the childcare pilots established in Public
Law 111-163. We supported the original provisions for these program
pilots and are pleased to support the proposal to expand them.
Likewise, we are supportive of the provisions in section 5 of the bill
that require VA to enhance the capabilities of the Department's women
veterans call center related to assistance with accessing health care
and benefits and referrals to community resources to obtain assistance
with services not furnished by VA.
DRAFT BILL TO ESTABLISH AND NAME OUTPATIENT CLINIC IN HAWAII
Introduced by Senator Inouye, this bill would authorize the
Secretary of Veterans Affairs to carry out a major medical facility
project lease for a VA outpatient clinic at Ewa Plain, Oahu, Hawaii and
designate such clinic as the Daniel Kahikina Akaka Department of
Veterans Affairs Clinic. DAV has no resolution on this issue and has no
national position on this bill.
DRAFT BILL ON MENTAL HEALTH ACCESS ACT OF 2012
This draft measure, the Mental Health Access to Continued Care and
Enhancement of Support Services Act of 2012, or the Mental Health
ACCESS Act of 2012, is a comprehensive bill focused on improving and
enhancing the programs and activities of the Department of Defense
(DOD) and VA related to suicide prevention and resilience and
behavioral health disorders of members of the Armed Forces and
veterans.
All of the sections in Title I of this bill are related to DOD
matters with the exception of sections 105, 106 and 109. These
provisions require collaboration between the two agencies with respect
to improving sharing of patient records and information under the
medical tracking system/electronic health record shared between DOD and
VA; participation of members of the Armed Forces in peer support
counseling programs of VA; and compliance of DOD with requirements for
use of VA's Schedule for Rating Disabilities in determinations of
disability of members of the Armed Forces. DAV recognizes the need for
the both Departments to collaborate on certain mental health matters
and we are supportive of these specific sections in accordance with DAV
Resolution No. 200, approved by our membership. This resolution
supports program improvements and enhanced resources to support
readjustment services for the post-deployment mental health needs of
war veterans. Further, DAV Resolution No. 177 calls for improved
collaboration between VA and DOD in making disability determinations.
As for the remaining sections in Title I of the measure, however, DAV
takes no formal position on the issues that fall exclusively under the
jurisdiction of DOD.
Sections in Title II of the measure deal with VA mental health
matters. Section 201would instruct the Secretary of Veterans Affairs to
develop and implement a comprehensive set of measures to assess mental
health care services VA is providing. The provisions would require VA
to specifically assess the timeliness of the furnishing of mental
health care; the satisfaction of patients who receive it; VA's current
capacity to furnish mental health care; and the availability and
furnishing of evidence-based therapies.
The section also would require that the Secretary develop and
implement guidelines and productivity standards for providers of mental
health care for the staffing of general and specialty mental health
care services, including those resident in community-based outpatient
clinics. The bill would require the Secretary to enter into a contract
with the National Academy of Sciences Institute of Medicine (IOM) to
create a study committee to assess and provide an analysis and
recommendations on the state of VA's mental health services. The study
committee would also be responsible for assessing barriers to accessing
mental health care by Operation Enduring Freedom, Operation Iraqi
Freedom, or Operation New Dawn (OEF/OIF/OND) veterans as well as the
quality of mental health care they are receiving.
We are especially pleased that the bill would require VA to provide
detailed recommendations for overcoming observed barriers, and to
improve access to timely, effective mental health care at VA health
care facilities and that the Secretary and IOM would be required to
include at least one former VHA official and at least two former VA
employees who were providers of mental health care as members of the
study committee. Likewise, we are pleased the bill includes provisions
to ensure transparency in the process--specifically that the measures
and guidelines developed and implemented as well as an assessment of
the performance of VA using such measures and guidelines are to be made
available to the public on a VA Web site and must be updated quarterly
at a minimum.
Given the previous hearings held by this Committee on mental health
matters and the findings from various informal surveys and official
reports on timeliness of VA mental health care and ongoing staffing
shortages, DAV fully supports the aforementioned provisions. These
requirements are in line with a mandate from our membership contained
in DAV Resolution No. 200.
Section 202 would expand the Vet Center mandate established in
Public Law 111-163 to include Readjustment Counseling Service (RCS)
furnishing counseling to certain members of the Armed Forces and their
family members. This language would authorize limited eligibility for
family members to receive counseling separately from a given
servicemember when those family members are dealing with combat-related
deployment problems. Under this section, counseling furnished could
include a comprehensive assessment of the veteran's or family member's
psychological, social, and other characteristics to ascertain whether
they are experiencing difficulties associated with coping with the
deployment of a member, or readjustment of the family to civilian life
of a veteran or servicemember following a deployment.
The RCS provides an optimal model of psychological counseling for a
veteran's family to assist with recovery and post-deployment mental
health challenges. Therefore, we believe this provision is fully
consistent with the RCS's mission and goals to help combat veterans
recover from that unique experience. Public Law 111-163 provided VA a
new authority for active duty personnel to receive Vet Center services
outside their military chains of command, as well as a number of other,
novel authorities enabling family caregivers of severely injured
veterans to receive direct VA services. Historically, Vet Centers have
been counseling family members in certain circumstances when such
counseling is helpful to keep families intact, to deal with survivors'
grieving of a lost servicemember or veteran, to deal with separation
anxieties and depression, and to aid family members in coping with a
number of deployment-related stresses. Therefore, we see these new
provisions as consistent with the RCS mission to continue as a non-
medical source of healing and recovery for this young population. We
believe this is an important, but incremental improvement in the RCS
mandate. Therefore, DAV fully endorses this provision in accordance
with DAV Resolution No. 189 that supports a comprehensive Vet Center
Program for combat veterans of all eras.
Section 203 establishes authority for the Secretary of Veterans
Affairs to furnish mental health care through facilities other than Vet
Centers to immediate family members of Armed Forces personnel deployed
in connection with a contingency operation; this authority would be
subject to the availability of appropriations for this purpose. We
support this provision, also on the strength of Resolution No. 189.
Section 204 stipulates the organization of the RCS in the VA and
notes that it is a distinct organizational element within the VHA that
provides counseling and other important health and psychological
services. This measure would require the Chief Officer of the
Readjustment Counseling Service to report directly to the Under
Secretary for Health with no intervening supervisory layers between
them. The provision would also specify qualifications of an individual
for holding this sensitive post.
For the past 35 years, the RCS has served as a quasi-independent
source of psychological counseling for combat veterans and family
members. In fact, the Committee may recall that the original charter
for the RCS was modeled on a novel readjustment counseling service
initiated independently by DAV following the Vietnam War when it became
apparent to our predecessors that VA was not addressing the urgent
counseling and readjustment needs of a number of Vietnam veterans. As
intended by Congress in establishing its original mandate in 1979, the
RCS was to be an independent, non-medical, non-psychiatric source of
care for certain veterans who did not want to be labeled ``mentally
ill'' by VA, but who were in need of services to aid them in
readjusting from the sacrifices they endured in military combat
environments. The RCS succeeded all expectations in playing that role.
Today's combat veterans have made it clear to DAV and others that they
desire a similar, non-stigmatizing service to aid them, and have found
the Vet Centers to be welcoming, non-judgmental places to receive that
help.
Without notice to this community and without any consultation
beforehand, the VHA journalized the RCS under its medical professional
arm. The RCS office now reports through, and is thus restrained by, a
gauntlet of bureaucracies led by VA physicians and those working for VA
physicians in VA Central Office. Reporting to physicians is wholly
inconsistent with the non-medical, psychological and pastoral mission
of RCS, and detracts from its historic role as planner, budgeter,
staffer and operator of all RCS programs in 300 Vet Centers in every
State and most major cities. No other VA medical professional service
in the current VHA configuration possesses this level of combined
responsibility or accountability as does the RCS. We cannot see any
advantage having been accrued to VHA as a consequence of this
realignment (except perhaps to promote medical and psychiatric
traditionalism), but many disadvantages have become apparent.
With these views in mind, we strongly endorse this section that
would return RCS to its traditional state of independence from medical
and psychiatric supervision in a VA bureaucracy.
The section also would require funding for the activities of the
Readjustment Counseling Service, including the operations of Vet
Centers, to be derived from amounts appropriated for the VHA for
medical services and not through the Veterans Equitable Resource
Allocation system that funds most other VA clinical care. The section
would also require the budget request for the RCS to be segregated from
other funding needs for VHA. We fully support these provisions on the
same basis that we support RCS being maintained as a separate entity in
VHA's organization, reporting only to the Under Secretary for Health.
If funding for RCS is routed through VERA, it is subject to the overall
needs of each VISN. This would give each VISN office the opportunity to
parse RCS funding to other needs deemed more urgent or higher priority.
We do not support this concept. RCS funding should be maintained and
justified by RCS only, exclusive of interference by outside interests.
The section also requires that, not later than March 15 of each
year, the Secretary shall submit a report to the Committee on Veterans'
Affairs of the Senate and the House of Representatives on the
activities of the RCS during the preceding calendar year. Each report
would include for each period covered: 1) a summary of the activities
of the RCS, including its Vet Centers; 2) a description of the workload
and additional treatment capacity of the Vet Centers, including, for
each Vet Center, the ratio of the number of full-time equivalent
employees and the number of individuals who received services or
assistance; 3) a detailed analysis of demand for and unmet need for
readjustment counseling services; and 4) the Secretary's plan for
meeting any such unmet needs. We support this provision.
Section 205 would instruct the Secretary of Veterans Affairs to
carry out a national program of outreach to societies, community
organizations, and government entities in order to recruit mental
health providers, who meet the quality standards and requirements of
the VA to provide mental health services for the Department on a part-
time, without-compensation basis. In carrying out this program the
Secretary could partner with a community entity or assist in the
development of a community entity, including by entering into an
agreement that would provide strategic coordination of the societies,
community organizations, and government entities in order to maximize
the availability and efficient delivery of mental health services to
veterans. The Secretary would be required to provide training to mental
health providers to ensure that clinicians who provided mental health
services under this authority gain sufficient understanding of military
and service specific culture, combat experience, and other factors that
are unique to the experience of OEF/OIF/OND veterans.
DAV is pleased to support this comprehensive draft measure and we
appreciate the Chairman's continued efforts on improving mental health
programs and services for our Nation's servicemembers, veterans and
their families. We are especially appreciative of your recognition of
the importance of the RCS's role in restoring new veterans to society
and family life following their strenuous deployments to Afghanistan
and Iraq, over this decade-long war. We particularly appreciate those
provisions in this bill.
DAV would again like to thank the Committee for the opportunity to
submit our views on the numerous legislative measures under
consideration at this hearing. Much of the proposed legislation would
significantly improve VA benefits and services for our Nation's
servicemembers, veterans and their families.
This concludes my testimony. I am happy to answer any questions
Committee Members may have related to my statement.
Chairman Murray. Thank you.
Thank you very much to all of our folks who have come today
to testify. We really appreciate it. I just am going to do a
couple of questions and then submit some for the record as our
time is running out rapidly.
But I did want to go back to Ms. Keil. The Department of
Defense, as I mentioned earlier, provides access to advanced
reproductive treatments and recently issued some guidance on
offering these services at no cost to severely injured
servicemembers and their spouses.
The VA, on the other hand, cannot provide these services,
and it is pretty clear they do not meet the reproductive health
needs of veterans who have experienced severe trauma as you
outlined to us in your testimony a few moments ago.
When you and your husband, Matt, were trying to conceive,
you faced some very substantial roadblocks from both the
Department of Defense and VA; and since that time, DOD has
changed their policy. They now do offer fertility services for
severely injured veterans.
I believe that veterans like Matt have earned DOD and VA
coverage and there should be no difference. I assume you agree
with that.
Ms. Keil. I absolutely agree. My understanding is that you
would need to travel to a military treatment facility in order
to receive those services that the DOD is offering, whether
that be Fort Bragg or Walter Reed. That is not an option for
families of the most severely injured such as my husband.
There is no way that I could travel to one of those
treatment facilities and to care for my husband, and I want him
there every step of the way.
So, that for us would not be an option. I feel that he,
with his service and sacrifice, I feel that he now falls under
the VA guidelines of care. He is a medically retired
servicemember, and he ultimately is the VA's responsibility.
So, I feel that we fall under their responsibility.
Chairman Murray. Thank you very much. I really appreciate
that.
Ms. Ilem, I just wanted to ask you. One of the issues I
hear a lot about especially for women veterans is the lack of
childcare. It is a substantial barrier to families accessing
health care, and Congress has begun to address that issue.
The last Congress, as you know, we created a pilot program
to provide childcare at several of our VA medical centers. This
year the legislation I have introduced expands upon that
success to include childcare at several Vet Centers.
This is important because Vet Centers, as you know, provide
mental health care and readjustment counseling services in a
comfortable, non-clinical setting that some veterans prefer.
So, I wanted to ask you. I was really pleased to hear your
testimony today about the positive experiences that a number of
your members have had.
How do you think expanding access to child care services
would improve the accessibility to care for our veterans?
Ms. Ilem. And we definitely appreciate your leadership on
that issue. It was a long time coming. It certainly has been
identified as a barrier over the years in numerous studies and
I think we heard from the recent event that you hosted with a
number of women veterans who need psychological counseling that
are using the Vet Center and even VA's that child care, having
access to child care was a big issue because for the children
it is just not an appropriate place for them to bring their
children, discussing some very private matters during those
sessions.
So, I think it absolutely opens the door one more step for
those that Vet Centers should be included and we welcome those
provisions.
Chairman Murray. OK. Thank you very much and again we are
out of time but I do want to thank all of our witnesses today,
and I will just let everyone know that I am going to be working
with all the Members of this Committee as we develop
legislation based on today's hearing on all of these bills as
well as our last legislative hearing for our markup which is
going to be held in July.
