Text: S.Hrg. 113-203 — HEARING ON PENDING HEALTH CARE LEGISLATION
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[Senate Hearing 113-203]
[From the U.S. Government Publishing Office]
S. Hrg. 113-203
HEARING ON PENDING HEALTH CARE LEGISLATION
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
MAY 9, 2013
__________
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COMMITTEE ON VETERANS' AFFAIRS
Bernard Sanders, (I) Vermont, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Johnny Isakson, Georgia
Sherrod Brown, Ohio Mike Johanns, Nebraska
Jon Tester, Montana Jerry Moran, Kansas
Mark Begich, Alaska John Boozman, Arkansas
Richard Blumenthal, Connecticut Dean Heller, Nevada
Mazie Hirono, Hawaii
Steve Robertson, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
----------
May 9, 2013
SENATORS
Page
Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont....... 1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North
Carolina....................................................... 2
Letter for the record........................................ 4
Begich, Hon. Mark, U.S. Senator from Alaska...................... 42
Boozman, Hon. John, U.S. Senator from Arkansas................... 45
WITNESSES
Hon. Landrieu, Mary L., U.S. Senator from Louisiana.............. 6
Prepared statement........................................... 7
Jesse, Robert L., M.D., Ph.D., Principal Deputy Under Secretary
for Health, U.S. Department of Veterans Affairs; accompanied by
Susan Blauert, Deputy Assistant General Counsel................ 8
Prepared statement........................................... 10
Additional views............................................. 19
Response to posthearing questions submitted by:
Hon. Mark Begich........................................... 32
Hon. Richard Blumenthal.................................... 38
Response to request arising during the hearing by:
Hon. Bernard Sanders....................................... 39,40
Hon. Mark Begich........................................... 44
Weidman, Rick, Executive Director for Policy and Government
Affairs, Vietnam Veterans of America........................... 47
Prepared statement........................................... 49
Jonas, Wayne B., M.D., President and Chief Executive Officer,
Samueli Institute.............................................. 54
Prepared statement........................................... 56
Ansley, Heather, Esq., MSW, Vice President for Veterans Policy,
VetsFirst...................................................... 58
Prepared statement........................................... 59
Gornick, Matt, Policy Director, National Coalition For Homeless
Veterans....................................................... 63
Prepared statement........................................... 65
Bowman, Thomas, Former Chief of Staff, U.S. Department of
Veterans Affairs............................................... 67
Prepared statement........................................... 69
APPENDIX
Hon. Boxer, Barbara, U.S. Senator from California; prepared
statement...................................................... 83
Hon. Donnelly, Joe, U.S. Senator from Indiana; prepared statement 84
American Legion, The; prepared statement......................... 84
Zumatto, Diane M., National Legislative Director, AMVETS;
prepared statement............................................. 92
Wallis, Anthony A., Legislative Director/Director of Government
Affairs, The Association of the United States Navy; prepared
statement...................................................... 94
Zampieri, Thomas, Ph.D., Director of Government Relations,
Blinded Veterans Association (BVA); prepared statement......... 96
Consortium of Academic Health Centers for Integrative Medicine;
prepared statement............................................. 100
Ilem, Joy J., Deputy National Legislative Director, Disabled
American Veterans (DAV); prepared statement.................... 102
Iraq and Afghanistan Veterans of America (IAVA); prepared
statement...................................................... 115
Integrative Healthcare Policy Consortium (IHPC); prepared
statement...................................................... 120
Kahn, Janet R., Ph.D., LMT, President and CEO, Peace Village
Projects, Inc.; prepared statement............................. 120
Paralyzed Veterans of America (PVA); prepared statement.......... 122
Service Women's Action Network (SWAN); prepared statement........ 128
Kelley, Raymond C., Director, National Legislative Service,
Veterans of Foreign Wars of the United States; prepared
statement...................................................... 130
Wounded Warrior Project; prepared statement...................... 135
HEARING ON PENDING HEALTH CARE LEGISLATION
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THURSDAY, MAY 9, 2013
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:03 a.m., in
room 418, Russell Senate Office Building, Hon. Bernard Sanders,
Chairman of the Committee, presiding.
Present: Senators Sanders, Begich, Burr, and Boozman.
OPENING STATEMENT OF HON. BERNARD SANDERS,
CHAIRMAN, U.S. SENATOR FROM VERMONT
Chairman Sanders. Welcome to today's hearing to examine
health legislation before this Committee. We have got a lot of
work to cover. Let us get started.
This Committee intends to be aggressive in bringing forth
legislation. We need to have stakeholders, people who are
familiar with the issues that we are dealing with, comment on
the concepts that we are bringing forth and then make those
modifications that make sense.
Today's agenda reflects important work by Senators on both
sides of the aisle. We have a number of pieces of legislation
that Members on this Committee have authored as well as pieces
authored by Members who are not on this Committee.
I think people are aware of the fact that veterans
throughout this country are addressing many serious issues. I
think both sides of the aisle in this Committee, as well as
outside of this Committee, you see Members who want to
introduce legislation to address some of those problems.
In the 111th Congress, I was pleased to support the
Caregivers and Veterans Omnibus Health Services Act of 2010,
which expanded services and benefits for caregivers of post-9/
11 veterans. The Caregiver Program allows these seriously
wounded veterans to receive care at home, provided by a family
caregiver. As of the end of February, more than 8,600 veterans
and their caregivers have benefited from this important
program.
For as long as injured veterans have returned from the
battlefield, family members have worked tirelessly to provide
the safe environment for these heroes to live comfortably at
home.
Historically, these caregivers have done this without any
support from the Federal Government. This changed with the 2010
law when, for the first time, veterans' caregivers became
eligible for supportive services and benefits.
These benefits included: a tax-free monthly stipend,
reimbursement for travel expenses, health insurance, mental
health services and counseling, training, and respite care.
These benefits and services gave caregivers the support they
needed to provide the best possible care for their loved ones.
I am very proud of the success of that piece of legislation.
However, when the law was passed, these services were only
made available to post-9/11 veterans and family members. The
legislation I have introduced, S. 851, expands the Caregiver
Program and extends these services and benefits to the
caregivers of veterans of all eras.
Through this expansion, family members who have been
providing care to eligible veterans from all other eras will be
able to access the same supportive services as the caregivers
of our most recent generation of veterans.
I hope that my colleagues will join with me in passing this
important bill so that all of our veterans and the their
families will be able to get the support that they need. There
are so many families out there who have done the right thing by
their loved ones, people who have been injured in war, and I
think we need to support them.
The other piece of legislation that I am working on is a
very consequential piece of legislation. In Vermont and all
over this country there is an increasing understanding that
health care is not just treating illness but it is preventing
disease, supporting wellness and utilizing complementary and
alternative medicine.
This broader understanding is growing by leaps and bounds.
I can remember not so many years ago--Senator Burr, you may
remember as well--when chiropractic care was thought to be
somewhat outside of the mainstream. That has certainly come
into the mainstream now. In fact, it is practiced within VA
health care today. We have some legislation before us today,
introduced by Senator Blumenthal, to expand access to
chiropractic care in VA.
Acupuncture is also being practiced in VA facilities.
Meditation and yoga are also being utilized in VA centers. I
was recently in Brooklyn, NY, and out in Los Angeles. What the
clinicians there tell me is that many veterans utilize these
complementary and alternative medicine services with success,
and the veterans enjoy it.
So, we are going to be introducing legislation to expand
those concepts. I will go into that in more length, but Senator
Burr, please say a few words. Senator Landrieu is also here,
and I know she has legislation that she wants to talk about. We
look forward to hearing from her.
STATEMENT OF HON. RICHARD BURR, RANKING MEMBER,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Thank you, Mr. Chairman. Thank you for
calling this important hearing. I welcome all of our witnesses
today and look forward to all of your testimony.
I also want to especially thank Tom Bowman for being here.
Boy, he is somebody who has devoted his career to the VA and we
are grateful for that, and I am grateful that you are here
today to testify.
Mr. Chairman, as we consider all the bills on today's
agenda, I think it is just as important to consider a few
things, especially before creating or expanding programs. I
believe we should start by considering how well existing
programs work and identify any gaps in services and
inefficiencies that exist.
By examining current programs, this will help us focus on
the changes that are truly needed and avoid creating any
duplication or overlap which is often very frustrating for
veterans and for their families.
Last, it is also important to consider the fiscal
challenges facing our Nation. We need to know the costs of any
program before that program is moved forward, and we must find
responsible ways to pay for all of these programs.
With all that in mind, I look forward to a productive
discussion about the bills on today's agenda. To start, I would
like to mention several of those bills which I have sponsored.
One is S. 543, the VISN Reorganization Act of 2013. This
legislation would reform VA's Veterans Integrated Service
Networks, or VISNs. In 1995, the veterans health care system
was divided into 22 geographic areas. That is now 21 VISNs.
Each region had its own headquarter with a limited management
structure to support the medical facilities in that region.
Since that time, 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, more importantly, should allow resources to be
reallocated to direct patient care.
Another bill is S. 529, which would change the start date
for eligibility of hospital care and medical services in
connection with exposure to the contaminated water at Camp
Lejeune, NC.
This legislation is very simple. It would change the date
from January 1, 1957, to August 1, 1953, which is based on a
letter sent to Under Secretary Hickey from Dr. Christopher
Portier, the Director of the National Center for Environmental
Health and Agency for Toxic Substance and Disease Registry.
In this letter, Dr. Portier states, ``according to our
water modeling, we estimate that the first month any VOC
exceeded the current EPA MCL in finished water was August 1953,
and at least one VOC exceeded its current MCL in Hadnot Point
drinking water from August 1953 through January 1985.''
Therefore, I believe there is credible evidence that warrants
the change in the commencement date.
I would ask unanimous consent at this time that this letter
be made a part of the record.
Chairman Sanders. Without objection.
[The letter follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Burr. Last, I would like to touch on one other
bill, S. 825, which is a bill Chairman Sanders and I introduced
together that would improve VA homeless prevention programs and
VA transitional housing.
This legislation will reduce barriers many homeless
veterans face including providing legal services, provide
services to dependent children of those veterans seeking
services through the transitional housing program and ensure
the safety of women by requiring facilities to meet the gender-
specific needs of homeless women veterans.
Mr. Chairman, all of these bills would provide common-sense
solutions to real issues affecting our Nation's veterans, their
families, and their survivors. I look forward to working with
you and with the rest of our colleagues to see that these and
other worthwhile bills on today's agenda can soon become law.
I thank the Chair.
Chairman Sanders. Senator Burr, thank you very much and
thank you for your support on the Homeless Veterans' Prevention
Act of 2013. I look forward to working with you to make sure
that we pass that important piece of legislation.
I also want to concur with you. Our job is, as an oversight
committee, to make sure that we do not see duplication, we do
not see waste. I happen to believe that, by and large, the VA
has a very strong health care system. They are doing a good
job. But it is a huge system and nobody, I think, can tell us
that everything is perfect. Our job is to see how we can
improve it, make it cost effective, and add new programs which
strengthen it.
With that, I am delighted to welcome our colleague from
Louisiana who is here to talk about a very important issue.
Senator Landrieu, thank you very much for being here.
STATEMENT OF HON. MARY L. LANDRIEU,
U.S. SENATOR FROM LOUISIANA
Senator Landrieu. Thank you so much, Senator Sanders, and
thank you, Senator Burr for your focus on the needs of our
veterans and improving our outreach to them and our health care
to them. I thank you for the diligence, Mr. Chairman, that you
bring to this issue particularly.
I wanted to bring to both of your attention a bill that I
have filed, S. 412, and I am happy that Senator Blumenthal,
Senator Isakson, and Senator Hirono have joined me at
cosponsoring this important legislation that is pending before
your Committee.
The bill is called Keep Our Commitment to Veterans Act. It
would give the go ahead to authorize major medical facilities
that have been in a holding pattern due to an unexpected and
recent change in the CBO scoring.
I am sure your Committee has heard many complaints about
this. I am sure both of you are very familiar with it, but I
wanted to bring it to your attention today very briefly.
Last September, the Veterans' Affairs Committees in the
House and the Senate were not able to authorize the VA-
requested fiscal year 2013 major medical facility leases in the
annual construction and extenders package due to a new scoring
method.
CBO changed the scoring method for major medical
facilities, significantly increasing the costs of these
facilities. Now, we find ourselves here in a situation in
Louisiana where we have had two clinics, Mr. Chairman, on the
board now in proposal for several years that are now in
complete limbo, and we have 20,000 veterans in this area of our
State, which is in southwest Louisiana--a growing, vibrant area
of our State--without access to a clinic.
Under the old scoring method, these 13 clinics would be
$126 million. Under the new scoring method, it is $1.4 billion.