I am optimistic that by the time of the next markup, the
President is going to be signing into law the Honoring America
Veterans and Caring for Camp Lejeune Families Act of 2012,
which includes legislation from our last markup.
Veterans legislation continues to be bipartisan and that is
as it should be. So, I want to thank all the members of our
Committee. The Senators who are working on legislation I look
forward to working with all of you in the coming weeks on this
critical legislation affecting our Nation's heroes.
Thank you very much.
With that, this Committee hearing is adjourned.
[Whereupon, at 11:59a.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Max Cleland, Secretary, American Battle Monuments
Commission
Mr. Chairman and Members of the Committee: Thank you for this
opportunity to offer testimony on several bills before the Committee.
As only one, S. 2320, the Remembering America's Forgotten Veterans
Cemetery Act of 2012, pertains to responsibilities of the American
Battle Monuments Commission, I will limit my testimony to it.
S. 2320 would direct the American Battle Monuments Commission to
provide for the ongoing maintenance of the former Clark Air Base
Cemetery in the Republic of the Philippines.
We agree that Clark cemetery is a problem that warrants resolution.
When the Air Force vacated Clark Air Base and the base rights agreement
with the Philippines expired, the cemetery became the responsibility of
the Philippine Government. Over time, this had the effect of leaving
its care in the hands of a few dedicated VFW volunteers. They have done
a wonderful job with limited resources, particularly considering that
burials of U.S. veterans have continued since the Air Force departure,
but the volunteers cannot be expected to continue that effort
indefinitely.
We do not know how many of the 8,000 dead at Clark cemetery are
U.S. veterans--the Clark Veterans Cemetery Restoration Association Web
site cites several thousand as confirmed veterans and others as
presumed veterans.
We are on record as stating that Clark cemetery does not fall
within our Commission's core commemorative mission. That remains true.
However, given the Air Force's history with the cemetery and the fact
that veterans' burials have continued, we initiated a meeting in ABMC's
Virginia Headquarters last December with representatives of the Air
Force and the Department of Veterans Affairs National Cemetery
Administration to explore possible solutions to this issue. A consensus
could not be reached on what should or could be done.
ABMC has serious concerns with S. 2320 as drafted. While this
bill's intention is laudable, we do not believe the bill addresses
adequately issues that must be resolved before any corrective action is
taken.
If the Congress should decide to move legislation forward, the
Administration believes such legislation should address three critical
elements: access, authority, and funding.
1. Access--To our knowledge, the United States has no legal
standing to undertake any work at Clark cemetery. The Department of
State would have to enter negotiations with the Philippine Government
to provide long-term U.S. access to the cemetery. This would have to be
accomplished before any agency of the Federal Government could maintain
the cemetery.
2. Authority--ABMC has no authority to spend its appropriations to
maintain a cemetery controlled by a foreign government and the
Administration does not support any change in this position.
3. Funding--The requirement that the Commission restore, operate
and maintain Clark cemetery ``subject to the availability of
appropriations for the restoration, operation, and maintenance of
cemeteries by the American Battle Monuments Commission'' is not
supportable. We cannot successfully complete a project of this scale
with existing appropriations without significant negative consequences
on the rest of ABMC's program. There is presently no government
estimate of the cost to restore and maintain Clark cemetery. The Clark
Veterans Cemetery Restoration Association estimated the restoration
cost at $2.0 million and annual maintenance costs at $250,000. There
are more than 8,000 graves to maintain at Clark cemetery-more than we
maintain at 19 of our 24 overseas cemeteries. Most of the headstones at
Clark are partially buried in volcanic ash. We believe the
association's estimates do not come close to the amount required given
the magnitude of the restoration work required.
ABMC's Fiscal Year 2013 budget request for Salaries and Expenses is
$2.7 million, or five percent, below our Fiscal Year 2012
appropriation. Most of that reduction will be taken in maintenance and
infrastructure programs. We cannot sustain such reductions indefinitely
while maintaining the standards our war dead deserve and that our
Nation demands.
We recognize that the Budget Control Act limits all agencies,
including ABMC, to a budgeted level in the out years, and that any
increase to our budget would have to be offset from another agency's
out year allowances. Nonetheless, if the Congress directs our agency to
take on a large-scale new program requirement such as the restoration
and maintenance of Clark cemetery, even the association's under-
estimated cost would reduce our Fiscal Year 2013 funding request by an
additional four percent--for a total reduction of $5.0 million. Taken
further, this would result in a 14 percent cut in program funding for
engineering and maintenance, horticulture, logistics and
interpretation.
This is not sustainable for an agency of our size and budget. An
unfunded new mission of the scope of Clark cemetery cannot help but
have a significant impact on our ability to execute our core mission.
Before closing, I must comment on Finding 8 of the bill, which
references the Commission's fund raising authority. We caution the
Committee from going down this road. Requiring private funding of new
memorial projects authorized by the Congress has become common
practice, but fund-raising results have not been universally
successful. It is not common practice to require private funding of our
Nation's overseas cemeteries. S. 2320 implies that the care of ABMC
cemeteries could become dependent on the uncertainties of public fund
raising. This carries with it the implication that the Congress is
prepared to back away from the commitment to provide perpetual care to
the war dead buried within them.
S. 2320 has serious issues that prevent us from supporting this
legislation.
______
Prepared Statement of the American Society for Reproductive Medicine
The American Society for Reproductive Medicine appreciates the
opportunity to provide comment on S 3313, the ``Women Veterans and
Other Health Care Improvements Act of 2012,'' and is pleased that the
Senate Veterans' Affairs Committee has considered this bill for a
public hearing.
ASRM is a multidisciplinary organization of nearly 8,000 medical
professionals dedicated to the advancement of the art, science, and
practice of reproductive medicine. ASRM members include obstetrician/
gynecologists, urologists, reproductive endocrinologists, nurses,
embryologists, mental health professionals and others. As the medical
specialists who present treatment options for patients and perform
procedures during what is often an emotional time for them, we
recognize how important a means to addressing their medical condition
can be for those hoping to build their families.
The ``Women Veterans and Other Health Care Improvements Act of
2012'' would direct the Secretary of Veterans Affairs to collaborate
with the Secretary of the Department of Defense and the Director of the
National Institutes of Health to facilitate research to improve the
long term reproductive health care needs of veterans who have a
service-connected genitourinary disability or a condition that was
incurred or aggravated in the line of duty that affects the veteran's
ability to reproduce. ASRM is very pleased that this bill recognizes
the need for greater attention, dedication and investment of Federal
resources to the disease of infertility. The National Institutes of
Health and the Centers of Disease Control are two public agencies that
devote resources to this disease, but due to the myriad of causes of
infertility, and the numerous implications of the disease, it is
vitally important that other Federal agencies work to make combating
infertility a priority. The attention to infertility by the agencies
governing our military service personnel and our separated from
military service personnel is long overdue and welcomed.
The bill allows that the Department of Veterans Affairs may furnish
fertility counseling and treatment, included assisted reproductive
technologies, to veterans and requires the Department of Veterans
Affairs to furnish fertility counseling and treatment, including
assisted reproductive technologies, to a spouse or surrogate of a
severely wounded veteran who has an infertility condition incurred or
aggravated in the line of duty as long as the spouse and veteran apply
jointly for such counseling and treatment.
ASRM solidly supports the provision of fertility services to
severely wounded veterans. It is nothing but unjust to send our
military personnel into harm's way and to not provide health care
services to address health care needs that arise due to their service
and dedication to our country.
Of course, because infertility is a disease and one that affects 1
in 8 couples, we advocate for the provision of health benefits to
address the disease for all those affected, no matter the cause.
Insurance coverage of infertility is rare. And while we can debate as
to what is essential and what is not essential when it comes to
coverage of health care, there is a huge gap when it comes to the
ability of individuals diagnosed with infertility to treat their
disease. In fact, the Federal Employee Health Benefits Program, the
largest employer-sponsored private health plan in the Nation, and a
model for the health reform law in several key areas, does not provide
coverage for most infertility services, and specifically for assisted
reproductive technology. ASRM would recommend that the Federal
Government can demonstrate its commitment to the importance of
addressing infertility by requiring its own health program to provide
coverage for infertility services for its own workforce.
We would like to raise a couple of additional shortcomings in the
bill.
First, the bill is written is such a way to give the Department of
Veterans Affairs the option (i.e. ``may'' furnish) to provide fertility
counseling and treatment for veterans generally, but ``shall'' provide
fertility counseling and treatment for spouses or surrogates when a
severe injury occurs to the veteran during the line of duty. As
written, the bill seems to leave out the required treatment of the
veteran himself or herself when injured during the line of duty.
Obviously this is not the intent of your bill, but the language should
be clarified to require coverage of the injured veteran himself or
herself. The source of the infertility can be male factor, female
factor or both.
The bill could go further to specifically include furnishing of
services to those affected by infertility caused by exposure to toxins
during their deployment as these exposures can also compromise one's
ability to reproduce. So too, fertility preservation is a common
concern for military personnel with orders to deploy, and coverage by
TRICARE for those who opt to attempt to preserve their fertility via
sperm banking should be allowed.
The bill limits required fertility counseling and treatments to a
spouse or surrogate of the injured veteran. Until such time that every
state legally recognizes the marriage of same sex partners, the effect
of this bill will be that only those veterans whose marriage is deemed
legal will be furnished those services outlined in the bill. This
effectively denies coverage to injured veterans who are single or who
are in same sex partnerships. It is no longer a stigma to reproduce
outside of the context of marriage, or a male/female marriage, and ASRM
would recommend that holding veterans to a standard that is not the
norm any longer in today's society is discriminatory.
ASRM would also recommend that you clarify the term ``surrogate''
in the bill as this word can have different meanings. It would be
appropriate to precede the word ``surrogate'' with the word
``gestational'' in the bill language. ASRM would further recommend that
the use of donor gamates be a covered treatment option.
Thank you for the opportunity to comment on this bill and for your
attention to this important public health issue.
______
LETTER FROM NATHANIEL BEELER OF AVON, INDIANA
Chairman Murray, Members of the Senate Veterans' Affairs Committee,
My name is Nathaniel Beeler and I am 10 years old, almost 11. I live in
Avon, Indiana. I am working to alert Senators about an important
veteran's issue that is addressed in Senate Bill S. 2320. Clark
Veteran's Cemetery in the Philippines urgently needs your support. Many
of our soldiers who sacrificed their lives for our country lie in
disgraceful conditions at the Clark Veteran's Cemetery in the
Philippines. I care deeply for the veterans who sacrificed their lives
for my very freedom and I think they should have respectful conditions
for the price they paid.
I first read about the cemetery last summer and I wanted to do
something to support our fallen heroes. I made a power point
presentation and presented this issue to my class in April and we wrote
letters to Senator Coats, Senator Lugar, and Congressman Todd Rokita.
Since then, I have expanded my efforts to include six petition drives.
I have collected a total of 764 signatures, ranging from kindergartners
to a WWII Pearl Harbor survivor. After I got out of school in May, I
decided to increase my efforts ten-fold.
I know it must grieve you also to know that our veterans are lying
in disgrace, buried in ash and weeds. Some have 8-12 inches of ash
covering their headstones so that you cannot read their information.
This is not how the United States treats their veterans. These brave
men and women, who sacrificed for my freedom, kept our freedom for many
generations to come. Now they lay in disgrace and dishonor and that
violates their sacrifice and ruins the vision of how the United States
treats their fallen comrades.
I know that I am only 10 years old, but I want to do something for
the veterans because of how much they have done for me. I live in
freedom and luxury in the greatest nation in the world, thanks to them.
I get to go to school without being blown up on the way, good food is
in our kitchen and available abundantly at the store even though we are
at war, and I sleep in a warm, comfortable bed without fear of being
attacked and killed in the night, all because of the sacrifice and
efforts of our veterans.
Here is the issue: When the Air Force left the Philippines due to
volcanic eruption, they left in a hurry, and failed to place the
cemetery under the proper agency to manage our cemeteries on foreign
soil. S. 2320 would place Clark under the ABMC. All of it is explained
in my PowerPoint presentation, which I will attach. [A paper version is
held in Committee files.] We have veterans buried there who died in the
Spanish American war all the way to an Iraqi veteran. I just read a
great book called The Great Raid of Cabanatuan and I learned about how
many Filipino people sacrificed and suffered and died alongside our
troops. They were brave young men and women who helped turn the tide in
WWII. Many suffered through or died on the Bataan Death March and were
POWs. A lot of them were freed and then went into the jungles and
mountains to lead or participate in the underground gorilla effort
against the Japanese. We could never have rescued our POW's without
their help. This has made me even more dedicated and motivated to
doubling up on my efforts to restore Clark Veteran's Cemetery.
Since you are all Members of the Senate Committee on Veterans
Affairs, you are very important and Clark needs your support! All of my
hope and trust is in you because only the U.S. Government can restore
this forgotten cemetery which contains our brave war dead. If the US
doesn't do something now, it will be like they have been abandoned
twice. I read a good book called Behind the Enemy Lines. It is about
brave men and women that fought for our country from the Revolutionary
War all the way to Iraq. The stories are so amazing, especially the
soldiers bravery! The stories reminded me of the men and women who are
buried at Clark. I am very devoted and motivated to bring them the
honor and dignity they have earned and deserve. By supporting this
bill, you could influence other Senators to support S. 2320, and have
the domino effect.
When I grow up, I hope to be a pilot in the Marines. I have read
that the Marines main statement is: ``Leave no man behind.'' But at
Clark, many Marines have been left behind, buried in ash and dishonor.
I will never stop fighting for them and their honor, because they never
stopped fighting for me and for you and for our Nation.