We have got to find, I think, an administrative way forward
here, not just for the clinics in Louisiana, of course, which I
am here to advocate for and the veterans communities that are
really in desperate need of these facilities and have been
promised year after year. But I understand, Mr. Chairman, that
this affects other States as well. I am sure you are well
aware.
So, on behalf on the 20,000 veterans and their families
that I am here to represent, I look forward to working with you
to find a solution to help these veterans that have served our
Nation so proudly and so ably.
We need to fix this situation. As an appropriator I most
certainly understand the challenges in our budget, yet perhaps
with some work between the Appropriations Committee and this
good oversight and authorizing Committee, we can find a way
forward.
It is an opportunity for us to make clear to our veterans
that the promises we made to them we want to hold to those
promises.
Thank you, Mr. Chairman, and I will submit the rest of my
statement for the record, and thank you, Senator Burr.
[The prepared statement of Senator Landrieu follows:]
Prepared Statement of Hon. Mary L. Landrieu,
U.S. Senator from Louisiana
Thank you Chairman Sanders and Ranking Member Burr for affording me
the opportunity to speak in support of S. 412, the ``Keep Our
Commitment to Veterans Act.''
I would also like to thank Senators Blumenthal, Isakson and Hirono
for cosponsoring this important legislation.
The Keep Our Commitment to Veterans Act would give the go ahead to
authorize major medical facilities that have been in a holding pattern
due to a change in Congressional Budget Office (CBO) scoring.
Last September, the Veterans' Affairs Committees in the House and
the Senate were not able to authorize VA's requested FY 2013 Major
Medical Facility Leases in the annual construction and extenders
package due to the way the leases were scored by the CBO.
The CBO changed the scoring methodology for major medical facility
leases, significantly increasing the cost of the facilities, by
requiring 19 years rent up front.
Now we find ourselves in a situation with no path forward.
Regardless of whether the CBO scoring method is right or wrong, this
sort of bureaucratic bottleneck is unacceptable.
Under the scoring method used in the past, the cost of the FY 2013
clinics would be a little over $126 million dollars. This amount was
factored into the budget baseline.
However, the 15 FY 2013 clinics are now being scored at a cost of
nearly $1.4 billion dollars. This is a thousand percent increase!! The
12 FY 2014 clinics would now cost $1.16 billion dollars.
Given the current budgetary climate, this is no time to implement
burdensome financial requirements. This scoring system will have
widespread implications for veterans nationwide, pulling the rug out
from under our Nation's vets.
The FY 2013 and FY 2014 clinics would serve over 1.3 million
veterans in 18 states.
Nearly 20,000 veterans would be served by the 2 delayed clinics in
my home state of Louisiana. Those are 20,000 veterans who have served
our Nation proudly.
These veterans served in international engagements such as World
War II, Korea, Vietnam, Iraq, and Afghanistan. They served in the Navy,
Marines, Army, and the Air Force. They served their country with pride
and have earned the care they were promised.
We need to fix this issue as it is only going to get worse. There
are approximately 50 leases that are due to expire before the end of FY
2016 and will be impacted if the budgetary treatment of major medical
facilities is not resolved.
This is an opportunity to make it clear that this Congress
recognizes the importance of properly authorizing and appropriating
funds in order to provide our veterans receive the care that they
deserve. The ``Keep Our Commitment to Veterans Act'' will do just that.
Chairman Sanders. Senator Landrieu, thank you very much for
focusing on an issue which, as you indicated, goes well beyond
Louisiana.
One of the great advances made by the VA in recent years
has been the expansion of the CBOC program which is what you
are talking about, Community-Based Outreach Clinics.
I think we all know that when veterans or nonveterans are
able to access affordable primary health care that keeps them
healthier, keeps them out of the hospital, in the long run it
saves our system money. The CBOC program has been very
successful in Vermont and all over this country. I do not want
to see an impediment from the way the CBO deals with this issue
limit our ability to expand CBOCs.
So, you raise a very important question which is something
that this Committee has got to address. Senator Burr, did you
want to add anything to that?
Senator Burr. As one who participated before the CBO
determination and exercise, the lease option I understand, the
benefits that it provided especially at the clinic and
outpatient level, and I look forward to working with you on
this.
Chairman Sanders. We will be dealing with CBO on this issue
to do our best.
Thank you, Senator, very much.
I would now like to bring up our first panel which is Dr.
Robert Jesse, Principal Deputy Under Secretary for Health at
the Department of Veterans Affairs. Dr. Jesse is accompanied by
Susan Blauert, Deputy Assistant General Counsel.
Thank you both very much for providing the Department's
perspective on the pending health care legislation. We look
forward to hearing your testimony. Dr. Jesse, why do you not
begin please.
STATEMENT OF ROBERT JESSE, M.D., Ph.D., PRINCIPAL DEPUTY UNDER
SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY SUSAN BLAUERT, DEPUTY ASSISTANT GENERAL COUNSEL
Dr. Jesse. Good Morning, Chairman Sanders, Ranking Member
Burr, and Members of the Committee. We thank you for the
opportunity to address the bills on today's agenda and to
discuss the impact of these bills on Veterans' Administrating
health care delivery.
As you mentioned, joining me today is Susan Blauert, VA's
Deputy Assistant General Counsel.
Chairman Sanders, we greatly appreciate your continued
efforts to support and improve veterans' health care. VA is
carefully reviewing two of your bills, one concerning
complementary and alternative medicine and the other expanding
the Family Caregiver Assistance Act.
We anticipate providing full views on these bills soon. In
the meantime, we will work with your staff to provide technical
assistance. We believe we can provide valuable insight as to
how VA can better integrate complementary and alternative
medicine into our mission to provide personalized proactive and
patient-driven care that support the health and well-being of
veterans.
In my oral remarks, I am going to briefly explain VA's
position on a few of the bills being considered today. A much
more detailed discussion of all the bills on the agenda can be
found in my written statement.
Generally, VA supports bills expanding services to
veterans. These bills include S. 325, which would increase the
maximum age for eligibility of children covered under CHAMPVA
Program and S. 455, which would make permanent our ability to
use paid drivers to expand access to VA health care for
individuals traveling for the purposes of medical care.
The VA also supports S. 529, which would expand the period
of eligibility for benefits for the Camp Lejeune veterans by 4
years. I would like to thank Ranking Member Burr for his
ongoing efforts to support our Camp Lejeune veterans.
VA has made a number of recommendations on the Camp Lejeune
program to make it easier to implement and easier for family
members and veterans alike. These include simplifying the
administrative eligibility requirements and shifting to DOD the
determination of whether the veteran and qualified family
members meet the 30-day requirement on Camp Lejeune. We believe
these modifications to S. 529 would greatly improve our ability
to implement the Camp Lejeune law.
We support much of bill S. 131, which would permit VA to
provide expanded reproductive services, including in-vitro
fertilization for certain veterans and their spouses suffering
from infertility. However, we do not support extending these
services to engage in surrogates who would bear children for
veterans primarily because variations and complexities in the
State laws and policies would make a surrogacy provision
extremely difficult to implement. We are concerned about our
authority to support veterans in dealing with the entirety of
the many complex issues involving surrogates.
So, a few of the provisions in this bill will require a
little more time before VA can provide a position. For now, we
remain hopeful, though, that Congress will enact the much-
needed extension of our authority to operate our existing child
care pilot so that we can continue to collect and analyze cost
and utilization data.
VA supports the intent of S. 422, the Chiropractic Care
Available to All Veterans Act of 2013, which would expand
access to chiropractic care to all veterans. However, VA
believes that the health administration is best situated to
determine the parameters of such an expansion.
Decisions regarding the delivery, care through staffing
versus a fee basis should be predicated both on demand and
local capability. That would include the availability of
licensed chiropractic professionals for hire into the VA system
or through referral to them in the community.
We acknowledge that there is need for a thorough assessment
of our current chiropractic services. In fact, such a study is
now nearing completion, and we would welcome the opportunity to
work closely with the Committee to ensure that legislation in
this area supports veterans' preferences.
And finally, I would like to address S. 543, which would
consolidate our existing 21 VISNs into 12 and proscribe a
specific VISN organizational structure and staffing model.
As we discussed last year, VA shares the goal of increasing
the efficiency of our operations. However, we do not support
the imposition of a staffing and organizational structure that
is not based on a complete assessment of business needs.
Last month, we provided the Committee staff an update on
our progress toward implementing our internal reorganization
and realignment. Standards have been established and we expect
all VISNs to have completed the first phase of the
reorganization by the end of this year. This will enhance
quality and consistency of the management processes and will
enable VHA to better assess cost effectiveness.
For phase two, a work group has been charted to undertaken
an analysis of VISN geographic boundaries and contemporary
referral patterns. A process we believe is necessary to form
any decision about redrawing the VISN scope. We look forward to
keeping the Committee advised on our analysis and the status of
work in this area.
I would like to conclude by thanking you all for the
opportunity to testify before the Committee and I will be
pleased to respond to questions that you or the other Members
have about the bills I have touch upon or other bills that were
addressed in my written statement.
Thank you.
[The prepared statement of Dr. Jesse follows:]
Prepared Statement of Robert L. Jesse, M.D., Ph.D., Principal Deputy
Under Secretary for Health, U.S. Department of Veterans Affairs
Good Morning Chairman Sanders, Ranking Member Burr, and Members of
the Committee. Thank you for inviting me here today to present our
views on several bills that would affect Department of Veterans Affairs
(VA) benefits programs and services. Joining me today is Susan Blauert,
Deputy Assistant General Counsel.
We do not yet have cleared views on sections 4, 10, 11, or 12 of
S. 131, S. 287, section 3 of S. 522, S. 800, S. 832, S. 845, S. 851,
S. 852, or the draft bill described as ``The Veterans Affairs Research
Transparency Act of 2013.'' Also, we do not have estimated costs
associated with implementing S. 131, S. 422, S. 455, or S. 825. We will
forward the views and estimated costs to you as soon as they are
available.
s. 49 veterans health equity act of 2013
S. 49 would amend Title 38, Part II, Chapter 17, of the United
States Code (U.S.C.) to include a new section 1706A. Section 1706A
would require the Secretary to ensure that Veterans in each of the 48
contiguous States have access to at least one full-service Department
medical center or to comparable hospital care and medical services
through contract with other in-State health care providers. Section
1706A would define a full-service Department medical center as a
facility that provides medical services including, hospital care,
emergency medical services, and standard-level-complexity surgical
care. Additionally, the Secretary would be required to submit a report
to Congress within one year describing VA's compliance with these
requirements and how the quality and standards of care provided to
Veterans has been impacted.
VA objects to this legislation because it is unnecessary. VA
engages in an extensive analysis of factors in order to identify
appropriate locations to site VA health care facilities in order to
best serve the patient population. These factors include, but are not
limited to, projected total Veteran population, Veteran enrollee
population, and utilization trends. VA analyzes this demand projection
data over a 20-year period and takes into account Veteran access to
various types of care and services. VA also utilizes its access
guidelines, which take into account an acceptable amount of time a
Veteran should reasonably travel to receive care depending upon whether
the Veteran resides in an urban, rural, or highly rural community.
VA engages in population-based planning and seeks to provide
services through a continuum of delivery venues, including outreach
clinics, community-based outpatient clinics, and medical facilities or
hospitals. When it is determined that a full-service hospital is not
required, VA uses a combination of interventions to ensure the delivery
of high quality health care such as contracting for care in the
community, use of telehealth technologies and referral to other VA
facilities. VA improves Veteran access to health care by providing care
within or as close to the Veteran's community as possible, regardless
of state boundary lines.
As an example, we note that VA is providing expanded acute care
services to New Hampshire Veterans through contracts with local health
care providers, in order to address the needs and concerns of the New
Hampshire constituency. This model has been used for more than a decade
to provide VA-coordinated care in a safe and cost effective manner.
Providing services in this manner ensures that Veterans who use the
Manchester VA Medical Center (VAMC) have available locally the same
level of acute care services as other Veterans within the VA New
England Healthcare System and elsewhere. Patients who require tertiary
care, such as cardiac surgery or neurosurgery, and extended inpatient
psychiatry will continue to be referred to appropriate VA facilities
for this care.
s. 62 check the box for homeless veterans act of 2013
S. 62 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 ``for
the purpose of providing services to homeless veterans.'' S. 62 would
require that in the President's annual budget submission for fiscal
year (FY) 2014 and each year thereafter, VA, Department of Labor, and
Department of Housing and Urban Development (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.
VA appreciates the sentiment behind this legislation, and we
believe in emphasizing that Veteran homelessness is a national issue
where communities and individuals across America can make great
contributions, in many different ways. We are glad to have a dialog
with the Committee on what VA is doing now to engage the public and
communities across the Nation, and discuss innovative ways we can
increase that engagement. Turning to S. 62, we applaud its intent, but
cannot offer VA's support for its way of increasing that engagement .