I am only 10 years old but I have been taught that the United
States is the most powerful and just nation in the world and we have
this title because of the many veterans who fought under our flag
because they believed that freedom was worth dying for. Even if they
were fighting for other people's freedom, they believed the ideas the
United States stands for are worth dying for. So now they lay in
disgrace when they are really heroes. We can't allow this to go on! We
have to act now.
I can only go out and get signatures of support and every one I
talked to agreed that we should be able to read the headstones of our
war dead. But you can make a law and fix this predicament.
A gold star mother signed my petition on Saturday, June 16th. I
have thought many times about all the mothers of those who are buried
at Clark, and how sad and exasperating it must be to have your child
buried in disgrace and dishonor when they sacrificed and gave of
themselves in order that we are a free country.
I hope you will support S. 2320! I have another petition drive
scheduled for July 4, 2012. It will be my biggest event yet--15,000
people attended in the past. I think I will gain many signatures and
much progress for the effort to restore Clark Veteran's Cemetery!
I am attaching my power point and my petitions to be admitted into
public testimony, along with my statement. I hope this is read and
admitted because I really want to help Clark Veteran's Cemetery to be
restored!
Sincerely,
Nathaniel Beeler.
______
Prepared Statement of Thomas Zampieri, Ph.D., Director of Government
Relations, Blinded Veterans Association
INTRODUCTION
The Blinded Veterans Association (BVA) is the only congressionally
chartered Veterans Service Organization exclusively dedicated to
serving the needs of our Nation's blinded veterans and their families.
The organization has served blinded veterans for 67 years. On behalf of
BVA, thank you for this opportunity to present statement for the record
on the issue of the current Department of Veterans Affairs (VA)
Beneficiary Travel Program. Chairwoman Patty Murray, Ranking Member
Burr, and members of the Senate VA Committee, thank you for the changes
you already have made to Beneficiary Travel in recent years, and today
we appreciate the introduction of S. 1755 to improve the access for
disabled blind and spinal cord injured veterans who require services at
the VA specialized Blind Rehabilitation Centers (BRCs) and Spinal Cord
Injury Centers (SCIs).
BENEFICIARY TRAVEL FOR BLINDED VETERANS: S. 1755
BVA thanks Senator Tester for introducing S. 1755. We also express
appreciation to Congressman Michaud for H.R. 3687, the companion House
bill legislation for disabled SCI and blinded veterans who are
currently ineligible for travel benefits. This bill would assist low-
income and disabled veterans by removing the travel financial burdens
to access vital care that improve independence and quality of life.
Veterans who must currently shoulder this hardship, which often
involves airfare, can be discouraged by these costs to travel to a BRC
or SCI site. The average age of veterans attending a BRC is 67 because
of the high prevalence of degenerative eye diseases in this age group.
It makes little sense to have developed, over the past decade,
outstanding blind rehabilitation programs with 13 Blind Centers and
with high quality inpatient specialized services, only to tell low
income, disabled blinded veterans that they must pay their own travel
expenses to access the training they need. To put this dilemma in
perspective, a large number of our constituents are living at or below
the poverty line while the VA Means threshold for travel assistance
sets $14,340 as the income mark for eligibility to receive the benefit.
VA utilization data revealed that one in three veterans enrolled in VA
health care was defined as either a rural resident or a highly rural
resident. The data also indicate that blinded veterans in rural regions
have significant financial barriers to traveling without utilization of
public transportation.
To elaborate on the challenges of travel without financial
assistance, the data found that for most health characteristics
examined, enrolled rural and highly rural veterans were similar to the
general population of enrolled veterans. The analysis also confirmed
that rural veterans are a slightly older and a more economically
disadvantaged population than their urban counterparts. Twenty-seven
percent of rural and highly rural veterans were between 55 and 64.
Similarly, approximately 25 percent of all enrolled veterans fell into
this age group.\1\ In FY 2007, rural veterans had a median household
income of $19,632, 4 percent lower than the household income of urban
veterans ($20,400).\2\ The median income of highly rural veterans
showed a larger gap at $18,528, adding significant barriers to paying
for air travel or other public transportation to enter a BRC or SCI
rehabilitation program. More than 70 percent of highly rural veterans
must drive more than four hours to receive tertiary care from VA.
Additionally, states and private agencies do not operate blind services
in rural regions. In fact, almost all private blind outpatient agency
services are located in large urban cities. With the current economic
problems with state budgets clearly in view, we expect further cuts to
these social services that will bring even more challenges to the
disabled in rural regions.
---------------------------------------------------------------------------
\1\ Department of Veterans Affairs, Office of Rural Health,
Demographic Characteristics of Rural Veterans Issue Brief (Summer
2009).
\2\ VSO IB 2013 Beneficiary Travel pg 119-120, 124-125.
---------------------------------------------------------------------------
Consider the following facts:
In a study of new applications for recent vision loss
rehabilitation services, 7 percent had current major depression and
26.9 percent met the criteria for subthreshold depression.\3\
---------------------------------------------------------------------------
\3\ Horowitz et al., 2005, Major and Subthreshold Depression Among
Older Adults Seeking Vision Rehabilitation Services The Silver Book
2012, Volume II pg 9 www.silverbook@ agingresearch.org.
---------------------------------------------------------------------------
Vision loss is a leading cause of falls in the elderly.
One study found that visual field loss was associated with a sixfold
risk of falls.\4\
---------------------------------------------------------------------------
\4\ Ramratten, et al., 2001 Arch Ophthalmology 119(12) 1788-94.
Prevalence and Causes of Visual Field Loss in the Elderly,
www.Silverbook.org/visionloss Silver Book, Volume II 2012 pg 9.
---------------------------------------------------------------------------
While only 4.3 percent of the 65 and older population
lives in nursing homes, that number rises to 6 percent of those who are
visually impaired, and 40 percent of those who are blind.\5\
---------------------------------------------------------------------------
\5\ Rein, David B. et al., 2006 The Economic Burden of Major Adult
Visual Disorders in the U.S. www.Silverbook.org/visionloss Silver Book,
Volume II 2012 pg 9.
---------------------------------------------------------------------------
Individuals who are visually impaired are less likely to
be employed-44 percent are employed compared to 85 percent of adults
with normal vision in working population age 19-64.\6\
---------------------------------------------------------------------------
\6\ Rein, et al. The Economic Burden of Major Adult Vision
Disorders in the U.S. 2006 www.Silverbook.org/visionloss Volume II
pg 10.
If blinded veterans are not able to obtain the blind center
training to learn to function at home independently because of travel
cost barriers, the alternative--institutional care in nursing homes--
may be far more expensive. The average private room charge for nursing
home care was $212 daily ($77,380 annually), and for a semi-private
room it was $191 ($69,715 annually), according to a MetLife 2008
Survey. Even assisted living center charges of $3,031 per month
($36,372) rose another 2 percent in 2008. BVA would point to these more
costly alternatives in describing the advantages of VA Beneficiary Care
so that veterans can remain in their homes, functioning safely and
independently, and with the rehabilitation training needed to re-enter
the workforce.
We caution that private agencies for the blind are almost always
outpatient centers and located in large urban cities. Many rural states
have no vision rehabilitation centers and they do not have the full
specialized nursing, physical therapy, audiology, pharmacy, radiology
or laboratory support services that are necessary for the clinical care
that BRCs and SCIs provide. The lack of electronic health care records
in private centers is also a problem when veterans return to VA for
their other medical follow-up care. BVA requests that all private
agencies be required to demonstrate peer reviewed quality outcome
measurements that are a standard part of VHA Blind Rehabilitative
Service. They must also be accredited by either the National
Accreditation Council for Agencies Serving the Blind and Visually
Handicapped (NAC) or the Commission on Accreditation of Rehabilitation
Facilities (CARF). Blind Instructors should be certified by the Academy
for Certification of Vision Rehabilitation and Education Professionals
(ACVREP).
CONCLUSION
Chairwoman Murray and Ranking member Burr, BVA again expresses its
thanks for the changes that the VA committee has made to these
Beneficiary Travel programs in the past couple of years. BVA requests
support for S. 1755, which will ensure that VHA cover travel costs by
changing Title 38, Section 111 of the U.S. Code Eligibility. Veterans
who would not otherwise be able to attend special rehabilitation
programs to improve their quality of life will now have that
opportunity. The end result will also be a previously unavailable means
for blind or spinal cord injured veterans to live independently in
their own homes. BVA appreciates the opportunity to provide this
statement for the record today.
______
Prepared Statement of Hon. Bruce E. Kasold, Chief Judge,
U.S. Court of Appeals for Veterans Claims
Chairman Murray, Ranking Member Burr, and Distinguished Members of
the Committee: Thank you for the opportunity to present written
testimony on a number of legislative proposals, in particular S. 2045,
which would establish in statute a duty station for the judges of the
United States Court of Appeals for Veterans Claims, consistent with
other Federal courts, as well as a requirement for active service
judges to reside within fifty miles of the District of Columbia. This
past March, I provided testimony to the House of Representatives
Committee on Veterans' Affairs, Subcommittee on Disability Assistance
and Memorial Affairs, on a mirror proposal in the House--H.R. 4213--and
my testimony today essentially is unchanged.
In the haste of creating the Court of Appeals for Veterans Claims--
the youngest Federal appellate court--the application of several policy
issues written in statute and applicable to Federal judges in general
appears to have been overlooked with regard to the judges of the Court
of Appeals for Veterans Claims. A defined duty station is one example.
The duty station for Federal judges generally is prescribed by statute,
see 28 U.S.C. Sec. 456, but until your proposal and that of H.R. 4213,
no similar legislation has applied to the Court of Appeals for Veterans
Claims. In the absence of legislation, the Court's Board of Judges has
determined that the duty station for all Court personnel, including
active judges other than recall-eligible retired judges, is the Court's
principal office. This mirrors your proposed bill.
With regard to a residence requirement, we note that congressional
mandate is mixed with regard to establishing such a requirement for an
appellate court with national jurisdiction. Although the judges of the
Court of Appeals for the Federal Circuit are required to reside within
50 miles of the District of Columbia, see 28 U.S.C. Sec. 456, the
judges of the Court of Appeals for the Armed Forces have no residency
requirement.
To the extent the perceived need for a residency requirement arises
from concerns over the efficient operation of the Court, we note that
working from a remote area is becoming more practical. Our cases are
now electronically filed and stored and are accessible anywhere a judge
can locate a computer. Decisions are circulated for review
electronically, and this is the preferred method to distribute cases
for review even for those present and working at the Court (as opposed
to working remotely). Conversations can and do take place by e-mail,
phone, and video (although video is not widely available at the Court
yet, but likely not far off). Indeed, recently, one of our judges was
on travel and worked a case electronically with his iPad while his wife
was driving the car. Moreover, the advent of e-filing and enhanced
electronic communication capability, as well as recent changes in the
administrative processing of appeals after they have been briefed--as
discussed in my testimony before this Committee last month--have
resulted in the Court's most productive years.
Should Congress proceed with a residency requirement for the Court,
we suggest that it be tied to the Washington, DC, greater metropolitan
area, and not just the confines of the District of Columbia, to be
consistent with the statutorily required location of the Court's
principal office, which can be anywhere in the Washington, DC, greater
metropolitan area. See 38 U.S.C. Sec. 7255.
With regard to the other legislative proposals before the
Committee, I note that they concern operations unrelated to the Court
or matters within the specific purview of the Department of Veterans
Affairs. Accordingly, I have no special insight to offer the Committee.
Thank you again for the opportunity to provide a written statement
on the proposed legislation.
______
Letter from Dennis L. Wright, Captain, U.S. Navy (Retired),
Chairman, Clark Veterans Cemetery Restoration Association
[Attachments listed were not submitted to the Committee.]
______
letter from the national coalition for homeless veterans
Chairman Patty Murray, Ranking Member Richard Burr, and
Distinguished Members of the Senate Committee on Veterans' Affairs: The
National Coalition for Homeless Veterans (NCHV) is honored to submit
this written testimony for the hearing on health and benefits
legislation on June 27, 2012. NCHV represents more than 2,100
community- and faith-based organizations nationwide that serve veterans
and their families in crisis. These organizations help our Nation's
most vulnerable heroes by providing health services, emergency and
supportive housing, job training and placement assistance, legal aid,
case management and other critical supports.
A few of the bills addressed at today's hearing would significantly
impact the ability of service providers to deliver the needed care to
help homeless and at-risk veterans achieve or maintain independent
living:
S. 1806, Sen. Barbara Boxer's bill to amend the Internal
Revenue Code of 1986 to allow taxpayers to designate overpayments of
tax contributions to the homeless veterans assistance fund
S. 3049, Sen. Mark Begich's bill to expand the definition
of homeless veteran for purposes of benefits under the laws
administered by the Secretary of Veterans Affairs
S. 3309, Sen. Patty Murray's ``Homeless Veterans
Assistance Improvement Act of 2012''
NCHV supports each of these measures. We offer a few targeted
recommendations to improve upon S. 3309, however.
S. 1806, A BILL TO AMEND THE INTERNAL REVENUE CODE OF 1986 TO ALLOW
TAXPAYERS TO DESIGNATE OVERPAYMENTS OF TAX CONTRIBUTIONS TO THE
HOMELESS VETERANS ASSISTANCE FUND
Limited Federal funds for homeless veteran assistance are often
concentrated in heavily populated areas. A significant number of
community- and faith-based service providers lie outside of major
metropolitan areas, which makes it is more difficult to compete for
Federal grants. However, the homeless and at-risk veterans served by
these organizations require the same help to reintegrate into society
as those in larger urban areas.
This bill would establish the Homeless Veterans Assistance Fund,
which would supplement proven Federal programs and could be authorized
to target nontraditional, or ``nonconforming entities,'' and support
high-demand activities such as:
Child care assistance for single veterans in employment
assistance programs
Transportation assistance to medical and employment
services
Security deposits and utility hook-up fees for housing
placements
Clothing, uniforms and tools for employment
The U.S. General Accounting Office has reported that American
taxpayers may have overpaid as much as $945 million, based on data from
tax year 1998. This amounts to an average overpayment of $438 per
taxpayer (``Tax Deductions,'' March 2002). Tax overpayments may be
inevitable, but they do not need to be meaningless. The simple act of
checking a box, as authorized by this bill, would enable taxpayers to
contribute all or part of their overpayments to help prevent and end
homelessness for those who have served this country in a way
increasingly few Americans ever will.
S. 3049, A BILL TO AMEND TITLE 39, UNITED STATES CODE, TO EXPAND THE
DEFINITION OF HOMELESS VETERAN FOR PURPOSES OF BENEFITS UNDER THE LAWS
ADMINISTERED BY THE SECRETARY OF VETERANS AFFAIRS
The Department of Veterans Affairs (VA) currently defines
``homeless veteran'' based on an incomplete citation of the McKinney-
Vento Homeless Assistance Act (42 U.S.C. 11302 (a)). The full
definition of ``homeless'' under this act includes the following:
``Any individual or family who is fleeing, or is attempting to
flee, domestic violence, dating violence, sexual assault,
stalking, or other dangerous or life-threatening conditions in
the individual's or family's current housing situation,
including where the health and safety of children are
jeopardized, and who have no other residence and lack the
resources or support networks to obtain other permanent
housing.''
Sen. Begich's bill serves a single purpose: to include this
provision in VA's definition of ``homeless veteran.'' Although some of
these veterans may already qualify for VA homeless assistance due to
the nature of their circumstances, we must make certain that we do not
deny these vulnerable families the help that they need.
S. 3309, ``HOMELESS VETERANS ASSISTANCE IMPROVEMENT ACT OF 2012''
Sec. 2. Requirement that recipients of grants from Department of
Veterans Affairs for comprehensive service programs for
homeless veterans meet physical privacy, safety, and security
needs of such veterans.
Earlier this year, the VA Office of Inspector General reported
``serious female veteran safety, security, and privacy issues'' at
certain Grant and Per Diem (GPD) Program sites (``Audit of the Homeless
Providers Grant and Per Diem Program,'' March 2012). Sec. 2 of this
bill would help to remove any ambiguity over the need for grantees to
fully address these issues in the grant application process.
Sec. 3. Modification of authority of Department of Veteran Affairs to
provide capital improvement grants for comprehensive service
programs that assist homeless veterans.
Successful GPD providers who have previously received Capital
Grants to establish their programs should have the opportunity to
compete for funding to maintain those program facilities, including
making the necessary renovations to serve homeless women veterans. Sec.
3 of this bill would give the VA Secretary the discretion to make these
grants.
Sec. 4. Funding for furnishing legal services to very low-income
veteran families in permanent housing.
Outstanding warrants can present a barrier to independent housing
for veterans and their families. Dozens of communities around the
country have responded to this issue by adopting veteran-specific court
programs. One such example is the Homeless Court Program (HCP)--a
collaboration between veteran service providers and local court systems
in which a veteran's participation in a rehabilitative program can be
considered ``payment'' for various misdemeanor offenses.
Sec. 4 of this bill would set aside at least 1.0 percent of SSVF
Program funding for providers that will provide ``legal services to
assist the veteran family with issues that interfere with the family's
ability to obtain or retain housing or supportive services.'' NCHV
recommends that this funding be targeted to communities that have
demonstrated both a commitment and an ability to resolve veterans'
legal issues. This could be accomplished by restricting these funds to
communities with established Veterans Court programs.
Sec. 5. Modifications to requirements relating to per diem payments for
services furnished to homeless veterans.
The Grant and Per Diem Program currently lacks authority to
directly serve veterans' dependent children. Under the current
authorization, veteran families are either forced to split up or be
denied entry into the program.
With the introduction and rapid expansion of the SSVF Program, VA
has recognized that homelessness cannot be effectively ended and
prevented without caring for the veteran family as a whole. This same
philosophy should apply to the GPD Program.
Sec. 5 of this bill would allow veterans' dependents to directly
receive services through the program. Additionally, under this section
the VA Secretary would be required to make per diem payments to
``nonconforming entities,'' such as those discussed earlier in this
testimony (regarding S. 1806). The Secretary is already authorized to
make these payments. A mandate would potentially benefit underserved
communities, but it should not be applied if it will compromise the
integrity of the highly competitive GPD Program.
Sec. 6. Authorization of grants by Department of Veterans Affairs to
centers that provide services to homeless veterans for
operational expenses.
Drop-in service centers are an important element of the GPD
Program. They provide essential services and referrals to homeless and
at-risk veterans who may not yet be ready or willing to enter into a
residential therapy program, or are unable to because of capacity
limitations. Yet with a reimbursement rate of no more than $4.86 per
hour per veteran accessing the service center, few grantees can afford
to maintain full-time staff for this purpose.
The operational grants allowed by Sec. 6 of this bill would help
support established service centers. NCHV recommends this provision
clearly identify staffing expense as an allowable operational cost.
Sec. 7. Expansion of Department of Veterans Affairs authority to
provide dental care to homeless veterans.
VA dental care for homeless veterans is a limited resource and does
not reach enough of the homeless veteran community. For many of these
men and women veterans, their job prospects and self-esteem suffer
until they are able to address such issues as severe oral pain and
missing teeth. The department's dental program helps them alleviate
these barriers.
Veterans who live in housing units supported by HUD-VASH vouchers,
meanwhile, have an enormous advantage over the homeless veteran
population at large: stable housing with regular case management and
counseling supports. Given these considerations, NCHV does not endorse
Sec. 7 of this bill, which would expand eligibility for VA's homeless
veteran dental care to a non-homeless population: HUD-VASH voucher
holders.
Sec. 8. Extensions of authorities and programs affecting homeless
veterans.
This section would impact nearly every major homeless veteran
program in the Federal Government. Among the critical FY 2013
reauthorizations included in this section are:
$250 million for the Grant and Per Diem Program
$300 million for the Supportive Services for Veteran
Families Program
$50 million for the Homeless Veterans Reintegration
Program (HVRP), the Nation's only employment program wholly dedicated
to serving homeless veterans
The GPD Program represents one of six pillars in the VA Secretary's
Five-Year Plan to End Veteran Homelessness: community partnerships. Its
role in ending veteran homelessness should not be diminished.
Therefore, NCHV is concerned that Sec. 8 of this bill would scale back
the program's authorization to $150 million well before the maturity of
the Five-Year Plan in 2015. We recommend that the program's
authorization be sustained at the $250 million level.
Additionally, while this section would reauthorize the Special
Needs Grant Program through 2015, NCHV maintains that the current
authorization level of $5 million is insufficient to meet the needs of
the program's target populations--particularly veterans with dependent
children. We recommend that the program's authorization should be at
least 15 percent of the total authorization for section 2011, title 38,
U.S. Code. This would help to ensure that the necessary capital funding
is available to provide safe, private and secure facilities for
homeless women veterans and single homeless veterans with dependent
children.
IN SUMMATION
NCHV has been at the center of the campaign to end veteran
homelessness since 1990, and knows better than most the role that the
Senate Committee on Veterans' Affairs has played in bringing our Nation
to within reach of the goal of ending veteran homelessness. With
passage of this legislation, this Committee will buildupon its rich
bipartisan legacy of leadership in providing assistance that is
responsive to the needs of an evolving veteran population.
We greatly appreciate the opportunity to submit this written
testimony on behalf of our Nation's homeless veteran service providers,
and look forward to working with this Committee to help advance
S. 1806, S. 3049, and S. 3309--with the above recommendations--to the
full Senate.
Respectfully,
John Driscoll,
President and CEO.
Matt Gornick,
Policy Assistant Director.
______
Prepared Statement of Paralyzed Veterans of America
Chairman Murray, Ranking Member Burr, and Members of the Committee,
Paralyzed Veterans of America (PVA) would like to thank you for the
opportunity to present our views on the broad array of legislation
impacting the Department of Veterans Affairs (VA) pending before the
Committee. These important bills will help ensure that veterans receive
the best health care and benefits services available to them.
S. 3313, THE ``WOMEN VETERANS AND OTHER HEALTH CARE IMPROVEMENTS ACT OF
2012''
PVA strongly supports the ``Women Veterans and Other Health Care
Improvements Act of 2012.'' If enacted, this bill would improve health
care services for women veterans within the VA.
PVA is particularly pleased to see the provisions related to
reproductive services for catastrophically disabled service-connected
veterans. One of the most devastating results of spinal cord injury or
dysfunction for many individuals is the loss of the ability to have
children and raise a family. PVA has long sought inclusion of
reproductive services in the spectrum of health care benefits provided
by the VA. Sections 2, 3 and 4, of the proposed legislation are
significant steps in securing these much needed and long overdue
treatment modalities that are critical components of catastrophically
disabled veterans' maximization of independence and quality of life.
Advancements in medical treatments have for some time made it
possible to overcome infertility and reproductive disabilities. For
some paralyzed veterans procreative services have been secured in the
private sector at great cost to the veteran and family. In April 2010,
a Memorandum promulgated by the Office of the Assistant Secretary of
Defense (Health Affairs) extended reproductive services, including in-
vitro fertilization, to servicemembers and retired servicemembers who
had a loss of reproductive ability due to serious injury while on
Active Duty. The Memorandum notes ``Although many medical and other
benefits are available to these members and their families, members
with spinal and other injuries that make it impossible to conceive a
child naturally are not provided TRICARE coverage, which can assist
them in becoming a parent.''
An implementing guidance memorandum described available
reproductive services as sperm retrieval, oocyte retrieval, in-vitro
fertilization, artificial insemination, and blastocyst implantation.
Similar to the Department of Defense's recognition that reproductive
services are crucial elements in affording catastrophically disabled
individuals and their spouses with life-affirming ability to have
children and raise a family, so too will passage of the provisions of
this bill that authorize the VA to offer similar services to veterans
disabled in service to the Nation.
This bill also proposes to improve access to VA care by making both
health care and benefits information available through the VA Women
Veterans Call Center, as well as referrals for community resources to
obtain assistance with services not furnished by the VA. While we
support improvements to the call center, PVA believes that VA must
continue working toward developing a comprehensive model of care that
provides woman veterans with a broader variety of quality services that
they need. The FY 2013 Independent Budget reported that 51 percent of
women veterans who utilize VA health care services also use non-VA
providers. Given this high percentage of woman seeking health care
services in the VA and with other providers, the VA must not only work
to improve the variety of services available to meet women's health
care needs, but it must also work to ensure that there is adequate care
coordination with the non-VA providers serving women veterans. Care
coordination is the only way to monitor the quality of care provided to
women veterans outside the VA health care system.
PVA also supports the proposed extensions of the pilot program for
counseling in retreat settings for women veterans newly separated from
service, and the pilot programs on assistance for child care for
certain veterans. Providing veterans with child care assistance
eliminates a barrier to care that prevents many veterans from receiving
appropriate health services. Women veterans are one of the fastest
growing populations within the VA health care system and we must make
certain that they have access to, and receive, quality health care
services through the VA.
S. 3238
PVA's National office has no position on naming the VA community-
based outpatient clinic in Mansfield, Ohio, as the David F. Winder VA
Community-Based Outpatient Clinic. PVA believes naming issues should be
considered by the local community with input from veterans
organizations within that community. With that in mind, we would defer
to the views of PVA's Buckeye Chapter.
S. 3206
PVA supports S. 3206, a bill that would extend the authorization
for the VA to pay a monthly assistance allowance to disabled veterans
training or competing for the Paralympic team. PVA continues to support
the partnership between the Paralympics and the VA to expand sports and
recreation opportunities to disabled veterans and injured
servicemembers. We believe that this has certainly been a worthwhile
program as the need for expansion of these activities is necessary. We
appreciate the role that the Paralympics have played in this expansion.
S. 3202, THE ``DIGNIFIED BURIAL OF VETERANS ACT OF 2012''
PVA fully supports the provisions of S. 3202, the ``Dignified
Burial of Veterans Act of 2012.'' Under current law, VA is not
authorized to purchase a casket or urn for veterans who have no
designated next-of-kin or who lack the resources to provide and
appropriate, dignified burial to properly memorialize the deceased
veteran. The proposed legislation would ensure that VA furnishes a
casket or urn to a deceased veteran when VA is unable to identify the
veteran's next-of-kin and determines that sufficient resources are not
otherwise available to furnish a casket or urn for burial in a national
cemetery. This provision is consistent with the requirements that would
be placed on the VA if the provisions of S. 2244, the ``Veterans
Missing in America Act,'' were enacted. Additionally, this bill would
require VA to issue a report to Congress on the industry standard for
urns and caskets and whether burials at VA's national cemeteries are
meeting that standard.
S. 3084, THE ``VISN REORGANIZATION ACT OF 2012''
PVA opposes S. 3084, a bill that would establish a new
organizational structure for the alignment of the Veterans Integrated
Service Networks (VISN) around the country. PVA has serious concerns
about the precedent that this legislation would set. The VA currently
uses the VISN structure as a management tool for the entire VA health
care system. It makes no sense for the Congress to legislate how the VA
should manage its system. Furthermore, this sets a dangerous precedent
whereby any member could decide that the VA's VISN alignment is not
satisfactory (in their opinion), and that it should be redrawn in such
a way to support his or her own state or district.
However, we believe that the current network alignment could be
reassessed and possibly realigned. There is certainly nothing that
suggests that 21 service networks is the optimal structure. But where
does the VA draw the line when establishing its health care system
structure? With the current 21 VISN's, the VA seems to do a good job of
managing a massive health care system. This is not to suggest that the
administration of these networks is not bloated, but the alignment
itself seems satisfactory.