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 to fund VA's programs could lead some to see these
obligations as a discretionary charity. VA does involve charities and
community organizations in its work, and they provide vital partners
and complements to the work VA is doing to end Veteran homelessness.
But VA prefers that all Federal funding come from affirmative
appropriations provided by the Congress, rather than voluntary
apportionments through the tax code.
s. 131 woman veterans and other health care improvement act of 2013
Section 2 of S. 131 would amend 38 U.S.C. section 1701(6) to
include fertility counseling and treatment, including treatment using
assisted reproductive technology, among those things that are
considered to be ``medical services'' under chapter 17 of title 38,
U.S.C.
VA supports section 2 of the bill, 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 consistent with VA's
goal to restore to the greatest extent possible the physical and mental
capabilities of Veterans and improve the quality of their lives. For
many, having children is an important and essential aspect of life.
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.
Section 3 of the bill would add a new section 1788 to title 38,
U.S.C., that would require VA to furnish fertility counseling and
treatment, including through the use of assisted reproductive
technology, to a spouse or surrogate of a severely wounded, ill, or
injured enrolled Veteran who has an infertility condition incurred or
aggravated in the line of duty, if the spouse or surrogate 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 who are seeking fertility counseling and
treatment. Section 1788 would not be construed to require VA to furnish
maternity care to a spouse or surrogate of a Veteran, or to require VA
to find or certify a surrogate for or connect a surrogate with a
Veteran. Subsection (d) of proposed section 1788 would define the term
``assisted reproductive technology'' to include ``in vitro
fertilization and other fertility treatments in which both eggs and
sperm are handled when clinically appropriate.''
VA supports section 3 in part, but must condition this support on
assurance of the additional resources that would be required were this
provision enacted. VA supports providing infertility services including
assisted reproductive technology to severely wounded, ill, or injured
enrolled Veterans described in section 3, and their spouses or
partners. VA does not, however, support coverage of such services for
surrogates at this time. The complex legal, medical, and policy
arrangements of surrogacy vary from state to state due to inconsistent
regulations between States, and we believe would prove to be very
difficult to implement in practice. Moreover, 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. VA acknowledges that surrogacy may offer the
only opportunity for Veterans and their spouses or 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 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 1788;
VA recommends that section 1788 be revised to refer to a ``spouse or
partner'' of a specified Veteran. In addition, the meaning and scope of
the coordination contemplated under proposed section 1788(b) (which
would authorize VA to ``coordinate fertility counseling and treatment''
for the spouses and surrogates of other Veterans not described in
section 1788(a)) is unclear, and could potentially account for spouses
and surrogates of all other Veterans. VA recommends that this be
clarified.
Section 5 of the bill would require VA to report annually to the
Committees on Veterans' Affairs of the Senate and House of
Representatives on the fertility counseling and treatment furnished by
VA during the preceding year. The first report would be required no
later than one year after enactment. Each report submitted under
section 5 would be required to contain specified information, including
the number of Veterans, spouses, and surrogates who received fertility
counseling and treatment furnished by VA; the costs of furnishing such
counseling and treatment; and coordination of such counseling and
treatment with similar services of DOD. VA does not object to such
reporting.
Section 6(a) would require VA, no later than 540 days after
enactment, to prescribe regulations to carry out proposed sections 1788
and 1789, and on fertility treatment to Veterans using assisted
reproductive technology. Section 6(b) would prohibit VA from providing,
until regulations are prescribed, fertility counseling and treatment
under 1788, assistance under 1789, and to a Veteran ``any fertility
treatment that uses an assisted reproductive technology that the
Secretary has not used in the provision of a fertility treatment to a
veteran before the date of the enactment.'' The term ``assisted
reproductive technology'' under section 6 would have the same meaning
given to the term in proposed section 1788 of section 3.
VA does not support Section 6(a). While 540 days accorded for the
drafting of regulations may seem like a long period of time, given the
complexities of the issues involved, VA estimates that amount of time
could be insufficient.
Section 7 of S. 131 would require the Secretary of VA and the
Secretary of Defense to share best practices and facilitate referrals,
as they consider appropriate, on the furnishing of fertility counseling
and treatment. VA does not object to this requirement.
Section 8 of the bill would add a new section 7330B to title 38,
U.S.C., 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 Secretary of Health and Human Services'' 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 the 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 7330B that may be useful for
other activities of the Veterans Health Administration (VHA) is
disseminated throughout VHA. No later than 3 years after enactment, VA
would be required to report to Congress on the research activities
conducted under section 7330B.
VA supports section 8 of S. 131. Generally, VA supports
implementing research findings that are scientifically sound and that
would benefit Veterans and improve health care delivery to 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 Secretary of Health and Human Services. 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 9 of S. 131 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 9 and has established an inbound calling system
specifically for women Veterans. By building on capabilities within
WVCC, the incoming call center allows women Veterans to call WVCC to
connect them to resources, assist with specific concerns, and provide
information on services and benefits. Many of the Veterans are calling
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 to discuss the benefits that might be available to
them. The call could also be transferred to the appropriate medical
center to assist eligible Veterans with obtaining a health care
appointment. Once the woman Veteran is connected to VA health care
services, the Women Veterans Program Manager can also assist her in
finding community resources that may not be provided by VA.
VA is unable to provide views on sections 4, 10, 11, and 12 at this
time, but will provide views on those provisions in a later submission
to the Committee.
s. 229 corporal michael j. crescenz act of 2013
S. 229 would designate the Department of VAMC located at 3900
Woodland Avenue in Philadelphia, Pennsylvania, as the ``Corporal
Michael J. Crescenz Department of Veterans Affairs Medical Center.'' VA
defers to Congress in the naming of this facility.
s. 325 increase of maximum age for children eligible for
medical care under champva program
Contingent upon Congress providing additional funding to support
the change in eligibility, VA supports S. 325, which would amend 38
U.S.C. section 1781(c) to extend eligibility for coverage of children
under the Civilian Health and Medical Program of the Department of
Veterans Affairs (CHAMPVA) until they reach age 26 so that eligibility
for coverage of children under CHAMPVA will be consistent with certain
private sector coverage under the Affordable Care Act. S. 325 would
extend eligibility for coverage of children under CHAMPVA regardless of
age, marital status, and school enrollment status up to the age of 26;
and the bill would ensure that CHAMPVA eligibility would not be limited
for individuals described in section 101(4)(A)(ii) (individuals who,
before attaining age 18, became permanently incapable of self-support).
The bill would not extend eligibility for children who, before
January 1, 2014, are eligible to enroll in an eligible employer-
sponsored plan (as defined in Internal Revenue Code section
5000A(f)(2)). This means that the age, school status, and marital
status requirements in 38 U.S.C. section 101(4) would, before 2014,
apply to children who are eligible to enroll in an eligible employer-
sponsored health plan and the bill would not extend eligibility for
coverage of those individuals. This provision in the bill is in
accordance with the discretion provided to grandfathered health plans
that are group health plans in the private sector under the Affordable
Care Act. The amendments made by S. 325 would apply with respect to
medical care provided on or after the date of enactment of the bill.
VHA estimates that this provision would cost $51 million in FY
2014; $301 million over 5 years; and $750 million over 10 years.
s. 412 keep our commitment to veterans act
S. 412 would authorize the Secretary to carry out certain major
medical facility leases in FY's 2013 and 2014 for VA.
Section 2 of S. 412 would authorize the Secretary to carry out
twelve major medical facility leases, all of which were included in
VA's FY 2013 Budget Submission. Specifically, Section 2 would authorize
the Secretary to carry out a major medical facility lease for a
Clinical Research and Pharmacy Coordination Center in Albuquerque, New
Mexico; a replacement Community Based Outpatient Clinic in Brick, New
Jersey; a New Primary Care/Dental Clinic Annex in Charleston, South
Carolina; a Community-Based Outpatient Clinic in Cobb County, Georgia;
an Outpatient Healthcare Access Center in Honolulu, Hawaii, to include
a co-located clinic with DOD and the co-location of VBA's Honolulu
Regional Office and the Kapolei VA Vet Center; a Community-Based
Outpatient Clinic in Lafayette, Louisiana; a Community-Based Outpatient
Clinic in Lake Charles, Louisiana; an Outpatient Clinic Consolidation
in New Port Richey, Florida; an Outpatient Clinic Expansion in Ponce,
Puerto Rico; a Lease Consolidation in San Antonio, Texas; an Errera
Community Care Center in West Haven, Connecticut; and a Community-Based
Outpatient Clinic in Worcester, Massachusetts.
Section 3 of S. 412 would provide new authorizations for the
Secretary to carry out a major medical facility lease, previously
authorized in FY 2010, for a Community-Based Outpatient Clinic in
Johnson County (Lenexa), Kansas; a major medical facility lease,
previously authorized in FY 2011, for a Community-Based Outpatient
Clinic in San Diego, California; and, a major medical facility lease,
previously authorized in FY 2006, for a Community-Based Outpatient
Clinic in Tyler, Texas.
VA supports this section, but requests that the amounts for each
lease be revised to be consistent with the prospectuses included in
VA's 2014 Budget Submission. The lease authorizations amounts and
project scopes changed to reflect more current estimates. VA suggests
modifying the language as set forth below.
``The Secretary of Veterans Affairs may carry out the
following major medical facility leases in FY 2014:
(1) Johnson County, Kansas, Community-Based Outpatient
Clinic, in an amount not to exceed $2,263,000.
(2) San Diego, California, Community-Based Outpatient Clinic,
in an amount not to exceed $11,946,100.
(3) Tyler, Texas, Community-Based Outpatient Clinic, in an
amount not to exceed $4,327,000.''
VA supports S. 412. VA's leasing program is an important component
of providing health care to Veterans. Leasing has been and continues to
be an essential part of VA's capital portfolio management, and
significantly supports VA's mission to meet the service needs of our
Nation's Veterans.
In addition, VA has put forth, in its FY 2014 budget, 12 additional
major medical facility lease projects, for a total of 27 major medical
facility leases. The 27 leases included in the FY 2014 Budget Request
are new and replacement leases. The 2014 Budget Request also proposes
changes to legislation to allow greater collaboration with other
Federal agencies and proposes changes to legislation to amend VA's
Enhanced-Use Lease statute. The proposed changes would enhance the
repurposing of VA's assets and improve the ability to develop joint
DOD/VA facilities. The details of the leases and proposed legislation
can be found in the VA budget documents transmitted to Congress on
April 10, 2013.
s. 422 chiropractic care available to all veterans act of 2013
S. 422 would require VA to establish programs for the provision of
chiropractic care and services at not fewer than 75 medical centers by
not later than December 31, 2014, and at all VAMCs by not later than
December 31, 2016. Currently, VA is required (by statute) to have at
least one site for such program in each VHA geographic services area.
Section 3(a) would amend the statutory definition of ``medical
services'' in section 1701 of chapter 17, U.S.C., to include
chiropractic services. Subsection (b) would amend the statutory
definition of ``rehabilitative services'' in that same section to
include chiropractic services. Finally, subsection (c) would amend the
statutory definition of ``preventive health services'' in that same
section to include periodic and preventive chiropractic examinations
and services.
The bill would also make technical amendments needed to effect
these substantive amendments.
In general, VA supports the intent of S. 422, but believes the
decision to provide on-site or fee care should be determined based on
existing clinical demands and business needs. Chiropractic care is
available to all Veterans and is already part of the standard benefits
package.
As VA increases the number of VA sites providing on-site
chiropractic care, we will be able to incrementally assess demand for
chiropractic services and usage, and to best determine the need to add
chiropractic care at more sites.
Currently, VA does not have an assessment that would support
providing on-site chiropractic care at all VAMCs by the end of 2016.
Such a mandate could potentially be excessive, given the availability
of resources for on-site chiropractors and non-VA care to meet the
current need for services. VA does not object to sections 3(a) and (b)
as those changes reflect VA's consideration of chiropractic care as
properly part of what should be considered medical and rehabilitative
services. VA, however, cannot support section 3(c) for lack of a
conclusive consensus on the use of chiropractic care as a preventative
intervention.
s. 455 transportation in connection with rehabilitation, counseling,
examination, treatment, and care
S. 455 would make permanent VA's broad authority to transport
individuals to and from VA facilities in connection with vocational
rehabilitation, counseling, examination, treatment, or care. That
authority currently will expire on January 10, 2014. This authority has
allowed VA to operate the Veterans Transportation Program which uses
paid drivers to complement the Volunteer Transportation Network, which
uses volunteer drivers. The Volunteer Transportation Network supported
by Veterans Service Organizations, especially the Disabled American
Veterans, is invaluable; however, with increasing numbers of
transportation-disadvantaged Veterans, there simply are not enough
volunteers to serve the level of need. Furthermore, volunteer drivers
are generally precluded from transporting Veterans who are not
ambulatory, require portable oxygen, have undergone a procedure
involving sedation, or have other clinical issues. Also, some
volunteers, for valid reasons, are reluctant to transport non-
ambulatory or very ill Veterans. Paid drivers have resulted in better
access to VA health care, often for those for whom travel is the most
difficult.
VA thus supports enactment of this bill, and proposed a five-year
extension of this authority in the FY 2014 President's Budget. The
budget assumes savings of $19.2 million in FY 2014 and $102.7 million
over five years. As a technical matter, we suggest the bill's insertion
of a new section 111A be changed to instead reflect the intent to
replace the existing section 111A with the revised version.
s. 522, wounded warrior workforce enhancement act
S. 522, the Wounded Warrior Workforce Enhancement Act, would direct
VA to establish two grant award programs. Section 2 of the bill would
require VA to award grants to institutions to: (1) establish a master's
or doctoral degree program in orthotics and prosthetics, or (2) expand
upon an existing master's degree program in such area. This section
would require VA to give a priority in the award of grants to
institutions that have a partnership with a VAMC or clinic or a DOD
facility. Grant awards under this provision must be at least $1 million
and not more than $1.5 million. Grant recipients must either be
accredited by the National Commission on Orthotic and Prosthetic
Education or demonstrate an ability to meet such accreditation
requirements if receiving a grant. VA would be required to issue a
request for proposals for grants not later than 90 days after the date
of enactment of this provision.
In addition to the two purposes noted above, grantees would be
authorized to use grants under this provision to train doctoral
candidates and faculty to permit them to instruct in orthotics and
prosthetics programs, supplement the salary of faculty, provide
financial aid to students, fund research projects, renovate buildings,
and purchase equipment. Not more than half of a grant award may be used
for renovating buildings. Grantees would be required to give a
preference to Veterans who apply for admission in their programs.
VA does not support enactment of section 2 of this bill. We believe
VHA has adequate training capacity to meet the requirements of its
health care system for recruitment and retention of orthotists and
prosthetists. VA offers one of the largest orthotic and prosthetic
residency programs in the Nation. In FY 2013, VA allocated $837,000 to
support 19 Orthotics/Prosthetics residents at 10 VAMCs. The training
consists of a year-long post masters residency, with an average salary
of $44,000 per trainee. In recent years, VA has expanded the number of
training sites and the number of trainees. Moreover, recruitment and
retention of orthotists and prosthetists has not been a challenge for
VA. Nationally, VA has approximately 240 orthotic and prosthetic staff;
there are currently only 7 positions open and being actively recruited.
Much of the specialized orthotic and prosthetic capacity of VA is
met through contract mechanisms. VA contracts with more than 600
vendors for specialized orthotic and prosthetic services. Through both
in-house staffing and contractual arrangements, VA is able to provide
state-of-the-art commercially-available items ranging from advanced
myoelectric prosthetic arms to specific custom fitted orthoses.
We also note the bill would not require these programs to affiliate
with VA or send their trainees to VA as part of a service obligation.
We also have technical concerns about the language in section 2,
subsection (e). Specifically, the language directs the appropriators to
provide funding ($15 million) in only one fiscal year, FY 2014, which
would expire after three fiscal years. This subsection contemplates
that unobligated funds would be returned to the General Fund of the
Treasury immediately upon expiration. Under 31 U.S.C. section 1553(a),
expired accounts are generally available for 5 fiscal years following
expiration for the purpose of paying obligations incurred prior to the
account's expiration and adjusting obligations that were previously
unrecorded or under recorded. If the unobligated balance of these funds
were required to be returned to the Treasury immediately upon
expiration, then VA would be unable to make obligation adjustments to
reflect unrecorded or under recorded obligations. A bookkeeping error
could result in an Antideficiency Act violation. Accordingly, we
recommend the deletion of paragraph (2) of subsection (e). Further, we
recommend that the words ``for obligation'' be deleted from paragraph
(e)(1) of section 2 because they are superfluous. Last, we note that 90
days after the date of enactment of this provision is not enough time
for VA to prepare a request for proposals for these grants.
VA is unable to provide views on section 3 at this time, but will
provide views for the record at a future time.
s. 529 modification of camp lejeune eligibility
Public Law 112-154 provided authority for VA to provide hospital
services and medical care to Veterans and family members who served on
active duty or resided at Camp Lejeune for no less than 30 days from
January 1, 1957, to December 31, 1987, for care related to 15 illnesses
specified in the public law. S. 529 would modify the commencement date
of the period of service at Camp Lejeune, North Carolina for
eligibility under 1710(e)(1)(F) from January 1, 1957, to August 1,
1953, or to such earlier date as the Secretary, in consultation with
the Agency for Toxic Substances and Disease Registry (ATSDR),
specifies.
VA supports this change due to information provided in the
scientific studies conducted by ATSDR. We do not believe this change
would result in substantial additional costs.
VA also recommends that the Committee consider including language
to simplify the administrative eligibility determination process and
thereby relieve some of the burden from the Veteran and family member.
Other special eligibility authorities included participation by DOD to
determine exposure while on active duty. The current statute for Camp
Lejeune Veterans and family members does not include this provision. VA
recommends including a requirement for DOD to determine if the Veteran
or family member met the 30-day presence requirement on Camp Lejeune.
s. 543 visn reorganization act of 2013
Section 2 of S. 543 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 VAMC, and would limit the number of employees at each
VISN headquarters to 65 full-time equivalent employees (FTEE). VA
opposes section 2 for the following reasons.
By increasing the scope of responsibility for each VISN
headquarters while reducing the number of employees at each, the
legislation would impede VA's ability to implement national goals.
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 essential service when needed. VHA has reviewed each VISN
headquarters and is working with each to streamline operations, create
efficiencies internal to each VISN, and realign resources. This will
achieve savings without the negative impact of the restructuring
proposed in S. 543.
The requirement in section 2 that VISN budgets be balanced at the
end of each fiscal year may have unintended consequences. Currently,
each VISN balances its accounts at the end of each fiscal year.
Sometimes this is achieved by providing additional resources from VHA.
These 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. Under
S. 543, VA may lose the flexibility to supplement VISNs with additional
resources, potentially compromising patient care.
Section 2 would also require VA 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. Further,
section 2 describes how the VISNs should be consolidated but fails to
articulate clearly the flow of leadership authority. Consequently,
S. 543 would blur the lines of authority from VHA Central Office,
regions, and VISNs to medical centers, which could actually impede
oversight and create confusion.
Additionally, the original VISN boundaries were drawn carefully
based on the health needs of the local population. By contrast, the
proposed combination of VISNs does not account for the underlying
referral patterns within each VISN. For example, it is unclear why
VISNs 19 and 20 should be consolidated. This 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 would
continue to oversee three states and eight health care systems or
medical centers. VA would appreciate the opportunity to review the
Committee's criteria for determining these boundaries.
Finally, section 2 seems to assume that locating the management
function away from a medical center represents an inefficient
organizational approach. That assumption is not valid in all cases.
Currently, six VISNs (1, 2, 3, 20, 21, and 23) are co-located with a
VAMC. The legislation's requirement for co-location with a VAMC 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 administrative space for VISN staff in at least
nine VISNs.
As a result, Veterans potentially would be forced to travel to
different locations for services or would 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 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 reality is that requiring co-
location would necessitate this result.
VA also does not support section 3 of S. 543. 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 support
centers including:
Financial quality assurance;
Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn outreach;
Women's Veterans programs assessments;
Homelessness effectiveness assessments;
Energy assessments; and
Other functions as the Secretary deems appropriate.
Certain services are more appropriately organized as national
functions rather than regional ones. For example, regional functions
addressing homelessness and women Veterans issues would duplicate
existing national services. The current structure (VISN accountability
and national oversight) ensures accountable leadership oversight that
is proximate to health care services provided to Veterans at VA
facilities. By contrast, S. 543 would create competing oversight
entities.
In addition, the functions listed in section 3 may not be the most
appropriate ones for consolidation. 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. We believe these types of functions are more
appropriate to move off-station. S. 543 appears to contemplate a
reduction in the FTEE associated with regional management but in
practice, the proposed regional support centers are likely to increase
overall staffing needs, resulting in a diversion of resources from
patient care. If each of the four regional support centers is 110 FTEE,
a realistic assumption given the scope of responsibilities identified
in the legislation, the proposed model would result in overall growth
of regional staff compared with VHA's current plans.
Currently, it is not possible to identify costs for the proposed
legislation; however, it is expected that the requirement to collocate
functions with Medical Centers will result in costlier clinical leases.
Additionally, the proposed VA Central Office, VISN, and Regional
Support Center structure will result in increased FTEE requirements.
s. 633 coverage under department of veterans affairs beneficiary travel
program of travel in connection with certain special disabilities
rehabilitation
S. 633 would amend VA's beneficiary travel statute to ensure
beneficiary travel eligibility for Veterans with vision impairment,
Veterans with spinal cord injury (SCI) or disorder, and Veterans with
double or multiple amputations whose travel is in connection with care
provided through a VA special disabilities rehabilitation program
(including programs provided by spinal cord injury centers, blind
rehabilitation centers, and prosthetics rehabilitation centers), but
only when such care is provided on an in-patient basis or during a
period in which VA provides the Veteran with temporary lodging at a VA
facility to make the care more accessible. VA would be required to
report to the Committees on Veterans' Affairs of the Senate and House
of Representatives no later than 180 days after enactment on the
beneficiary travel program as amended by this legislation, including
the cost of the program, the number of Veterans served by the program,
and any other matters the Secretary considers appropriate. The
amendments made by this legislation would take effect on the first day
of the first fiscal year that begins after enactment.
VA supports the intent of broadening beneficiary travel eligibility
for those Veterans who could most benefit from the program, contingent
on provision of funding, but believes this legislation could be
improved by changing its scope. As written, the bill could be construed
to apply for travel only in connection with care provided through VA's
special rehabilitation program centers and would apply only when such
care is being provided to Veterans with specified medical conditions on
an inpatient basis or when the Veteran must be lodged. VA provides
rehabilitation for many injuries and diseases, including for Veterans
who are ``Catastrophically Disabled,'' at numerous specialized centers
other than those noted in S. 633, including programs for Closed and
Traumatic Brain Injury (CBI+TBI), Post-traumatic Stress Disorder and
other mental health issues, Parkinson's Disease, Multiple Sclerosis,
Epilepsy, War Related Injury, Military Sexual Trauma, Woman's Programs,
Pain Management, and various addiction programs. In addition, many of
these programs provide outpatient care to Veterans who might not
require lodging but must travel significant distances on a daily basis
who would not be eligible under this legislation.
Therefore, VA feels that the legislation as written would provide
disparate travel eligibility to a limited group of Veterans. However,
VA does support the idea of travel for a larger group of
``Catastrophically Disabled'' Veterans (including Veterans who are
blind or have SCI and amputees) and those with 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.
VHA estimates costs for this provision as $2.4 million for FY 2014;
$13.1 million over 5 years; and $29.8 million over 10 years.
s. 825 homeless veterans prevention act of 2013
This bill would amend title 38 to improve the provision of services
for homeless Veterans and their families. VA supports many of the
sections of this bill, including increasing the amount of per diem
payments for Veterans that are participating in the Grant and Per Diem
(GPD) program through a ``transition in place'' grant, providing
permanent authority for VA's Veteran Justice Outreach program,
authorizing VA to fund entities to provide legal services to Veterans
who are homeless or at risk of homelessness, and extending a number of
VA's existing homeless authorities, provided that any additional
resources necessary to implement these provisions are enacted. However,
we do have reservations concerning the following sections.
Section 4 would amend 38 U.S.C. section 2012(a) to permit a grantee
receiving per diem payments under VA's Homeless Provider GPD program to
use part of these 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.
VA supports the intent of section 4. We feel that this authority is
needed to fully reach the entire homeless population. However, we are
concerned that full implementation of the legislation would require
additional funding to avoid diminished services for the population of
homeless Veterans now being served by VA.
Section 5 would require the Secretary to assess and measure the
capacity of programs receiving grants under 38 U.S.C. section 2011.
VA does not support section 5 because it would be an unnecessary
and duplicative reporting requirement. VA already monitors occupancy
rates and geographic distribution of GPD grantees through a number of
resources. Furthermore, section 5 would impose a new reporting
requirement on GPD grantees, a burden that would be felt by community
providers not just the Department.
Section 9 would extend dental benefits under 38 U.S.C. section 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).
VA supports the intent of section 9, 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. Studies have shown that after dental care,
Veterans report significant improvement in perceived oral health,
general health, and overall self-esteem; thus, supporting the notion
that dental care is an important aspect of the overall concept of
homeless rehabilitation. Increasing access to dental care for HUD-VA
Supportive Housing program participants is, therefore, an important
step in VA's Plan to End Veteran Homelessness.