Meanwhile, it is our understanding that the Veterans Health
Administration is already considering a realignment of its VISN
structure. If this is in fact the case, then we believe the VA should
provide more information on this plan.
S. 3052
PVA supports the provisions of S. 3052. This legislation affirms
the important role that veterans' service organizations (VSO) play in
assisting veterans with their claims for benefits. It would ensure that
veterans who choose to file a claim for benefits electronically are
informed about their options for representation from a VSO national
service program. We would offer one suggestion about the proposed
language of the bill. We believe that the qualifier--``to the degree
practical''--at the beginning of the new Section 5103B should be
removed from the bill. We see no reason why it would not be practical
to inform veterans of their representation options. However, this
language gives the VA an excuse should it choose not to provide this
information.
S. 3049
PVA supports S. 3049, a bill that expands the legal definition of
``homeless veterans'' to align with the commonly accepted legal
standard for homelessness that exists in this country. Due to an
oversight in the law, the legal definition of ``homeless veterans''
differs significantly from the existing definition of homelessness.
Specifically title 38 U.S.C. does not recognize as being homeless an
``individual or family who is fleeing, or is attempting to flee,
domestic violence, dating violence, sexual assault, stalking, or other
dangerous or life-threatening conditions in the individual's or
family's current housing situation'' (42 U.S.C. Sec. 11302b). The
wording change proposed by S. 3049 would allow veterans who experience
a domestic violence situation, and choose to leave that situation, to
access the same benefits available to all other homeless veterans.
Currently, in order to qualify for benefits offered to homeless
veterans through the VA, an individual must only meet the definition of
homeless in outlined by 42 U.S.C. Sec. 11302a. It only makes sense that
the VA's definition for homelessness align with the larger Federal
standard.
S. 2320, the ``Remembering America's Forgotten Veterans Cemetery
Act of 2012''
Since 1991, the veterans' cemetery at Clark Air Force Base in the
Philippines has remained unattended and seriously deteriorated.
Volunteers have over the years tried to do some minor maintenance, but
those efforts have proven futile at best. No Federal assistance has
been provided to upkeep the Clark Veterans Cemetery. Meanwhile, the
remains of more than 8,300 servicemembers and their dependents remain
interred there.
The fact that the final resting place for those who have served and
sacrificed is in such a state of decay is wholly unacceptable. The
American public would not stand for any national cemetery in this
county to be maintained in this manner, and similar hallowed grounds
outside of the United States should not be treated in this way as well.
PVA supports S. 2320 which would give the American Battle Monuments
Commission (ABMC) authority to care for Clark Veterans Cemetery. The
ABMC is the best suited to assume this authority with their experience
in care for cemeteries and monuments in foreign lands. We must however
emphasize that adequate additional resources must be provided to the
ABMC to ensure that the proper care is given to the cemetery.
S. 2259, the ``Veterans' Compensation Cost-of-Living Adjustment Act
of 2012''
PVA supports S. 2259, the ``Veterans' Compensation Cost-of-Living
(COLA) Adjustment Act of 2012,'' that would increase, effective as of
December 1, 2012, the rates of compensation for veterans with service-
connected disabilities and the rates of dependency and indemnity
compensation (DIC) for the survivors of certain disabled veterans. This
would include increases in wartime disability compensation, additional
compensation for dependents, clothing allowance, and dependency and
indemnity compensation for children. PVA continues to oppose the
provision of this legislation that would round down any benefit to the
next lower whole dollar amount.
Last year marked the first time in three years that veterans (and
Social Security recipients) received a COLA increase. While our economy
continues to struggle, veterans' personal finances have been affected
by rising costs of essential necessities to live from day to day and
maintain a certain standard of living.
S. 2045
PVA does not support the proposed legislation. We believe that
imposing the locality residence requirement would lead to the negative
impression across the country that the Court of Appeals for Veterans
Claims is an ``inside the beltway club,'' a common concern often raised
by people on many issues outside of the Washington metropolitan region.
Perhaps more importantly, we are concerned that imposing this locality
restriction could eliminate some of the most qualified judges from
consideration for the Court. In fact, we understand that one of the
currently sitting judges works remotely from his home in another state
and continues to be one of the most productive judges on the Court.
S. 2244, THE ``VETERANS MISSING IN AMERICA ACT OF 2012''
The purpose of the Missing in America (MIA) Project is to locate,
identify and inter the unclaimed cremated remains of American veterans
through the joint efforts of private, state and Federal organizations.
The non-profit organization seeks to ``provide honor and respect to
those who have served this country by securing a final resting place
for these forgotten heroes.'' The proposed legislation would require
the VA to assist entities in possession of unclaimed or abandoned human
remains in determining if any such remains are the remains of veterans
or other individuals eligible for burial in a national cemetery.
Additionally, the legislation would require the VA to cover the cost of
funeral expenses and burial in the event that no next-of-kin can be
identified. PVA fully supports this legislation. We would only
emphasize that Congress must provide any additional resources necessary
to allow VA to provide burial services.
S. 1849, THE ``RURAL VETERANS HEALTH CARE IMPROVEMENT ACT''
PVA supports S. 1849, a bill that requires a five year strategic
plan for the VA Office of Rural Health (ORH) to improve access and the
quality of health care services for veterans in rural areas.
Approximately 40 percent of veterans who utilize VA health care
services live in rural areas, with a significant proportion of this
population residing in ``highly rural'' areas. If enacted, S. 1849
would require the VA to create a strategic plan for the ORH that
includes identifying goals and objectives for recruitment and retention
as well as for improving timeliness of care provided to veterans living
in rural areas.
PVA believes that attracting and retaining adequate staff within
the Veterans Health Administration (VHA) is one of the most critical
elements to providing quality health care in a timely manner. However,
recruiting and retaining medical professionals in rural settings
continues to be a challenge as the population of veterans residing in
rural areas continues to grow. PVA believes that the requirements of
S. 1849 to provide specific goals and objectives to improve rural
health care for veterans has the potential to further develop and
expand upon the improvements that VA has already made in the area of
rural health care. Particularly, PVA is pleased that this bill requires
VA leadership to define specific goals and objectives in the areas of
recruitment and retention, and enhance the use of current programs
using technology to increase veterans' access to VA health care
services.
While PVA supports S. 1849, it must be noted, that this bill
requires the VA ORH to develop a strategic plan that includes goals and
objectives for ensuring timeliness and improving the quality of health
care services provided through contract and fee-basis providers. PVA
believes that non-VA providers serve a purpose in meeting the health
care needs of veterans residing in rural areas and are an essential
component of the VA providing timely care in remote settings. However,
such options should not be used as a method or course to eliminate VA
facilities. PVA believes that the greatest need is still for qualified
VA health care providers to be located in rural settings. We believe
that the VA is the best health care provider for veterans. Providing
primary care and specialized health services is an integral component
of VA's core mission and responsibility to veterans. Over the years, VA
has earned a reputation as a leader in the medical field for its
quality of care and innovation in providing ``veteran-specific'' health
care.
Providing quality health care in rural settings is a continuous
challenge for the VA, however, Congress, the VA, and stakeholders such
as veteran service organizations must continue to develop innovative
strategies to meet the health care needs of rural veterans. PVA
believes that the strategic plan proposed in S. 1849 is a step in the
right direction.
S. 1838
While PVA has no specific position on this proposed legislation, we
believe that it could be beneficial therapy for veterans dealing with
Post-Traumatic Stress Disorder (PTSD) and other mental health issues. A
model program for this service was created in 2008 at the Palo Alto VA
Medical Center in conjunction with the Assistance Dog Program. This
program, maintained by the Recreational Therapy Service at the Palo
Alto VAMC, is designed to create a therapeutic environment for veterans
with post-deployment mental health issues and symptoms of PTSD to
address their mental health needs. Veterans participating in this
program train service dogs for later placement with veterans with
hearing and physical disabilities. As we understand it, in 2006, Walter
Reed Army Medical Center conducted a similar, privately-funded, pilot
program where service dogs were used in therapeutic settings.
In these programs, training service dogs for fellow veterans is
believed to be helping to address symptoms associated with post-
deployment mental health issues and PTSD in a number of ways.
Specifically, veterans participating in the programs demonstrated
improved emotional regulation, sleep patterns, and sense of personal
safety. They also experienced reduced levels of anxiety and social
isolation. Further, veterans' participation in these programs has
enabled them to actively instill or re-establish a sense of purpose and
meaning while providing an opportunity to help fellow veterans
reintegrate back into the community. Given the apparent benefit to
veterans who have participated in similar programs as the one proposed
by S. 1838, we see no reason to oppose this legislation.
S. 1799, the ``Access to Appropriate Immunizations for Veterans Act
of 2011''
PVA supports S. 1799, which proposes to amend title 38, United
States Code to provide for requirements related to the immunization of
veterans. It is accepted fact that proper and timely administration of
immunizations can prevent the onset of more significant medical issues.
By requiring the Secretary to ensure these immunizations are
administered in compliance with the recommended adult immunization
schedule, and requiring quality measures to ensure this is done, it can
be expected that veterans using the VA will be healthier and less
likely to suffer potential medical ailments. The Department of Defense
(DOD) follows these procedures to ensure a more ready military force.
It only makes medical and economic sense that the health gains achieved
by the DOD program for individuals prior to leaving service should be
continued to maintain and benefit the health of veterans. Proper and
timely immunizations are a guarantee of better medical health in the VA
patient population.
S. 1755
PVA strongly supports S. 1755, a bill to amend title 38, United
States Code, to provide certain disabled veterans coverage under the
beneficiary travel program of the VA when seeking services for special
disabilities rehabilitation. Currently, the Department of Veterans
Affairs (VA) does not provide travel reimbursement for catastrophically
disabled non-service-connected veterans who are seeking inpatient
medical care. PVA believes that expanding VA's beneficiary travel
benefit to this population of severely disabled veterans will lead to
an increasing number of catastrophically disabled veterans receiving
quality comprehensive care, and result in long-term cost savings for
the VA.
Under S. 1755, Section 111 of title 38 U.S. Code would be amended
to extend travel reimbursements benefits for inpatient care to
catastrophically disabled non-service-connected veterans who have
incurred a spinal cord injury or disorder, visual impairment, or
multiple amputations. For this particular population of veterans, their
routine annual examinations often require inpatient stays, and as a
result, significant travel costs are incurred by these veterans.
Eliminating the burden of transportation costs as a barrier to
receiving health care, will improve veterans' overall health and well
being, as well as decrease, if not prevent, future costs associated
with both primary and long-term chronic, acute care.
Too often, catastrophically disabled veterans choose not to travel
to VA medical centers for care due to significant costs associated with
their travel. When these veterans do not receive the necessary care,
the result is often the development of far worse health conditions and
higher medical costs for the VA. For veterans who have sustained a
catastrophic injury like a spinal cord injury or disorder, timely and
appropriate medical care is vital to their overall health and well-
being.
S. 1707, THE ``VETERANS SECOND AMENDMENT PROTECTION ACT''
Regarding S. 1707, the ``Veterans Second Amendment Protection
Act,'' PVA has no formal position on this legislation.
S. 1705
PVA's National office has no position on naming the VA medical
center in Spokane, Washington, as the ``Mann-Grandstaff Department of
Veterans Affairs Medical Center. PVA believes naming issues should be
considered by the local community with input from veterans
organizations within that community. With that in mind, we would defer
to the views of PVA's Northwest Chapter.
S. 1631
PVA generally supports the intent of S. 1631, legislation that
authorizes the VA to establish a center for technical assistance for
non-VA health care providers who furnish care to veterans in rural
areas. As previously stated, we believe that the VA is the best health
care provider for veterans. However, when veterans reside in rural
areas and do not have timely access to VA health care services, it is
important that the care provided outside of the VA meet the proper
standards of quality and can be properly coordinated with VA medical
professionals. S. 1631 proposes to improve collaboration on veterans'
health care matters between VA and non-VA providers serving veterans in
rural areas by encouraging exchange of health care information between
providers, creating shared internet-based information databases to
collect information on mechanisms to improve health care for veterans
in rural areas, and creating systems to monitor fee expenditures of the
VA relating to non-VA provider services.
PVA recognizes that veterans frequently seek health care services
from non-VA providers independently and through VA purchased care and
contract care programs. Therefore the VA must continue its efforts to
increase care coordination, as this bill proposes, with private
providers to ensure that veterans receive the best possible health care
services available. With this in mind, PVA is concerned that the
creation of the Rural Veterans Health Care Technical Assistance Center
will contribute to growing VA administrative costs and perhaps will
result in a duplication of efforts, as it appears that the purpose of
the center is in direct alignment with VA's Office of Rural Health. It
is unclear in the bill exactly where the supervisory authority of the
center will come from; therefore, PVA recommends that the center be
housed within the ORH to most efficiently utilize VA resources.
S. 1391
PVA supports S. 1391. According to reports, sexual assault in the
military continues to be a serious problem, despite several actions by
the Department of Defense (DOD) to combat the issue, including required
soldier and leader training. As the military works to reduce the threat
and incident of military sexual trauma (MST), it is important that
victims of MST, both women and men, have the ability to receive care
from the VA and receive timely, fair consideration of their claims for
benefits. This is particularly important given the number of MST
occurrences that go unreported. While current policies allowing
restricted reporting of sexual assaults should reduce the number of
incidents which have ``no official record,'' it can still be
anticipated that there are those who will not report the incident out
of shame, fear of reprisals or stigma, or actual threats from their
attacker. To then place a high burden of proof on the veteran who has
experienced MST to prove service-connection, particularly in the
absence of an official record, would add further trauma to an already
tragic event.
One particular recommendation that PVA would like to make about the
proposed language is a clarification on what constitutes a ``mental
health professional.'' We would hope that the intent of this
legislation is not to limit ``mental health professionals'' to only VA
health care professionals.