Additionally, to help clarify that subsection (c) of section 8
describes legal services provided, rather than the organizations that
provide them, we recommend adding the phrase ``capable of providing the
legal services'' after the word ``organizations'' in section 8(d)(1).
Mr. Chairman, this concludes my statement. Thank you for the
opportunity to appear before you today. I would be pleased to respond
to questions you or the other Members may have.
______
Additional Views Received from the
U.S. Department of Veterans Affairs
s. 131, woman veterans and other health care improvement act of 2013
Section 2 of S. 131 would amend 38 U.S.C. Sec. 1701(6) to include
fertility counseling and treatment, including assisted reproductive
technology, among those things that are considered ``medical services''
under chapter 17 of title 38, U.S.C. As discussed in VA's May 9, 2013,
testimony, VA supports section 2 of the bill, conditioned on the
availability of the additional resources needed to implement this
provision.
VA estimates that section 2 would cost $81.5 million in fiscal year
(FY) 2015; $296 million over five years; and $652 million over ten
years. These estimates reflect the costs of new services that are not
included currently in the medical benefits package and costs associated
with maternity services for additional pregnancies that may result from
the use of assisted reproductive technology. These estimates do not
reflect potential costs associated with additional enrollment or
utilization of currently covered services that may result if the bill
is enacted.
Among other things, section 3 of S. 131 would add a new section
1788 to title 38, U.S.C., that would require VA to furnish fertility
counseling and treatment, including assisted reproductive technology,
to a spouse or surrogate of a severely wounded, ill or injured enrolled
Veteran who has an infertility condition that was incurred or
aggravated in the line of duty, if the spouse or surrogate and Veteran
apply jointly through a process prescribed by VA. As discussed in VA's
May 9, 2013 testimony, VA supports section 3 of the bill in part,
conditioned on the availability of the additional resources that would
be required to implement this provision.
VA estimates that section 3 would cost $102 million in FY 2015;
$319 million over five years; and $717 million over ten years. These
estimates include coverage of spouses and partners of covered Veterans.
These estimates do not include costs associated with coverage of
surrogates; as discussed in VA's May 9, 2013 testimony, VA does not
support coverage of surrogates at this time.
Section 4 of S. 131 would authorize the Secretary to provide
adoption assistance to severely wounded, ill, or injured Veterans who
suffer from infertility conditions incurred or aggravated in the line
of duty. VA understands the intent of this provision but has numerous
concerns that merit further consideration. VA would need to consider
the possible associated responsibilities that could go along with
monetary adoption support, including adequate oversight of the agencies
or entities that would receive the funds and potential issues of State
law. VA also must carefully consider additional demands on its
resources that would not be directed at core medical services for
Veterans.
VA estimates that section 4 would cost $96.27 million in FY 2015;
$521.46 million over five years; and $1.16 billion over ten years.
Section 10 of S. 131 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
10(a) would increase the number of locations at which VA is required to
carry out the pilot program from three to fourteen. Section 10(b) would
extend the duration of the pilot from two to four years. Section 10(c)
would amend section 203(f) to authorize the appropriation of $400,000
for each of FY 2013 and FY 2014 to carry out the pilot program.
VA supports section 10 of S. 131. VA has completed the final year
of the original two-year pilot program, and the report required by
section 203 was submitted to Congress on May 9, 2013. Initial reports
show favorable results, indicating that the retreats, which focus on
building trust and developing peer support in a therapeutic
environment, supply participants with tools needed for successful
reintegration into civilian life. Additional retreats would generate
more data to inform a comprehensive assessment of the program during
the new final reporting phase under section 10.
Although VA supports section 10, there may not be fourteen distinct
geographic locations that satisfy the retreat requirements, such as the
need for specialized locations for outdoor team-building exercises. VA
would continue to look for new locations, but recommends that section
10(a) be amended to require VA to carry out the pilot program in up to
fourteen locations, some of which may be repeat locations from the
original pilot program.
In addition, VA recommends that section 10(b) be amended to require
the pilot program be ``carried out through September 30, 2015,'' rather
than requiring that it be ``carried out during the four-year period
beginning on the date of the commencement of the pilot program.'' This
would ensure that VA has a sufficient period of time to carry out
additional retreats for eligible women Veterans and generate data for
analysis. For the same reason, we recommend section 10(c) be amended to
authorize the appropriation of $400,000 ``for each of fiscal years 2013
through 2015'' to carry out the pilot program.
VA estimates section 10 would cost $337,320 in FY 2014 and, if the
pilot extends through FY 2015, $350,520 in FY 2015, for a total cost of
$687,840.
Section 11(a) of S. 131 would add a new section 1709B to title 38,
U.S.C. that would make permanent VA's authority to provide assistance
to qualified Veterans to obtain child care so that such Veterans can
receive certain health care services. VA would be required to carry out
the program in no fewer than three Veterans Integrated Service
Networks. This section would also identify certain forms of assistance
that may be provided. VA's pilot program providing such services under
section 205 of Public Law 111-163 would expire upon enactment of
section 11(a).
VA does not support a permanent mandatory authority to provide
child care assistance. VA has four operational pilot locations where
child care assistance is provided pursuant to section 205 of Public Law
111-163. The first pilot began operation in October 2011. The remaining
pilots were set up in a staggered fashion with the most recent pilot
not beginning until 2013. Under current law, all pilots are scheduled
to end on October 2, 2013, therefore, not affording three pilots the
benefit of two full years of operation.
Without two full years of operational data from each pilot, VA is
not able to adequately assess long-term utilization needs and cost
implications of the program. In light of this longer term analysis that
includes an evaluation of resources, VA believes permissive authority
to allow expansion of the program would be preferable to a permanent
mandatory authority to provide child care assistance. Permissive
authority would allow facilities at the local level to make a
determination based on need and utilize resources, space and security
as necessary.
VA is unable to provide an accurate cost estimate for a permanent
mandatory child care program, in part, because of the lack of data on
the existing pilots that have run for less than two years, but also
because such an estimate would be dependent on location of the sites,
the ability to contract in the area of the designated sites, and the
utilization of services.
Section 11(b) of S. 131 would add a new section 1709C to title 38,
U.S.C. that would require VA to carry out a program to provide
assistance to qualified Veterans to obtain child care so that such
Veterans can receive readjustment counseling and related mental health
services. The program would be carried out in at least three
Readjustment Counseling Service Regions selected by VA. This section
would identify certain forms of child care assistance that may be
provided, and it would define ``Vet Center'' as ``a center for
readjustment counseling and related mental health services for veterans
under section 1712A of [title 38, U.S.C.].''
VA supports section 11(b) in principle. Some Veterans who use Vet
Center services, especially those who have served in Iraq or
Afghanistan, have voiced concern that a lack of child care has impacted
their ability to use Vet Center services consistently. Although Vet
Center staff are always searching for new initiatives to increase
Veteran access to services, VA has concerns about implementing child
care assistance under section 11(b) without the opportunity to pilot
this type of benefit. A pilot program is needed because VA currently is
unable to predict utilization of this type of assistance. Comparisons
to medical center pilots are not useful because Vet Centers provide
services during non-traditional hours, including after normal business
hours and on weekends when requested by the Veteran. This inability to
predict utilization affects VA's ability to budget the program
appropriately. VA recommends that section 11(b) be modified to
authorize a pilot program to determine the feasibility, advisability,
and costs of providing child care assistance to Veterans who utilize
Vet Center services.
VA is not able to provide an accurate cost estimate for section
11(b) because VA lacks child-care experience for the special Vet Center
context as described above and comparable models.
Section 12 of S. 131 would add a new section 323 to title 38,
U.S.C., entitled ``Contractor user fees.'' Under proposed section
323(a), VA would be required to impose a fee on each person with whom
the Secretary engages in a contract for a good or service as a
condition of the contract. The fee amount would be the lesser of: (1)
seven percent of the total value of the contract, and (2) the total
value of the contract multiplied by an applicable percentage calculated
for the fiscal year. Before each fiscal year, VA would be required to
establish an annual estimate of the total value of contracts for the
next fiscal year and an annual estimate of the total cost of furnishing
fertility counseling and treatment--including the use of assisted
reproductive technology--and payments under proposed section 1789
(under section 4 of S. 131) for the next fiscal year, both of which
would be used in estimating the applicable percentage for the fiscal
year (the percentage by which the former exceeds the latter). The
Secretary would have discretion to waive the fee for a person as the
Secretary considers appropriate if the person is an individual or
``small business concern'' (as defined in section 3 of the Small
Business Act). Fees could not be collected under proposed section
323(a) unless the expenditure of the fee is provided for in advance in
an appropriations Act.
Proposed section 323(e) would establish a fund in the Treasury to
be known as the ``Department of Veterans Affairs Fertility Counseling
and Treatment Fund,'' and all amounts received under proposed section
323(a) would be deposited in the fund. Subject to the provisions of
appropriations Acts, amounts in the fund would be made available,
without fiscal year limitation, to VA to furnish fertility counseling
and treatment--including the use of assisted reproductive technology--
to eligible individuals and to make payments under proposed section
1789 (under section 4 of S. 131). Amounts received by VA under proposed
section 323(a) would be treated for the purposes of sections 251 and
252 of the Balanced Budget and Emergency Deficit Control Act of 1985 as
offsets to discretionary appropriations (rather than as offsets to
direct spending), to the extent that such amounts are made available
for expenditure in appropriations Acts for the purposes specified.
VA does not support section 12, which VA estimates could result in
up to 7 percent less money available for contract actions. That is
because contractors could be expected to pass this cost back to VA in
the form of higher contract prices. Applying the proposed fee to ``a
contract for a good or service'' without limitation would subject VA
Administrations' and Offices' (e.g., Veterans Benefits Administration,
National Cemetery Administration, Office of Human Resources and
Administration, and Office of General Counsel) budget dollars for
contracts to funding health care services. This would impact these
entities' budgets, particularly in smaller offices, for a purpose that
is wholly unrelated to their primary functions. In this difficult time
of budget limitations, this is impractical and could negatively impact
overall VA performance. In addition, determining a percentage and
implementing it for the beginning of each fiscal year would be
difficult administratively, as would the process of collecting and
accounting for these funds. (As a technical matter, the word ``person''
should be replaced with ``contractor'' throughout this provision.)
In many industries and for many contractors, the existing profit
margins would not tolerate a 7 percent cut.
s. 287, expansion of the definition of homeless veteran
VA supports S. 287, which would broaden the definition of
``homeless Veteran'' in 38 U.S.C. Sec. 2002(1). Section 2002(1)
currently defines homeless Veteran by reference to the definition of
homeless person found in subsection (a) of the McKinney-Vento Homeless
Assistance Act, 42 U.S.C. Sec. 11302. The bill would amend Sec. 2002(1)
to also refer to subsection (b) of Sec. 11302, which includes in the
definition of homeless person ``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.''
VA serves Veterans fleeing from domestic violence and intimate
partner violence (DV/IPV) when they otherwise meet the definition of
homeless and when it is clinically appropriate to do so. Even when it
is not clinically appropriate to place a Veteran affected by DV/IPV in
a VA homeless program, VA works closely with local community
organizations to identify resources that would most effectively address
the needs of the Veteran. S. 287 would more closely align the
definitions of homeless used by VA and the Department of Housing and
Urban Development. This would facilitate data sharing and promote
comprehensive interagency program evaluation.
Although VA supports the bill, we note that it may not always be
clinically appropriate to merely place a victim of DV/IPV in a VA
homeless program. VA clinical experience and empirical research has
shown that effective DV/IPV intervention involves collaboration among
many programs and agencies. An array of services, from crisis
intervention to long-term assistance, is needed to serve Veterans
fleeing violent relationships. Immediate crisis intervention may
include medical care and assistance with food, shelter, child care and
general safety. Long-term assistance may include ongoing medical care,
counseling to cope with the lasting emotional and psychological effects
of DV/IPV, and services to address economic and housing stability.
In recognition of the complex needs of Veterans affected by DV/IPV,
VA recently chartered a Domestic Violence Task Force. The Task Force
will develop a national plan to address DV/IPV issues in depth.
However, as noted, effectively addressing the problem of DV/IPV will
require collaboration between many programs and local, State, and
Federal agencies.
Within VA, there is a continuum of care with homeless services
ranging from rapid stabilization to permanent supportive housing. VA's
homeless programs may help prevent future DV/IPV by providing Veterans
with alternative housing options so that they can safely exit abusive
relationships. VA is committed to Veterans affected by DV/IPV, and VA
programs addressing DV/IPV specifically will continue to collaborate
with VA homeless programs to ensure those fleeing DV/IPV get the care
and support they need.
VA is not able to provide an accurate cost estimate for S. 287
because we lack detailed data regarding the size and characteristics of
this population. We do note that many VA providers have limited
training related to DV/IPV, and that S. 287 would likely require
additional training. This would generate additional costs and a
commensurate requirement for funding.
The definition of ``homeless veteran'' in 38 U.S.C. Sec. 2002(1)
also applies to the Homeless Veterans Reintegration Programs (HVRP)
administered by the U.S. Department of Labor. VA defers to the
Secretary of Labor on the application of the new definition of
homelessness to the HVRP program.
s. 422, chiropractic care available to all veterans act of 2013
VA provided views on S. 422 in our testimony on May 9, 2013. In
general, VA supports the intent of S. 422, but believes the decision to
provide on-site or fee care should be determined based on existing
clinical demands and business needs. Chiropractic care is available to
all Veterans and is already part of the standard benefits package. As
VA increases the number of VA sites providing on-site chiropractic
care, we will be able to incrementally assess demand for chiropractic
services and usage, and to best determine the need to add chiropractic
care at more sites.
Currently, VA does not have an assessment that would support
providing on-site chiropractic care at all VAMCs by the end of 2016.
Such a mandate could potentially be excessive, given the availability
of resources for on-site chiropractors and non-VA care to meet the
current need for services. VA does not object to sections 3(a) and (b)
as those changes reflect VA's consideration of chiropractic care as
properly part of what should be considered medical and rehabilitative
services. VA, however, cannot support section 3(c) for lack of a
conclusive consensus on the use of chiropractic care as a preventative
intervention. VA estimates the costs associated with S. 422 to be $4.99
million in FY 2014; $26.8 million over five years; and $59 million over
ten years.
s. 522, wounded warrior workforce enhancement act
Section 3 of S. 522 would require VA to award a $5 million grant to
an institution to: (1) establish the Center of Excellence in Orthotic
and Prosthetic Education (the Center) and (2) improve orthotic and
prosthetic outcomes by conducting orthotic and prosthetic-based
education research. Under the bill, grant recipients must have a robust
research program; offer an education program that is accredited by the
National Commission on Orthotic and Prosthetic Education in cooperation
with the Commission on Accreditation of Allied Health Education
Programs; be well recognized in the field of orthotics and prosthetics
education; and have an established association with a VA medical center
or clinic and a local rehabilitation hospital. This section would
require VA to give priority in the grant award to an institution that
has, or is willing and able to enter into: (1) a memorandum of
understanding with VA, the Department of Defense (DOD), or other
Government agency; or (2) a cooperative agreement with a private sector
entity. The memorandum or agreement would provide resources to the
Center or assist with the Center's research. VA would be required to
issue a request for proposals for grants not later than 90 days after
the date of enactment of this provision.
VA does not support section 3 because VA would not have oversight
of the Center and there would be no guarantee of any benefit to VA or
Veterans. Further, we believe that a new Center is unnecessary. DOD has
an Extremity Trauma and Amputation Center of Excellence (EACE), and VA
works closely with EACE to provide care and conduct scientific research
to minimize the effect of traumatic injuries and improve outcomes of
wounded Veterans suffering from traumatic injury. VA also has six
Research Centers of Excellence that conduct research related to
prosthetic and orthotic interventions, amputation, and restoration of
function following trauma:
1. Center of Excellence for Limb Loss Prevention and Prosthetic
Engineering in Seattle, WA.
2. Center of Excellence in Wheelchairs and Associated
Rehabilitation Engineering in Pittsburgh, PA.
3. Center for Functional Electrical Stimulation in Cleveland, OH.
4. Center for Advanced Platform Technology (APT) in Cleveland, OH.
5. Center for Neurorestoration and Neurotechnology in Providence,
RI.
6. Maryland Exercise and Robotics Center of Excellence (MERCE) in
Baltimore, MD.
These centers provide a rich scientific environment in which
clinicians work closely with researchers to improve and enhance care.
They are not positioned to confer terminal degrees for prosthetic and
orthotic care/research but they are engaged in training and mentoring
clinicians and engineers to develop lines of inquiry that will have a
positive impact on amputee care. Finally, the requirement to issue a
request for proposals within 90 days of enactment would be very
difficult to meet as VA would first need to promulgate regulations
prior to being able to issue the RFP.
VA estimates that sections 2 (views previously provided) and 3 of
S. 522 would cost $160,000 in FY 2014 and $21.7 million over 5 years.
s. 800, treto garza far south texas veterans inpatient care act of 2013
VA does not support S. 800. The bill would require VA to ensure
that the South Texas Health Care Center in Harlingen, Texas, which
currently operates as an expanded outpatient clinic, include a full
service inpatient health care facility. More specifically, S. 800 would
require the facility to provide 50 inpatient beds, an urgent care
center, and a full range of services for women Veterans that are
already provided at the outpatient clinic on location.
The region served by the South Texas VA Health Care Center in
Harlingen, referred to in S. 800 as Far South Texas, has been the
subject of three studies by VA since 2007 (two conducted internally and
one by an outside contractor) to assess the need for an acute care
inpatient facility. The conclusions of the most recent study affirm
those of previously conducted studies, indicating no sound basis for
building an inpatient facility in this area. Completed analysis of
enrolled Veteran population demographics, demand for services or
utilization, and geospatial analysis of drive time access measures
indicate that Veterans in the area have access to acute inpatient care
through contracts at rates that meet or exceed the current VA standard.
Based on these studies and for the following reasons, VA believes the
Harlingen facility should remain an expanded outpatient clinic.
Currently, VA provides inpatient care in the relevant geographic
region through contracts with non-VA providers. Nearly all enrollees in
the relevant counties have access to acute care facilities within a 60-
minute drive from their home. Through these contracts, supplemented by
referrals of complex cases to San Antonio VA Medical center, VA
provides complete inpatient care for Veterans in Far South Texas. The
expenditure to build and operate a new 50 bed inpatient facility would
not significantly increase the percentage of Veterans gaining access to
inpatient care within a 60 minute drive from their home. Consolidating
inpatient care for Veterans at a new VA hospital, when compared to the
current contract model, would increase operating expenses by
approximately $14-15 million annually without significantly increasing
the percentage of enrollees meeting VA's access standard.
VA estimates that construction to add inpatient care to this
facility would cost $406.5 million. VA estimates that total salary
expenditures for the first year full year of operation, FY 2121, would
be $51.29 million.
s. 825, homeless veterans prevention act of 2013
S. 825 would amend title 38 to improve the provision of services
for homeless Veterans and their families. In our May 9, 2013 testimony,
VA indicated that it supported many of the sections of S. 825 but did
not provide detailed views on all sections. Outlined below are VA's
views and costs on sections 2-3 and 5-10 of S. 825. VA is working to
develop a cost estimate for section 4.
Section 2(a) of S. 825 would amend current law to authorize the
Secretary, when awarding grants under the Grant and Per Diem (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
supports Section 2(a). As VA works toward ending Veteran homelessness,
VA does not anticipate a pressing need to create additional
transitional housing beds. Consequently, rehabilitating and maintaining
current GPD beds would be a more cost effective way of maintaining GPD
transitional beds nationwide.
Section 2(b) would amend current law to prohibit the Secretary from
making a grant under the GPD Program unless the prospective grantee
agrees to maintain the physical privacy, safety and security needs of
homeless Veterans receiving services though the project. VA supports
Section 2(b). This new requirement would reinforce the GPD Program's
inspection efforts and ensure that grantees comply with VA's ongoing
efforts to meet the privacy, safety and security needs of Veterans
participating in the program. As a practical matter, current GPD
grantees would absorb the costs of these improvements because VA lacks
authority to remodel or renovate existing GPD facilities.
VA does not anticipate that section 2(a) would lead to additional
costs beyond the current authorization of appropriations (38 U.S.C.
2013). The provision would allow VA to allocate existing funds to
support rehabilitating and maintaining existing GPD projects. Section
2(b) also would not result in any additional costs. If subsequent
legislation provided more specific definitions of physical, privacy,
safety and security, however, it is possible that VA could incur costs
or costs that cannot presently be determined.
Section 3 would amend current law to increase the per diem payments
for Veterans who are participating in the GPD Program through a
``transition in place'' (TIP) grant. The per diem payments under GPD
TIP would be increased by 150 percent of the VA State Home rate. VA
supports Section 3. Supporting Veterans' transition from homelessness
to permanent housing is fundamental to ending homelessness among
Veterans. By allowing Veterans to ``transition in place'' to permanent
housing, the Department would provide a valuable alternative for
Veterans who may not need or be interested in participating in the
Housing and Urban Development--VA Supportive Housing (HUD-VASH)
program.
VA estimates that section 3 would be cost neutral since the funds
would come from existing appropriations to the GPD program.
As indicated in our testimony on May 9, 2013, VA supports the
intent of section 4. VA has not yet completed its cost analysis for
this provision, however, and will provide the completed cost estimate
as soon as it is completed.
Section 5 would require VA to assess and measure the capacity of
programs receiving grants under 38 U.S.C. 2011 or per diem payments
under 38 U.S.C. 2012 and 2061 and to use the information to set goals,
inform funding allocation decisions, and improve the referral of
homeless Veterans to programs receiving funding. VA supports the intent
of section 5 but does not believe legislation is needed because VA
conducts internal assessments of service programs.
VA estimates that section 5 would cost approximately $21,000 to
gather and analyze the required information, and to draft the required
report.
Section 6 would repeal section 2065 of 38 U.S.C. to remove the
requirement that VA report to the Senate and House of Representatives
Veterans' Affairs Committees on VA's activities during the preceding
calendar year related to VA's programs homeless assistance programs.
VA supports section 6. Time spent on this reporting function would
be better used by VA personnel to internally asses the programs and
implement changes to enhance the benefits and services provided to
homeless Veterans. VA conducts ongoing data analysis of VA homeless
programs and remains committed to reporting data to the Committees upon
request.
Section 6 would result in a small cost savings for VA. In FY 2013,
VHA Homeless Programs prepared the FY 2012 VA Specialized Homeless
Programs Report to Congress. At that time, VHA Homeless Programs
estimated that it cost approximately $2,800 to produce the report. If
Section 6 were enacted, VA expects that this would save at least $2,800
in each subsequent FY.
Section 7 would strike section 2023(d) of 38 U.S.C. and replace it
with section 2023(e). This would eliminate the September 30, 2013 end
date for VA's Veteran Justice Outreach (VJO) Program and VA's
Healthcare for Reentry Veterans (HCRV) Program, programs that provide
referral and counseling services for Veterans who are transitioning out
of penal institutions and are at risk of homelessness. VJO's goal is to
avoid the unnecessary criminalization of mental illness and extended
incarceration among Veterans by ensuring that eligible Veterans
involved with the criminal justice system have timely access to VA's
mental health and substance use services when clinically indicated, and
other VA services and benefits as appropriate. Similarly, HCRV's goals
are to prevent homelessness, reduce the impact of medical, psychiatric,
and substance abuse problems upon community readjustment, and decrease
the likelihood of re-incarceration for Veterans leaving prison.
VA supports section 7. Making these programs permanent would
recognize the crucial role these programs play in preventing and ending
Veteran homelessness.
Section 7 would not result in any new costs. The provision
permanently authorizes VA's Veterans Justice Programs, including VJO
and HCRV, but does not require direct spending and would be subject to
available appropriations.
Section 7 would also eliminate the September 30, 2013 end date for
the Department of Labor's Incarcerated Veterans Transition Program. VA
defers to the Secretary of Labor for his views on the extension of this
program.
Section 8 would authorize the Secretary to fund entities to provide
legal services to Veterans, particularly those who are homeless or at
risk of homelessness. Section 8 recognizes that the Secretary may
partner with a wide variety of organizations for the provision of
services. Additionally, the language authorizes VA to fund only a
portion of the cost of legal services; VA may not pay for all of these
services. This would require VA to properly leverage any expenditure
under this authority by finding viable public or private entities
capable of providing legal services.
VA supports section 8. Homeless and at-risk Veteran access to legal
services remains a crucial but largely unmet need. Lack of access to
legal representation for outstanding warrants or fines, child support
arrearages, driver's license revocation, and other legal matters
continues to contribute to Veterans' risk of becoming and remaining
homeless. A demonstration project conducted by the Department of
Veterans Affairs, the Department of Health and Human Services' Office
of Child Support Enforcement, and the American Bar Association
indicates that legal services are instrumental in assisting Veterans
who have child support arrearages.''
VA estimates that section 8 would cost $750,000 in FY 2014; $3.9
million over five years; and $8.2 million over ten years.
Section 9 would extend dental benefits under 38 U.S.C. Sec. 2062 to
enrolled Veterans who are 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). Section 9 would also
amend current law to permit breaks in the continuity of assistance or
care for which the Veteran is not responsible.