S. 1264, THE ``VETERAN VOTING SUPPORT ACT OF 2011''
PVA supports S. 1264, the ``Veteran Voting Support Act of 2011.''
PVA advocates for the rights of veterans, persons with disabilities,
and all Americans, which enable them to participate in the election
process. Making the voting process accessible and available for
paralyzed veterans has been a priority for our organization.
PVA supports the requirement of the VA to provide information
relating to requesting an absentee ballot and making absentee ballots
available upon request. PVA also supports the provision of the bill
that would permit nonpartisan organizations to provide voter
registration information at facilities of the VA.
THE ``HOMELESS VETERANS ASSISTANCE IMPROVEMENT ACT OF 2012''
PVA generally supports the provisions of the draft legislation, the
``Homeless Veterans Assistance Improvement Act.'' Many of the grant
programs outlined in the legislation will help veterans who are
homeless or are facing the prospect of homelessness to overcome the
hurdles that they may face. PVA is disappointed to see that the annual
amount authorized the Secretary of Veterans Affairs to carry out
homeless veterans programs is being decreased from $200 million to $150
million. This step reflects a concern that we raised in the past that
changing authorization levels for funding homeless programs would
likely be an empty gesture.
PVA is particularly pleased to see the extension of the Homeless
Veterans Reintegration Program (HVRP). However, we are concerned that
this extension only provides for one additional year. The HVRP program
is perhaps one of the most cost-effective and cost-efficient programs
in the Federal Government. Despite being authorized $50 million per
year, it generally is appropriated less than half of that authorized
level every year. And yet, it continues to serve a large number of
veterans who are taking the necessary steps to overcome homelessness.
Ultimately, in order to ensure that the myriad of homeless programs
are successful, fully sufficient resources must be provided to these
programs. Otherwise, overcoming homelessness becomes a policy without
the possibility of true success.
THE ``MENTAL HEALTH ACCESS ACT OF 2012''
PVA supports the proposed legislation, the ``Mental Health ACCESS
Act of 2012.'' The proposed bill would improve and enhance the programs
and activities of the VA regarding suicide prevention and resilience,
and behavioral health disorders for veterans and servicemembers. While
the VA has made tremendous strides in the quality of care and variety
of services provided to veterans in the area of mental health, PVA
believes that issues involving access to mental health care continue to
exist and more must be done to make certain that all veterans receive
timely and effective services. It is for this reason that we thank the
Committee for reviewing this important piece of legislation.
Under the proposed bill, the VA is required to conduct a
comprehensive assessment of VA mental health care services with
particular attention to the areas of timeliness of care, mental health
staffing, and the availability and furnishing of evidence-based
therapies. The bill goes a step further and requires the VA to
establish a ``Study Committee'' to assist in developing and
implementing the aforementioned improvements in mental health care
delivery. PVA believes that a comprehensive assessment of VA mental
health services is much needed, and we also support the requirement to
have the VA develop and implement guidelines for the staffing of
general and specialty mental health care services, including community-
based outpatient clinics. Such staffing guidance is especially
important in light of VA's recent announcement to hire additional
mental health professionals.
One of the most significant provisions of the bill is the proposal
to amend title 38, United States Code, Section 1712A to expand
eligibility for readjustment counseling and related mental health
services. If enacted, this bill will enable VA to provide certain
members of the Armed Forces, and their family members, with counseling
services through VA Vet Centers. PVA strongly supports these amendments
as we understand that servicemember deployments and veteran
readjustment to civilian life not only affects the individuals who
served their country, but also their family members, loved ones, and
others that serve as close support networks. Nonetheless, with such a
significant expansion of services now becoming available to this new
population, PVA is concerned that the cost increases associated with
this change have the potential to limit the quality and availability of
services for the intended groups. PVA recommends that the VA and
Congress conduct an assessment that evaluates the ability of Vet
Centers to provide the services needed by veterans, servicemembers, and
their family members to best determine if and when these services can
be provided.
Additionally, the draft legislation gives the VA Secretary the
authority to furnish mental health care through facilities other than
Vet Centers to immediate family members of servicemembers deployed in
connection with a contingency operation. Again, PVA supports and
understands the intended purpose of this provision, however, should the
VA provide the prescribed services, both VA and Congress must work to
ensure that adequate resources are made available to meet the new
demand.
PVA would once again like to thank the Committee for the
opportunity to submit our views on the legislation considered today.
Enactment of much of the proposed legislation will significantly
enhance the health care and benefits services available to veterans,
servicemembers, and their families. We look forward to working with the
Committee to ensure quick enactment and implementation of these
important changes.
This concludes PVA's statement. We would be happy to receive any
questions that you may have.
______
Letter from Barbara Collura, President, Resolve
The National Infertility Association,
McLean, VA, June 26, 2012.
Hon. Patty Murray,
Chairman,
Committee on Veterans' Affairs
U.S. Senate, Washington, DC.
RE: Testimony for hearing on S. 3313
Dear Chairman Murray: On behalf of the 7.3 million Americans who
are diagnosed with infertility, I commend you for introducing S. 3313,
the ``Women Veterans and Other Health Care Improvements Act of 2012.''
Infertility is a devastating diagnosis to receive and it is further
complicated by lack of insurance coverage for most Americans. As you
know, TRICARE, and other medical benefits for active duty military and
veterans, does not include coverage for infertility treatments
including assisted reproductive technologies, such as in vitro
fertilization (IVF). This places an added hardship on our servicemen
and women and veterans with infertility that is unnecessary.
RESOLVE: The National Infertility Association applauds your efforts
to provide fertility counseling and medical treatment to veterans
wounded in the line of duty. These veterans have many necessary medical
services available to them upon returning home, yet if their military
service has rendered them infertile, they have no access to medical
treatment to have a child. This is an injustice that your bill seeks to
correct. By providing this coverage, veterans have a chance at the
family they always dreamed of. For many wounded veterans, assisted
reproductive technologies such as IVF may be their only hope of ever
having a biological child with their spouse. IVF has been practiced for
over 30 years and is a safe and effective treatment for many types of
infertility that cannot be treated with medication or surgical
procedures. In recent years, professional guidelines have made IVF even
safer and more effective through reducing the incidence of multiple
births, improving egg and embryo freezing technologies, and improving
pregnancy rates through embryo quality.
RESOLVE would like to suggest that infertility coverage be expanded
to include all veterans and active duty military so that all those with
infertility in our Armed Forces have access to the care they need.
Infertility affects men and women equally, and some infertility is
unexplained. It is important that men and women receive access to care
at the same level. Many couples find that they need to utilize third
party reproduction to have a child, such as using donated sperm, eggs
(oocytes), or embryos. Others can have a biological child but need a
gestational carrier surrogate to carry the pregnancy. The cost for
these medical services should be included in this legislation.
Our wounded veterans deserve access to the best medical care that
is available for their medical condition, and this bill will do just
that. So much has been taken away from our wounded veterans; don't take
away their dream of having a child, especially when medical treatment
exists to help them. RESOLVE stands ready to assist the Department of
Veterans Affairs in providing the necessary support and information to
our veterans who pursue care for their infertility.
Thank you again for introducing this bill.
Sincerely yours,
Barbara Collura,
President.
______
Letter from Ron Sims, Seattle, Washington
Enclosures
Enclosures from Ron Sims regarding Clark Veterans Cemetery
______
Prepared Statement of Morris Klein, Esq., Attorney at Law, Bethesda,
Maryland, and Lois Zerrer, Zerrer Elder Law Office, LLC, Springfield,
Missouri, on Behalf of the Special Needs Alliance
Chairwoman Murray, Senator Burr and Members of the Committee, Thank
you for inviting the Special Needs Alliance (SNA) to submit testimony
this morning.
The SNA is a national, not-for-profit organization of attorneys
dedicated to the practice of disability and public benefits law. Our
mission is to maintain a professional organization of attorneys skilled
in the complex areas of public entitlements, estate, trust and tax
planning, and legal issues involving individuals with physical and
cognitive disabilities, including veterans with disabilities. SNA
membership is based on a combination of relevant legal experience in
the disability and elder law fields, direct family experience with
disability, active participation with national, state and local
disability advocacy organizations, and professional reputation.
It is our privilege to provide comments on S. 3270, legislation
that will impose a ``look-back'' period for veterans and their spouses
who transferred countable assets and then seek a Non-Service-Connected
Disability Pension for assistance to pay for their care needs.
NEED TO SPECIFY RESOURCE STANDARD
We respectfully request that the bill ultimately include a
provision requiring the VA to specify the maximum amount of resources
an applicant may retain to be eligible for benefits.
The VA does not have a clear, fixed standard as to what amount of
resources an applicant may possess to be eligible for benefits. Other
means-tested programs that consider resources, particularly SSI and
Medicaid, have specified maximum amounts of resources (the amount for
SSI is $2,000 and the amount for Medicaid is determined by the state,
usually between $2,000 and $4,000). Administrators at the VA apparently
have discretion in determining whether a particular applicant has
sufficient resources to qualify for the program. This can result in
unequal treatment between applicants. A veteran can only ``guess''
whether the resources he or she has is low enough to be eligible for
benefits. Moreover, a veteran in one region may qualify for benefits
while a veteran in another region would not be eligible. This lack of
consistency makes it difficult for a veteran to determine whether or
not to apply for benefits. The lack of consistency is particularly
disquieting now that an applicant may face a ``penalty'' for
transferring resources. Ironically, the smaller the benefit the veteran
receives, the greater the penalty (up to the 36 month maximum).
CONSIDERATION OF SPECIAL NEEDS TRUSTS
We respectfully request that the bill ultimately include a
provision exempting special needs trusts from consideration as a
countable resource.
The GAO suggested an eligibility scheme that is similar to other
means-tested programs. Other means-tested programs, such as SSI and
Medicaid, do carve out an exception for special needs trusts. A special
needs trust is different than the purchase of annuities that the GAO
has criticized in a recent report, and is not the type of trust
contemplated or discussed as abusive. Only a person who has suffered a
disability can become a beneficiary of a special needs trust.
Specifically, a special needs trust allows a person who has a physical
or mental disability to have assets held in trust to help pay for care
needs that would not be covered by public benefits. Special needs
trusts had been used for many years. In 1993, Congress explicitly
authorized the use of special needs trusts for the benefit of
individuals who are under the age of 65 and disabled as defined by the
Social Security Administration. The assets of an individual with a
disability that are placed in a properly drafted special needs trust
are not considered available for purposes of qualification for SSI and
Medicaid. Such trusts are irrevocable and require funds to be used only
for the sole benefit of the beneficiary, and any funds remaining in the
trust after the beneficiary dies must be ``paid back'' to the state
Medicaid agency to the extent the agency paid for the beneficiary's
care. See 42 U.S.C. Section 1396d4(A).
Congress has heretofore not taken a position on special needs
trusts as they apply to VA benefits. A VA General Counsel opinion
(VAOPGCPREC 33-97, VA General Counsel Opinion dated August 2, 1997)
concluded that funds in a special needs trust are counted as resources.
Thus, unlike applicants for other government needs-based benefits,
veterans who are applicants for the improved pension and Aid and
Attendance benefits who are also beneficiaries of special needs trusts
will have the funds in the trust counted as an available resource. This
in effect discriminates against the veteran who is treated differently
than non-veterans in their ability to set aside such funds.
We believe that there is no meaningful distinction between the
treatment of special needs benefits for other public benefit programs
and the VA program, and we respectfully urge the Committee to extend
the current treatment of special needs trusts to VA benefits.
TRANSFERS TO CHILDREN WITH DISABILITIES
The legislation should ultimately carve out an exemption for
transfers to blind and disabled children.
Continuing with the GAO suggestion that the VA eligibility
standards follow other public benefit programs, this legislation should
also exempt transfers to the children of veterans who are blind or
disabled. Federal law for Medicaid and SSI eligibility have exempted
such transfers to blind and disabled children. See 42 U.S.C. Section
1396p(a)(2)(B) and 1396p(c)(2)(A) and (B).
ELIGIBILITY DATE AS APPLIED TO REDETERMINATIONS
The law should only apply to transfers made after the law goes into
effect.
It appears clear from the language of the legislation that the
imposition of a look-back period is to be applied prospectively, as the
changes go into effect one year after the bill is signed into law.
However, the law applies to annual redeterminations as well, and since
there is a three-year look back, a beneficiary may lose benefits
resulting from transfers made two years before the effective date of
the law. We therefore suggest that the law be clarified to state that
transfers made prior to the effective date of the law shall not be
subject to the look-back period.
Thank you again for the opportunity to share these thoughts on
S. 3270. The Special Needs Alliance looks forward to working with the
Committee to address these technical issues in the legislation. Please
let us know if we can be of further assistance.
______
Prepared Statement of Anu Bhagwati, Executive Director,
Service Women's Action Network
Chairman Murray and Members of the Committee: Thank you for the
opportunity to present the views of the Service Women's Action Network
(SWAN) concerning three bills included in this legislative hearing:
S. 1391, S. 3049 and S. 3313.
SWAN is a nonprofit service organization founded to improve the
welfare of current U.S. servicewomen and to assist all women veterans.
SWAN offers personal support and guidance to fellow women veterans,
provides legal and counseling services from military law experts and
caseworkers, recommends sound policy reform to government officials,
and educates the public about servicewomen's issues through various
media outlets. Conceived as a support network by and for women
veterans, SWAN serves all military women, regardless of era,
experience, or time in service.