VA supports the intent of section 9, conditioned on the
availability of additional resources that would be required if the
provision is enacted. VA recognizes the need for dental care and
supports the improvement of oral health and well-being for Veterans
experiencing homelessness. Studies have shown that after dental care,
Veterans report significant improvement in perceived oral health,
general health and overall self-esteem, thus, supporting the notion
that dental care is an important aspect of the overall concept of
homeless rehabilitation. Increasing access to dental care for HUD-VASH
program participants is, therefore, an important step in VA's Plan to
End Veteran Homelessness.
VA estimates that section 9 would cost $88.6 million in FY 2014;
$148.5 million over five years; and $216 million over 10 years.
Section 10 contains extensions to various existing VA authorities
in U.S. Code. Section 10(a) would authorize appropriations of
$250,000,000 for FY 2014 and $150,000,000 each fiscal year thereafter
for VA's GPD Program.
VA supports Section 10(a) in part. Under current law, the amount
authorized to be appropriated for FY 2014 will be reduced from
$250,000,000 to $150,000,000 and then remain the same for each
subsequent fiscal year. We support section 10(a) to the extent that it
would retain the program's current level of authorization for FY 2014.
We have concerns, however, about decreasing the authorization level to
$150,000,000 for FY 2015 and each subsequent year. Such a decrease
would be highly problematic. At the current rate, GPD expenditures
would far exceed the amount authorized to be appropriated for the
program for FY 2015 and thereafter. VA would require additional funding
to support the existing projects at anticipated per diem and occupancy
rates in FY 2015 and beyond. Otherwise, VA would be forced to cut per
diem payments to GPD community providers or to summarily terminate GPD
projects presently serving homeless Veterans.
Section 10(b) would extend the authorization of annual
appropriations of $50,000,000 for the U.S. Department of Labor's
Homeless Veterans Reintegration Programs through fiscal year 2014. We
defer to the views of the Secretary of Labor on this provision.
Section 10(c) would extend VA's general treatment and
rehabilitation authority (codified at 38 U.S.C. 2031(a)) for seriously
mentally ill and homeless Veterans from December 31, 2013 to
December 31, 2014. VA supports reauthorizing VA's Health Care for
Homeless Veterans Program, VA's program offering outreach services and
contract therapeutic housing, but suggests that section 2031 be amended
in subsection (b) by striking ``2013'' and inserting ``2016.'' VA does
not anticipate any additional costs associated with this section.
Section 10(d) would extend VA's operation of comprehensive service
centers for homeless Veterans under section 2033 of 38 U.S.C. from
December 31, 2013 to December 31, 2014. VA supports section 10(d),
which would re-authorize VA's Community Resource and Referral Centers
but suggests that section 2033 be amended in subsection (d) by striking
``2013'' and inserting ``2016.'' VA does not anticipate any additional
costs associated with this section.
Section 10(e) would extend through December 31, 2014, the
Secretary's authority under section 2041 of 38 U.S.C. 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, 2013. VA supports section 10(e) because it will help VA
meet the Secretary's goal of ending Veteran homelessness by 2015. While
any extension of authority under 38 U.S.C. 2041 would result in a
reduction in property sales proceeds, neither a one-year, nor a five-
year extension would result in any significant loan subsidy costs.
Section 10(f) would require VA to make available (from amounts
appropriated for Medical Services) $300,000,000 for FY 2013 for its
program under section 2044 of 38 U.S.C. offering financial assistance
for supportive services for very low-income Veteran families in
permanent housing (Supportive Services for Veterans Families, or SSVF).
VA has already budgeted $300 million for the SSVF Program in FY 2014.
VA supports section 10(f), which would re-authorize appropriations for
the SSVF Program, VA's premier prevention and rapid re-housing program.
However, VA suggests that 38 U.S.C. 2044(e)(1) be amended by adding
after subparagraph (E): ``(F) Such sums as may be necessary for fiscal
year 2014, and thereafter.'' This change would provide VA with the
flexibility to devote the necessary funding to operations under the
SSVF Program. SSVF is an essential part of VA's plan to end Veteran
homelessness, and VA may need to devote more resources to SSVF as VA
concludes the Veteran homelessness initiative. There are no costs
associated with this section as it provides authorization for
appropriations beginning in FY 2014.
VA also suggests that 38 U.S.C. 2044(e)(3) be amended to read:
``From amounts appropriated to the Department for Medical Services,
there shall be authorized $1,500,000 for each fiscal year to carry out
the provisions of subsection (d).'' These changes would allow VA to
devote more resources to technical assistance for SSVF grantees. By the
beginning of FY 2014, VA will have more than tripled the number of SSVF
grantees from the first grant round. With this influx of grantees, VA
needs a larger authorization so that VA can provide ongoing training
and assistance to these grantees.
Section 10(g) would extend VA's GPD Program for homeless Veterans
with Special Needs through 2015. VA supports this measure but suggests
that 38 U.S.C. 2061 be amended in subsection (d) by striking ``for each
of fiscal years 2007 through 2013.'' VA does not anticipate any
additional costs associated with this section.
Section 10(h) would extend VA's authority under 39 U.S.C. 2064 to
offer technical assistance grants for non-profit community-based
groups. VA supports this measure. VA does not anticipate any additional
costs associated with this section.
Section 10(i) would extend VA's Advisory Committee on Homeless
Veterans from December 31, 2013, to December 31, 2014. VA supports this
measure but suggests that 38 U.S.C. 2066 be amended in subsection (d)
by striking ``2013 and inserting ``2016.'' This technical change would
authorize the Advisory Committee through the end of the Veteran
homelessness initiative so that the Committee can assess the successes
of the initiative and identify actions that could be taken to improve
other VA Programs as well as other homelessness programs across the
country. VA does not anticipate any additional costs associated with
this section.
s. 832, improving the lives of children with spina bifida act of 2013
Section 2 of S. 832 would require VA to carry out a three-year
pilot program to assess the feasibility and advisability of furnishing
children of Vietnam Veterans and certain Korea service Veterans born
with spina bifida and children of women Vietnam Veterans born with
certain birth defects with case management services under a national
contract with a third party. The Secretary would have the option to
extend the program for an additional 2 years.
Under the bill, a covered individual is any person who is entitled
to health care under chapter 18 of title 38 and who lives in a rural
area and does not have access to case management services. The
Secretary would be responsible for determining the appropriate number
of covered individuals to participate in the pilot. S. 832 would
require VA to provide these individuals with coordination and
management of needed health care, monetary, and general care services
authorized under Chapter 18; transportation services; and such other
services as the Secretary considers appropriate. The bill would also
require the Secretary to inform all covered individuals of the services
available under the pilot program and to submit preliminary and final
reports to the Senate and House Committees on Veterans Affairs.
VA supports section 2 of the bill but notes that VA already has
authority to provide case management services, and currently reimburses
beneficiaries for case management services by an approved provider.
Support of section 2 of S. 832 is contingent on appropriation of any
additional funds for services beyond what are currently provided by VA.
See 38 U.S.C. Sec. 1803(c)(1)(A). In addition, VA is reviewing the
viability of providing case management via contract to increase access
to these services to all covered beneficiaries, including those in
rural areas. As this beneficiary population ages into adulthood,
increased case management and care coordination services are needed to
meet their unique health care challenges, and a systematic approach to
offering these services may better serve this group of beneficiaries.
In addition, VA has several technical comments to the bill
language. As noted above, section 2(e)(2) would require VA to provide
``transportation services'' to all covered individuals in the program.
These services could include transportation for both health care
purposes and personal purposes such as for vacations etc. The services
could also include transportation for visiting family and friends and
for those providing health care and other services to the covered
individuals. It is unclear whether the Committee intends to require VA
to provide the full extent of transportation services described above
and not permit VA to limit transportation services provided. If this is
not the case, we recommend that the Committee clearly authorize VA to
limit the scope of transportation services by adding ``as the Secretary
considers appropriate'' after ``transportation services'' in section
3(e)(2).
As noted above, section 2(e)(1) would require VA to provide
``[c]oordination and management of needed health care, monetary, and
general care services authorized under chapter 18 of title 38, United
States Code.'' The reference to ``monetary, and general care services''
is confusing. The term ``health care'' is already defined in chapter
18, and that definition does not include monetary and general care
services. It is unclear whether monetary and general care services are
intended to be services in addition to what is included in the
definition of ``health care.'' If so, we recommend revising this
provision to read: ``[c]oordination and management of needed health
care authorized under chapter 18 of title 38, United States Code, and
monetary and general care services.'' We further recommend defining the
terms ``monetary services'' and ``general care services.'' Finally, we
note that section 2(a) would require VA to enter into ``a national
contract with a third party entity'' to carry out the pilot program
while section 2(f)(2) would require VA to enter into ``contracts'' for
the same purpose. It may be possible to provide these services through
a national contract but in case that is not feasible, we would prefer
the flexibility to enter into contracts regionally as needed.
Accordingly, we recommend replacing the words ``a national contract
with a third party entity'' in section 2(a) with the words ``contracts
with third party entities.''
VA estimates the total costs for section 2, including case
management, care coordination and oversight, to be $3.024 million in FY
2014; $15.98 million over five years; and $36.97 million over ten
years.
Section 3 of S. 832 would require VA to carry out a three-year
pilot program to assess the feasibility and advisability of providing
assisted living, group home care, and similar services in lieu of
nursing home care to covered individuals. The Secretary would have the
option to extend the pilot for an additional two years. Section 3(d) of
the bill would require VA to provide covered individuals with assisted
living, group home care, or such other similar services; transportation
services; and such other services as the Secretary considers
appropriate. The bill would also direct the Secretary to provide
covered individuals with notice of the services available under the
pilot; to consider contracting with appropriate providers of these
services; and to determine the appropriate number of covered
individuals to be enrolled in the pilot and criteria for enrollment.
Section 3 of the bill would also specify preliminary and final
reporting requirements.
VA does not support section 3 of the S. 832. The provision would
extend benefits to spina bifida beneficiaries beyond what VA is
authorized to provide to Veterans, including service-connected
veterans. Service-connected Veterans who need assisted living, group
home care, and similar services are equally deserving of receiving
these benefits.
VA is unable to develop an accurate cost estimate at this time;
however, we have several technical comments to the bill language.
Section 3(a) would require VA to commence carrying out this program not
later than 180 days after enactment of this Act. This would not be
sufficient time because VA would be required to issue regulations,
including a notice and public comment period, prior to carrying out
this program. In particular, regulations would be required to define
assisted living and group home care, to designate what services are
similar to assisted living and group home care, and to identify any
other services appropriate for the care of covered individuals under
the pilot program. Finally, VA would be required by regulation to
establish the criteria for enrollment of the appropriate number of
covered individuals.
By requiring VA to carry out the program of providing assisted
living, group home care, or similar services to covered individuals
``in lieu of nursing home care,'' VA could only provide these services
if the spina bifida beneficiary would otherwise need nursing home care.
We question whether many spina bifida beneficiaries who need nursing
home care could be provided care instead in assisted living facilities,
group homes or similar institutions. The Committee may wish to consider
deleting the reference to ``in lieu of nursing home care.''
Section 3(b) defines ``covered individuals'' for purposes of this
section to be spina bifida beneficiaries who are entitled to health
care under subchapter I or III of chapter 18 of title 38, United States
Code. This would include many beneficiaries who do not need assisted
living, group home care, or similar services. The scope of services
that VA is required to provide under this program includes services
that could be useful to these beneficiaries even if they do not need
assisted living, group home care, or similar services. These services
include transportation services and such other services as the
Secretary considers appropriate for the care of covered individuals
under the program. This section thus could be interpreted to require VA
to provide these additional services to covered beneficiaries even if
they are not in need of assisted living, group home care, or similar
services in lieu of nursing home care. If the Committee intends this
program to be for only spina bifida beneficiaries who need care in
assisted living facilities, group homes or similar institutions, we
recommend amending the definition of covered individual to require that
they be determined to need assisted living, group home care, or similar
services.
As noted above, section 3(d)(2) would require VA to provide
``transportation services'' to all covered individuals in the program.
These services could include transportation for both health care
purposes and personal purposes such as for vacations. The services
could also include transportation for visiting family and friends and
for those providing health care and other services to the covered
individuals. It is unclear whether the Committee intends to require VA
to provide the full extent of transportation services described above
and not permit VA to limit transportation services provided. If this is
not the case, we recommend that the Committee clearly authorize VA to
limit the scope of transportation services by adding ``as the Secretary
considers appropriate'' after ``transportation services.''
Section 3(g) would limit funding for this program to amounts
appropriated or otherwise made available before the date of enactment
of this Act. This would severely limit funding for the program. We
suggest deleting ``before the date of enactment of this Act.''