SWAN has been working on improving benefits for women veterans,
both within the VHA and VBA as an ongoing policy priority for many
years and is extremely encouraged by the engagement and leadership
shown by the Committee over the years on key issues that are critical
to ensuring that women veterans receive the very best in care and
benefits. It is with that goal in mind that SWAN provides hearing
testimony on the following bills:
S. 1391--TO AMEND TITLE 38, UNITED STATES CODE, TO IMPROVE THE
DISABILITY COMPENSATION EVALUATION PROCEDURE OF THE SECRETARY OF
VETERANS AFFAIRS FOR VETERANS WITH POST TRAUMATIC STRESS DISORDER OR
MENTAL HEALTH CONDITIONS RELATED TO MILITARY SEXUAL TRAUMA, AND FOR
OTHER PURPOSES.
SWAN fully supports S. 1391. In 2010, the VA adopted a new
evidenciary standard for combat-related Post Traumatic Stress Disorder
(PTSD) claims. Prior to this change, veterans filing a claim for
combat-related PTSD had to demonstrate they were traumatized by a
specific event by supplying incident reports, witness statements or
other evidence. Since the policy change, the evidence required has been
reduced to having the veteran's trauma claim related to fear of hostile
military or terrorist activity and that it is consistent with the
veteran's service record. The intent behind this change was to expedite
and increase access to much needed disability benefits for
servicemembers suffering from the invisible wounds of war.\1\
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\1\ http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1922
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However, when making these changes. The VA did not include PTSD
caused by Military Sexual Trauma (MST), even if that trauma was a
result of sexual assault or sexual harassment in a combat zone. By
excluding MST-based PTSD claims in this procedural reform, the VA has
created a double-standard and an unfair burden on women veterans who
must submit additional evidence to support a service connection. This
has a particularly disparate impact on women since MST is the leading
cause of PTSD among women veterans, while combat trauma is the leading
cause of PTSD among men.\2\ SWAN has recently worked with a woman who
had both an MST-based PTSD claim and a combat PTSD claim pending. She
abandoned her MST PTSD claim and only pursued her combat PTSD claim
after her MST claim was repeatedly rejected even after she provided the
additional evidence requested by the VA.
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\2\ Street et al. 2008. ``Sexual harassment and assault experienced
by reservists during military service: Prevalence and health
correlates.'' Journal of Rehabilitation Research and Development 45:
409-420; Kang et al. 2005. ``The role of sexual assault on the risk of
PTSD among Gulf War veterans.'' Annals of Epidemiology 15(3):191-195.
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Additionally, SWAN has discovered through data obtained from the VA
through a Freedom of Information Act (FOIA) request that there is a
disparity in the approval rates of MST-based PTSD claims as compared to
all other PTSD Claims, to include combat PTSD claims. Between 2008 and
2010, only 32% of MST PTSD claims were approved whereas 53% of all
other PTSD claims were approved, and nearly 50% of PTSD claims from
Iraq and Afghanistan veterans were approved.\3\
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\3\ In conjunction with the ACLU, SWAN filed a Freedom of
Information Act (FOIA) request to obtain data concerning gender
differences in approval for MST-related PTSD claims. Based on data
analyzed for fiscal years 2008-2010 SWAN discovered that only 32% of
all PTSD claims related to sexual trauma are accepted. Conversely, 53%
of PTSD claims overall are accepted. About half of PTSD claims filed by
Iraq and Afghanistan veterans are accepted.
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The end state of the current policy is this: For 2 out of 3
veterans who are survivors of in-service sexual assault they receive no
disability benefits related to their PTSD. This lack of benefit care
results in tremendous hardship for MST survivors, leading to untold
mental and physical suffering, destroyed families, homelessness and
suicide. This is not conjecture, it is supported by the facts: 40% of
homeless women veterans report they were victims of military sexual
assault,\4\ and the VA reports that the increase risk for sexual
assault in the military is a factor in increased suicide among
veterans.\5\
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\4\ Williamson, Vanessa and Erin Mulhall. 2009. ``Invisible Wounds:
Psychological and Neurological Injuries Confront a New Generation of
Veterans.'' New York: IAVA. ; Mulhall, Erin. 2009. ``Women Warriors:
Supporting She `Who Has Borne the Battle.''' New York: IAVA.
\5\ http://www.charleston.va.gov/features/
Female_Veterans_at_Higher_Risk_for_Suicide.asp
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In 2011 SWAN began working with Under Secretary for Benefits,
Allison Hickey to correct this disparity and create a fair policy.
Initially, General Hickey was amenable to changing the policy due to
the clear difference in language found in 38 CFR Sec. 3.304(f)(3). She
soon moved away from that position and instead issued a letter to the
Regional Offices which did absolutely nothing to help. The RO letter
simply reiterated the current policy with an added emphasis on giving
the veteran's application the benefit of the doubt. She also issued
instructions to increase training for claims officers but in practice,
this has done nothing to improve the process. The claims officer is
free to disregard the new instructions and still be justified in
rejecting a MST-based PTSD claim based on the policy.
What is not understood by the VA is in many cases, it is
exceedingly difficult for a veteran suffering from MST-related PTSD to
produce evidence to satisfy the subjective standards of the reviewing
officer. This is due in part to the nature of sexual trauma--it often
takes years after the initial assault for survivors to begin to seek
out help many months or years after that to begin the arduous claims
process. This extended amount of time between the event and the claim
is a leading cause of rejections.
Additionally, there a lack of official paperwork generated in most
MST investigations, and although new policy changes have been made,
there has existed for years and years, poor DOD-wide document retention
policies for those forms that are produced. A new claim has the
advantage of the new document retention policies, but any claim prior
to 2011 does not. Finally, according to the DOD, in 2011 only 15
percent of sexual assaults are reported, which means in 85% of sexual
assault cases no official paperwork even exists to support a claim. In
spite of current VBA rules which allow for non-DOD evidence to aid in
the determination of a service-connected disability, the VBA still
routinely denies MST-related claims, even in cases where non-DOD
evidence is in abundance.
Due to these systemic shortcomings that lead to ever increasing
issues for veterans, in lieu of requirements for victims of in-service
sexual assault to submit the corroborating evidence under the current
policy, Committee support of S. 1391 is critical. The VA must extend to
these claimants the same evidentiary relief it has recently afforded to
veterans who experienced trauma due to operational deployment-related
stressors.
s. 3049--to amend title 38, united states code, to expand the
definition of homeless veteran for purposes of benefits under the laws
administered by the secretary of veterans affairs.
The U.S. Department of Housing and Urban Development recently
changed their definition of ``homeless'' to include persons who flee
their home due to domestic violence or sexual violence. S. 3049 would
align the VA's definition of ``homeless'' with HUD's definition,
pursuant to the Homeless Emergency Assistance and Rapid Transition to
Housing (HEARTH) Act.\6\
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\6\ http://www.hudhre.info/hearth/
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SWAN supports S. 3049 and feels that aligning these definitions
among Federal agencies is critical for two reasons: 1) There are
established partnerships between the VA and HUD at the state level, and
having parity in the definition would ensure an increased efficiency
when operating together; 2) More specifically, the way in which the VA
defines a ``homeless person'' can preclude them from getting emergency
shelter or other services if they are a victim of domestic violence.
Domestic violence is a leading cause of homelessness, particularly
among women and families. According to a 2008 report by the US
Conference of Mayors, 28% of families were homeless due to domestic
violence and 39% of cities cited domestic violence as the primary cause
of family homelessness.\7\ In spite of a decrease in overall veteran
homelessness, women veterans are accounting for an increasing number of
homeless. According to the GAO, the number of homeless women veterans
has doubled from 3.89% in 2006 to 6.32% in 2010.\8\ It is critical that
the Committee support S. 3049 in order to ensure that all veterans,
including those who flee unsafe and abusive situations have adequate
access to emergency and transitional housing.
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\7\ http://www.nationalhomeless.org/factsheets/domestic.html
\8\ GAO, Homeless Women Veterans: Actions Needed to Ensure Safe and
Appropriate Housing, GAO-12-182 (Washington, DC: Dec 2011).
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S. 3313--WOMEN VETERANS AND OTHER HEALTH CARE IMPROVEMENTS ACT OF 2012
SWAN fully supports S. 3313, the Women Veterans and Other Health
Care Improvement Act. The provisions in this bill that would establish
VA reproductive and infertility research and treatments, improve the
VA's women call center, increase the number of women's counseling
retreat locations from three to 14 and extend the pilot programs for
assistance for child care all address extremely important issues facing
women veterans, and would markedly improve the veteran's ability to
receive and sustain much needed medical assistance and care. SWAN would
like to comment further on the infertility provisions found in the
bill.
Two weeks prior to the introduction of this bill, SWAN received a
letter from a supporter named Heidi who lives in Illinois. Heidi
described in detail her difficult, painful and ultimately disfiguring
journey through the VA system in an effort to correct a fertility
issue. She eventually sought help out-of-pocket at a non-VA hospital.
There, her doctors struggled to correct the damage that had already
been done. ``I'm sure he did all he could,'' Heidi wrote, ``but I was
too damaged. I decided that I am not going to be able to have kids so I
need to forget about it.''
There is a critical need in the VA for proper research and
treatment for infertility, particularly in light of the high rates of
genitourinary issues including urinary tract infections (UTIs)
experienced by military women. According to a study conducted in 2008
by the Defense Advisory Committee on Women in the Services (DACOWITS),
for deployed female servicemembers the most common health risk is
urinary tract infection.\9\ This has the long-term effect of increasing
infertility specifically among military women due to the operational
nature of the military. The National Institute of Health has found a
vast amount of evidence linking the presence of genitourinary infection
with infertility.\10\ It is therefore incumbent upon the VA to provide
proper research and treatment for infertility for these women, and
critical for the Committee to support S. 3313.
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\9\ http://www.defense.gov/news/newsarticle.aspx?id=48827
\10\ http://www.ncbi.nlm.nih.gov/pubmed/360560
I thank the Chair and the Committee for their time and attention in
reading this testimony. I am available to answer any further questions
if needed.
______
Prepared Statement of Charles Huebner, United States Olympic Committee
S. 3206--TO EXTEND THE AUTHORIZATION OF THE U.S. PARALYMPIC INTEGRATED
ADAPTIVE SPORTS PROGRAM AND TO PROVIDE A MONTHLY ASSISTANCE ALLOWANCE
TO DISABLED VETERANS TRAINING OR COMPETING FOR THE PARALYMPIC TEAM
Chairman Murray and Ranking Member Burr, and Members of the
Committee, my name is Charlie Huebner and I am the Chief of Paralympics
for the United States Olympic Committee (``USOC''). Thank you for the
opportunity to submit a statement in support of S. 3206, which extends
the authorization for the highly successful partnership between the
USOC and the Department of Veteran Affairs to provide Paralympic sports
activities for disabled veterans in their communities. Paralympic
programs are sports for physically disabled athletes. These adaptive
sports activities have become an integral part of their recovery to a
full and healthy life after completing their service to our country.
In 2008 Congress passed the Veterans Benefits Improvement Act,
which authorized the Department of Veterans Affairs to award grants to
the United States Paralympics to ``plan, develop, manage, and implement
an integrated adaptive sports program for disabled veterans and
disabled members of the Armed Forces.'' The program did not commence
until Fiscal Year 2010 and the authorization expires at the end of
Fiscal Year 2013. It is imperative that Congress act this year to
extend the authorization for this program to ensure there is no
interruption in the services being provided to our disabled Veterans.
The USOC, which itself was created by Congress, is one of only four
National Olympic Committees that mange both Olympic and Paralympic
sport. We are one of only a handful of National Olympic Committees that
are 100% privately funded, with our major competitors outspending us
often as much as 5-to-1.
Beginning in 2003, the USOC, at the request of Congressional
leaders, and the Military and Veteran community began providing
technical assistance, training and leadership in providing programs to
injured servicemembers and Veterans, with a focus on developing
sustainable programming at the community and installation level.
The USOC has a strong history and expertise in more than 47 sports
(including non-Paralympic sports). We have expertise in serving persons
with a variety of physical disabilities. The USOC has inspiring Olympic
and Paralympic ambassadors that compel partners and competing
organizations to collaborate for a common cause. With more than 50
member organizations like the National Recreation and Parks Association
and USA Hockey, we have a membership infrastructure of community sport
organizations that touch thousands of U.S. communities, and allow for
financial and programmatic efficiencies and significant private sector
investment.
Because of the extraordinary increase in need, in 2008 the USOC
began accepting Federal funding for these programs, while continuing to
expend considerable private resources in support of these efforts. The
majority of these funds are distributed via grants to community sport
organizations to implement and develop local program.
The Paralympic Movement began shortly after World War II utilizing
sports as a form of rehabilitation for injured military personnel
returning from combat. Injured military personnel and Veterans are the
soul of the Paralympic movement. When discussing the Paralympic
movement, we are not just talking about a small number of elite
athletes that will make future Paralympic teams. Rather, we are
referring to the thousands of disabled active duty military personnel
and Veterans that have participated in the growing number of physical
activity programs created throughout the United States under the
leadership of the USOC and our community partners--like Paralyzed
Veterans of America, Disabled Sports USA, USA Shooting, and Metro
Tacoma Parks and Recreation--that allow Veterans with physical
disabilities an opportunity to re-engage in life by simply skiing with
their buddies or playing in the backyard with their kids. As
programming expands daily, we see a population that has lower secondary
medical conditions, higher self-esteem, lower stress levels and higher
achievement levels in education and employment. Increasingly, empirical
research specific to this population is beginning to bear this out.
More importantly, we see a population that inspires all Americans to
pursue excellence, in sports and in life.
We cannot emphasize enough the importance of our more than 200
partner organizations located in more than 170 communities and 47
states, and the District of Columbia. The Federal funding that the
Veterans Integrated Adaptive Sports program has provided has enabled
these organizations to leverage many millions of dollars more to
provide the full range of Paralympic sports programming to our
Veterans. We are proud to have the support and partnership of groups
including the American Legion, The Fisher House Foundation, the Blinded
Veterans Association, and the USO in endorsing S. 3206.
We are also proud that our leadership, and our partners, accepted
the responsibility to serve those who have served us. Because of your
leadership in developing and providing funding for this USOC and VA
partnership, we are able today to report on the several accomplishments
that have been reached since the launch of the program in June 2010.
Our primary emphasis in the first two years was to meet the immediate
need to develop programming for the thousands of disabled Veterans
returning to their communities and hometowns. Since June 2010, the VA,
USOC and our more than 200 partners have:
Distributed more than 300 grants to community sport
organizations to develop sustainable activity programs for disabled
Veterans returning to their hometowns.
These community programs are investing millions of dollars
in private resources, combined with grants from the VA-USOC grant pool,
to reach thousands of veterans with a focus on sustainable and
consistent physical activity at the local level.
The VA and USOC have emphasized and led an effort to
promote collaboration between the DOD, VA, and community sport
organizations to recognize and enhance programmatic and financial
efficiencies. To date, grant recipients have collaborated and partnered
with over 70 VA and DOD medical facilities across the country.
Created the Paralympic Resource Network, an online
database of Paralympic programs nationally which is designed to link
individuals with physical and visual disabilities to sports programs in
their communities.
Launched successful regional Pilot programs to test
approaches for veteran recruitment and programming strategies that can
be replicated in other areas in five locations including: Chicago-land
area; New England; Northern California; Georgia/ Southeast region; and
Texas/Gulf State area.
Inaugurated the VA Rehabilitative Adaptive Sports
Conference that provided VAMC personnel and leadership with the tools,
resources, and training necessary to successfully develop and implement
adaptive sport and recreation programs for disabled veterans at VA
facilities by collaborating with external community partners.
Distributed training stipends to over 90 Veteran athletes;
40 of these athletes have met the national team standard in their
respective sports.
Again, we felt it was imperative in the first two years to focus
the majority of our efforts on development and expansion of sustainable
programs at the community due to the significant volume of Veterans
returning home. Based on our experience in collaborating with the VA
and feedback from the congressional committees of jurisdiction and our
community partners, we recognized that program development should shift
to a more regional focus and enhanced oversight and monitoring needed
to be put in place with respect to program resources, generally, and
the growing number of sub-recipients. While sustainable and consistent
program development is a continued focus, we have already proactively
made adjustments in collaboration with the VA to accomplish the
following:
Increase resources devoted to program oversight and
monitoring in light of the expanded number of grant participants. This
includes increasing our oversight beyond a self-reporting system, with
desktop and personal site visits to grantees. With pro-bono services
provided by a leading consultant firm, the USOC and VA have developed
and instituted a new grant monitoring process, initiated internal
audits of grant sub-award recipients, and re-deployed three USOC staff
members to focus 100% on monitoring and oversight. In year one and two,
staff that was also focused on developing programming, were also
responsible for monitoring and oversight. We have determined that with
more than 200 program partners and an estimated 150 grant recipients,
it was not feasible for the program staff to also be responsible for
monitoring and oversight. Please find attached the updated monitoring
plan that the re-deployed staff are aggressively implementing and will
meet.
In 2011 and 2012, the USOC declined to accept the
federally-allowed administrative fee of five percent (5%), allowing an
estimated $700,000 to be re-invested into programming and grants.
Enhance awareness and educational materials of the impact
and importance of consistent physical activity for Veterans at the
national, regional and local level. For example, in a recent public and
privately-funded initiative around the USOC-hosted Warrior Games, the
USOC and VA reached more than 67.0M Americans with educational
programming about the importance of sport in the rehabilitation
process.
Recommend additional resources to support VA--USOC
regional coordinators that can enhance collaboration and impact of
programs in targeted regions throughout the United States. The emphasis
on developing and sustaining collaboration among competing entities is
a critical and time-consuming aspect to this cost efficient strategy.
We believe a neutral entity must lead this effort.
Continue to increase the number of community partners that
are providing much-needed sport and recreation programs, primarily at
their cost, at the local level for the disabled Veteran population.
In closing, I would like to highlight one program that embodies all
of our strategies, collaboration, training, technical assistance,
awareness and financial support, along with an emphasis on hiring
Veterans. Joe Brown is originally from Arizona. His family has a strong
military history. His grandfather died as a POW during the Korean War.
His father was an Air Force fighter pilot. Joe played football at the
Ohio State University and three years in the NFL. But the Army Rangers
were continually calling, so he joined the Army, the Rangers, and
deployed to Iraq in 2004 and again in 2007.
During his 2007 tour he was calling in air strikes atop a three-
story building, trying to help a unit in trouble. As his unit was
leaving the building, Brown fell down a 30-foot shaft, suffering a
severe brain injury. Brown knew the importance of physical activity and
sport in the rehabilitation process. He attended the USOC VA Paralympic
Leadership Conference to gain valuable training and connect with other
organizations and agencies in his region. He pursued a position in the
parks and recreation industry near a military facility so he could
serve injured servicemembers and Veterans. He was hired by Harker
Heights Parks and Recreation outside of Ft. Hood, Texas. Harker Heights
was awarded a $23,000 VA-USOC grant in 2010. Joe leveraged that initial
grant and has built a sustainable, on-going program that serves more
than 80 veterans who can now participate in an array of physical
activity programs under Joe's leadership.
I would like to thank the Committee, the VA leadership,
particularly Secretary Eric Shinseki; Mike Galloucis, Executive
Director of the Department of Veterans Affairs' Office of Public and
Intergovernmental Affairs; Chris Nowak, the Director of the VA's
National Veterans Sports Programs and Special Events; our
organizational partners in carrying out this program; of course,
Senators Boozman and Begich, who introduced S. 3206, and other Members
of the Committee who have joined them in cosponsoring this legislation
that extends a program that is so critical to supporting our Nation's
finest.
______
Letter from Heather L. Ansley, Esq., MSW, Vice President of Veterans
Policy, VetsFirst
VetsFirst, a program of United Spinal Association,
Washington, DC, July 5, 2012.
Hon. Barbara Boxer
112 Hart Senate Office Building
U.S. Senate, Washington, DC.
Dear Senator Boxer: VetsFirst, a program of United Spinal
Association, wishes to express our support for S. 1806, which would
allow individuals to designate tax overpayments as contributions to a
fund for homeless veterans. This legislation would supplement the
efforts of the Department of Veterans Affairs (VA) and other agencies
that assist homeless veterans and their families.
Homelessness among veterans and their families is a critical
problem that requires the attention of all Americans. Homeless veterans
represent all eras of military service, including those who served in
Iraq and Afghanistan. Our nation must provide the services and supports
needed by homeless veterans to ensure that current and future
generations of veterans will no longer endure homelessness.
VetsFirst believes that this legislation will allow Americans the
opportunity to personally invest in our nation's homeless veterans. The
creation of the Homeless Veterans Assistance Fund will provide a new
source of revenue to help our homeless veterans and their families, not
supplant current efforts by VA and other agencies. Ending homelessness
among our nation's veterans will require access to housing, health
care, and employment. The additional funds provided through this
legislation will give an important boost to already occurring
assistance.
We appreciate your leadership on this issue and urge swift passage
of this critical legislation that will help to eliminate and prevent
homelessness for our nation's veterans and their families. If you have
any questions, please contact Heather Ansley, Vice President of
Veterans Policy, at (202) 556-2076, ext. 7702 or by e-mail at
[email protected].
Sincerely,
Heather L. Ansley, Esq., MSW,
Vice President of Veterans Policy.
______
Letter from Dennis L. Wright, Captain, U.S. Navy (Retired),
Chairman, Clark Veterans Cemetery Restoration Association
[Attachments listed were not submitted to the Committee.]
______
Prepared Statement of Wounded Warrior Project
Chairman Murray, Ranking Member Burr and Members of the Committee:
Wounded Warrior Project (WWP) welcomes your consideration today of the
Mental Health Access to Continued Care and Enhancement of Support
Services (ACCESS) Act of 2012, and is very pleased to offer our views
on its important provisions to improve and enhance VA behavioral health
programs.
This Committee's painstaking and patient conduct of a series of
hearings regarding the performance of VA's mental health care system
has made clear that--despite the dedicated efforts of its mental health
clinicians--the Department of Veterans Affairs (VA) is not meeting its
fundamental obligation of providing timely, effective mental health
care to veterans of Operations Enduring Freedom, Iraqi Freedom and New
Dawn (OEF/OIF/OND) who are struggling with combat-related mental health
conditions.
We applaud the Committee's oversight work and welcome VA's recent
plan to increase its mental health staffing. While an important
initiative, it is only a partial, and still-untested step, in the
context of addressing wide-spread challenges.
For years, VA has reported to Congress on the health care
utilization of OEF/OIF/OND veterans. These data indicate that a
relatively high percentage of these veterans have accessed VA medical
facilities, and a significant percentage have been ``seen'' and
diagnosed (or provisionally diagnosed) with a mental disorder. But
these often updated and somewhat misleading reports are silent as to
whether, for example, veterans have continued in treatment or reported
improved. In that regard, one of the leading researchers on the mental
health toll of the conflicts in Iraq and Afghanistan, Dr. Charles W.
Hoge, has provided a more disturbing snapshot, underscoring real gaps
in the VA mental health system:
``* * * veterans remain reluctant to seek VA care, with half of
those in need not utilizing mental health services. Among
veterans who begin PTSD treatment with psychotherapy or
medication, a high percentage drop out * * * With only 50
percent of veterans seeking care and a 40 percent recovery
rate, current strategies will effectively reach no more than 20
percent of all veterans needing PTSD treatment.'' \1\
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\1\ Charles W. Hoge, M.D., ``interventions for War-Related
Postraumatic Stress Disorder: Meeting Veterans Where They Are,'' JAMA,
306(5): (August 3, 2011) 548.
The Committee's oversight has most effectively identified,
documented, and sparked VA action on some of the most glaring problems
of timeliness and access. But VA's responses--initially denying
staffing problems, and subsequently hurriedly reversing course--create
the impression of reactionary work with little substantive strategic
planning. VA does not provide confidence that effective systems are in
place or will be put in place to assure that wider gaps in the system
will be closed or even that warriors will not re-experience in a year
or two the kind of timeliness and access problems the Committee
identified over the course of three hearings. We concur, therefore,
that strong legislation is needed, and welcome the Committee's
consideration of Title II the bill which offers promise of markedly
improving veterans' access to needed treatment. WWP strongly supports
those provisions.
This legislation addresses important issues, while also implicitly
recognizing the need for further and perhaps deeper analysis. Given the
complexity of VA's mental health system, the variability of veterans'
experience from facility to facility, the unreliability or absence of
key data (as discussed in your most recent hearing on VA mental
health), it is critical that VA seek a comprehensive independent,
expert assessment to help assure that warriors will have reliable
access to timely, effective mental health care across the system. We,
therefore, applaud the inclusion in this measure of a requirement that
VA contract with the National Academy of Sciences (NAS) to conduct a
comprehensive assessment of VA mental health care (to include assessing
barriers to care for OEF/OIF/OND veterans, the quality of care, and the
range of services provided) and to provide VA specific detailed
recommendations. NAS has served VA well in the past. We believe it can
provide very helpful recommendations on overcoming barriers and
improving access to timely, effective mental health care as well as on
improving the effectiveness and efficiency of VA mental health
services. Recommendations from a prestigious body (which under the bill
would rely on a panel including members with VA expertise and
experience) should provide a strong foundation for closing critical
gaps that result in warriors never seeking needed treatment, dropping
out of treatment prematurely, or simply not thriving despite getting
some care. We also see real benefit in the bill's requiring VA to
consult with NAS in developing and implementing staffing guidelines and
other measures to assess timeliness, patient-satisfaction, capacity and
provision of evidence-based therapies.
Importantly, warriors consistently express high satisfaction with
the experience of getting help from Vet Centers. They cite relatively
unique aspects of that experience, including the opportunity to work
with clinicians who are themselves are often combat veterans and
understand the warrior-experience; Vet Centers' outreach-focused
approach; and access to family services. As such, we appreciate the
bill's focus on Vet Center services and the organizational status,
funding and planning for the Readjustment Counseling Service. We also
applaud the bill's clarifying that Vet Center staff can play an
important outreach role and foster warriors' readjustment by
participating in recreational, rehabilitative programs such as WWP's
Project Odyssey.
This bill is also important in recognizing that communities can
play an important role in providing veterans access to needed mental
health services and fostering their reintegration, and that VA can be
an invaluable partner in such community efforts. We welcome the
encouragement the bill provides VA to partner with community groups in
support of those efforts, as well as the important direction that VA
provide training in military culture and combat experience to
clinicians who would be providing mental health services through such
community initiatives.
Finally, we applaud the bill's requirement that every VA medical
center provide for peer outreach and peer support services. With too
many veterans either still reluctant to seek mental health care or
dropping out of care, the importance of peer-outreach and peer-support
cannot be overemphasized.
We look forward to working with the Committee to advance these
important provisions in furtherance of ensuring that warriors are able
to get timely, effective mental health care.
______
Testimony Submitted by Senator Barbara Boxer of California
Letter from AMVETS Department of California Service Foundation
______
Prepared Statement of Brian A. Hampton, Maj. USAR (Ret.), President,
Center for American Homeless Veterans, Inc.
______
Letter from the California Association of Veteran Service Agencies
______
Letter from the National Coalition for Homeless Veterans
______
Letter from Michael Blecker, Executive Director, Swords to Plowshares
______
Letter from Raymond C. Kelley, Director,
National Legislative Service, VFW
______
Testimony Submitted by Senator Dean Heller of Nevada
Letter from Fang A. Wong, National Commander, The American Legion
______
Letter from Matt Gornick, Policy Assistant Director,
National Coalition for Homeless Veterans