Finally, this section does not provide for what happens to covered
beneficiaries who are in assisted living when the pilot ends, who have
no place else to go, and who have insufficient personal funds to stay
in their current location. Although VA does not support section 3 of
S. 832, if enacted we recommend authorizing VA to continue providing
assisted living, group home care, or similar services to those who had
received these services prior to the completion of the program to avoid
adverse impact on this population.
s. 845, to improve the professional educational assistance program
VA supports S. 845, which would amend 38 U.S.C. Sec. 7619 by
eliminating the December 31, 2014 sunset date for the Health
Professionals Scholarship Program (HPSP). The HPSP authorizes VA to
provide tuition assistance, a monthly stipend, and other required
education fees for students pursing education/training that would lead
to an appointment in a healthcare profession. This program will help VA
meet future need for health care professionals by obligating
scholarship recipients to complete a service obligation at a VA health
care facility after graduation and licensure/certification.
Extending this program for an additional five years would allow VA
to offer additional scholarships to satisfy recruitment and retention
needs for critical health care providers. The regulation development
process is lengthy, involving legal review and public comment, and VHA
anticipates that final HPSP regulations will be published by early
2014. If HPSP expires in December 2014, the program would be in
operation for less than one academic year.
VA estimates that this bill would cost $850,000 in FY 2014 and
$23.73 million over five years.
s. 851, caregivers expansion and improvement act of 2013
The Caregivers and Veterans Omnibus Health Services Act of 2010,
Public Law (P.L.) 111-163 (the Act), signed into law on May 5, 2010,
provided expanded support and benefits for caregivers of eligible and
covered Veterans. While the law authorized certain support services for
caregivers of covered Veterans of all eras, other benefits under the
Act were authorized only for qualified family caregivers of eligible
Veterans who incurred or aggravated a serious injury in the line of
duty on or after September 11, 2001. These new benefits for approved
family caregivers, provided under the Program of Comprehensive
Assistance for Family Caregivers, include a monthly stipend paid
directly to designated primary family caregivers and medical care under
CHAMPVA for designated primary family caregivers who are not eligible
for TRICARE and not entitled to care or services under a health-plan
contract.
S. 851, the Caregivers Expansion and Improvement Act of 2013, would
remove ``on or after September 11, 2001'' from the statutory
eligibility criteria for the Program of Comprehensive Assistance for
Family Caregivers, and thereby expand eligibility under such program to
Veterans of all eras who otherwise meet the applicable eligibility
criteria.
Recently, VA sent a report to the Committees on Veterans' Affairs
of the Senate and House of Representatives (House) (required by Section
101(d) of the Act) on the feasibility and advisability of such an
expansion, as would be effected by S. 851. In that report, VA noted
that expanding the Program of Comprehensive Assistance for Family
Caregivers would allow equitable access to seriously injured Veterans
from all eras (who otherwise meet the program's eligibility criteria)
and their approved family caregivers. VA also noted that families
across every generation have been caregivers who have sacrificed much
for their Veteran and this Nation.
In the report, VA noted difficulties with making reliable
projections of the cost impact of opening the Program of Comprehensive
Assistance for Family Caregivers to eligible Veterans of all eras, but
estimated a range of $1.8 billion to $3.8 billion in FY 2014.
VA cannot responsibly provide a position in support of expanding
the Program of Comprehensive Assistance for Family Caregivers without a
realistic consideration of the resources necessary to carry out such an
expansion, including an analysis of the future resources that must be
available to fund other core direct-to-Veteran health care services.
This is especially true as VA presses to buttress mental health
services and ensure the fullest possible access to care in rural areas.
VA is also mindful as we look ahead to the allocations for the Veterans
Benefits and Services functions in the Senate-passed and House-passed
FY 2014 budget resolutions (S. Con. Res. 8 and H. Con. Res. 25,
respectively).
We wish to make it very clear that VA believes an expansion of
those benefits that are limited by era of service would result in
equitable access to the Program of Comprehensive Assistance for Family
Caregivers for long-deserving caregivers of those who have sacrificed
greatly for our Nation. However, VA cannot endorse this measure before
further engaging with Congress on these top-line fiscal constraints,
within the context of all of VA health care programs. VA welcomes
further discussion of these issues with the Committee.
s. 852, veterans health promotion act of 2013
Section 2 of S. 852, the Veterans Health Promotion Act of 2013
would require VA, acting through the Director of the Office of Patient
Centered Care for Cultural Transformation (OPCC&CT), to operate at
least one center of innovation for complementary and alternative
medicine (CAM) in health research, education and clinical activities in
each VISN.
Section 3 of the bill would require VA to establish a 3-year pilot
program through OPCC&CT to assess the feasibility and advisability of
establishing CAM centers within VA medical centers to promote the use
and integration of such services for mental health diagnoses and pain
management. The pilot would operate in no fewer than 15 separate
medical centers and would provide voluntary CAM services to Veterans
with a mental health condition diagnosed by a VA clinician or a pain
condition for which the Veteran has received a pain management plan
from a VA clinician. Section 3 would also impose quarterly and final
reporting requirements.
VA supports sections 2 and 3 of S. 852. CAM practices already are
widespread within VA, although with significant variation. According to
the National Institute of Health (NIH) National Center for
Complementary and Alternative Medicine (NCCAM), defining CAM is
difficult. Thus, VA recommends using the term ``Integrative Health''
(IH) instead. In addition, because IH impacts the entire spectrum of
healthcare and involves practitioners across healthcare professions and
all points of care, VA recommends that the legislation not limit the
provision of care to clinicians who provide IH services exclusively.
VA supports an integrated implementation of sections 2 and 3 that
could build on the existing infrastructure within VHA and OPCC&CT that
could include: (1) Expanding the capacity of existing VHA OPCC&CT
Centers of Innovation to serve as National Integrative Health Centers
of Innovation to develop and implement innovative clinical activities
and systems of care, serve as regional learning centers, and work
collaboratively with the identified pilot sites; (2) Creating
additional sites of innovation (i.e., one in each VISN) that could
develop specific models for the delivery of Integrative Health,
including CAM; (3) Expanding the OPCC&CT Field Implementation Teams and
educational initiatives to include IH and IH coaching to support the
implementation of these sites/pilot projects; (4) Creating a national
strategy and to address any barriers to implementation identified
through the pilot and Centers of Innovation; and (5) Developing an
evaluation strategy to assess impact.
These pilots would also operate in conjunction with existing
initiatives, including the Mental Health Innovations Committee, the VA/
DOD Health Executive Council's Pain Management Work Group, VHA's
National Pain Office, and IH pilot projects being undertaken at three
Polytrauma Centers by OPCC&CT and the Physical Medicine and
Rehabilitation Service National Program Office. Building on these
pilots, VA recommends the legislation specify a total of ``up to five''
pilot projects at Designated Polytrauma Centers rather than five. The
funding source for this proposed legislation is unclear, and
implementation of sections 2 and 3 would be problematic without
additional funding.
Section 4 of S. 852 would require VA to carry out a 3-year pilot
program through the award of grants to public or private nonprofit
entities to assess the feasibility and advisability of using wellness
programs to complement the provision of mental health care to veterans
and family members eligible for counseling under 38 U.S.C.
Sec. 1712A(a)(1)(C). Grantees would be required to periodically report
to the Secretary, and VA in turn would report to Congress every 180
days during the pilot period.
VA supports section 4 but recommends that contracts be used instead
of grants, because of the limited ability to fund grants within
existing VA funding authority. In addition, VA uses the term ``well-
being'' instead of wellness because well-being is a broader concept
that incorporates whole person health, inclusive of mind, body and
spirit.
As a component of the pilots identified in section 3 of S. 852, VA
would pilot at up to five sites the use of wellness programs as a
complementary approach to mental health care. This would be
accomplished by training peers, volunteers, and patient advocates as IH
coaches who will link Veterans to community organizations that can
provide support focused on the Veterans' health and well-being,
including self-development and spirituality, concepts that until
recently were not associated with traditional medical care in the
United States.
Section 5 of S. 852 would require VA to carry out a 2-year pilot
program through the National Center for Preventive Health to assess the
feasibility and advisability of promoting health in covered Veterans
through support for fitness center membership. Covered Veterans would
be defined as any Veteran who is determined by a VA clinician to be
overweight or obese at the commencement of the pilot and who resides
more than 15 minutes driving distance from a fitness center at a VA
facility that would otherwise be open to the public for at least 8
hours, 5 days a week. The program would be piloted at no less than ten
VA medical centers. VA would cover the full reasonable cost of a
fitness center membership at a minimum of five locations; VA would
cover half of the reasonable membership costs at a minimum of five
other locations.
Section 6 of S. 852 would require VA to carry out a 3-year pilot
program to assess the feasibility and advisability of promoting health
in covered Veterans through the establishment of VA fitness facilities
at no fewer than 5 VA medical centers and 5 VA outpatient clinics.
Covered Veterans would include any Veteran enrolled under 38 U.S.C.
1705. In selecting locations, VA would consider rural areas and areas
not in close proximity to an active duty military installation. Section
6 would set a $60,000 cap on spending for a fitness facility at a VA
medical center and a $40,000 cap on spending for a facility at an
outpatient clinic. Under the bill, VA could not assess a fee for use of
the facilities.
VA strongly supports the intent of sections 5 and 6 to support
physical activity interventions for overweight or obese and all
Veterans because of the substantial evidence that physical activity has
significant health benefits and is an important component of weight
management and other chronic disease self-management strategies, but
does not support the provisions as drafted.
VA is committed to providing effective physical fitness education,
training, and support for all Veterans to enhance their health and well
being. VA has a number of programs available for Veterans, both young
and old, that encourage regular physical activity. The Gerofit program
is an example of an effective physical activity intervention for frail
elderly Veterans. A new program has been developed to reach overweight/
obese Veterans in the MOVE! Weight Management Program who receive care
in outpatient clinics. This program uses telehealth technology to
provide group sessions, led by a physical activity specialist at a VA
medical center, to multiple outpatient clinic sites simultaneously.
Costs for this bill are still under development, but we believe it
could be challenging to implement the programs in this Bill on a
system-wide scale. Constructing space in medical centers and outpatient
clinics for fitness centers may not be feasible in many locations. As
noted above, we are committed to encouraging physical activity and VA
will continue to develop cost effective and innovative ways to support
active, healthy lifestyles for all Veterans.
Section 7 of S. 852 would require VA to enter into a contract to
study the barriers encountered by Veterans in receiving CAM from VA.
Specifically, VA would study the perceived barriers associated with
obtaining CAM, the satisfaction of Veterans with CAM in primary care,
the degree to which Veterans are aware of eligibility for and scope of
CAM services furnished by VA, and the effectiveness of outreach to
Veterans about CAM. The head of specified VA departments would be
required to review the results of the study and to submit findings to
the Under Secretary for Health.
VA supports section 7 of the bill. The current healthcare system
supports conventional approaches to prevention and disease care.
Barriers exist and need to be addressed in order to optimize and
incentivize health and well-being. VA would coordinate research
activities around the design, diffusion, and evaluation of IH. The
creation and diffusion of the IH initiative will be informed by
Veterans and VA healthcare team end users. VA recommends studies in two
areas of focus: (1) Veteran and healthcare team end users; and (2)
system properties. With respect to the first area, VA could ascertain
from Veterans VHA healthcare team end users their experiences with IH
and the real and perceived barriers to IH. With respect to the second
area of focus, VA could study the current VHA system and other barriers
(laws, policies, business practices, workload capture, credentialing
and privileging, etc.) that support or impede the delivery of IH.
Findings of a comprehensive report would inform recommendations for
system changes and program design and implementation. VA would
coordinate and oversee the writing, approval process, and dissemination
of the report. VA estimates the requirements of this section would cost
approximately $2,000,000.
Section 8 would define the term ``complementary and alternative
medicine'' to have the meaning in 38 U.S.C. 7330B, as added by section
2 of the bill. As stated in sections 2 and 3 above, VA recommends using
the term Integrative Health instead of CAM.
VA is working to develop a complete cost estimate for this bill. As
noted in the views, fully implementing an enterprise wide system of
integrative health and complementary alternative medicine is complex
and would include multiple types of clinicians, clinical practices and
new products and services. On a smaller scale, the same is true for
pilot sites. VA is analyzing the multiple components that would go into
the full cost estimate and will provide to the Committee upon
completion of this analysis.
s. 877, the veterans affairs research transparency act of 2013
S. 877, the ``Veterans Affairs Research Transparency Act of 2013,''
would permit public access to research results on VA Web sites.
Specifically, the bill would require VA to make available data files
that contain information on research, data dictionaries on data files
for research, and instructions how to access such files. Under the
bill, VA would also be required to create a digital archive of peer-
reviewed manuscripts that use such data. Finally, the bill would direct
VA to submit to the Senate and House Committees on Veterans Affairs
annual reports that include the number, title, authors, and manuscript
information for each publication in the digital archive.
VA supports the objectives of this bill but does not believe that
legislation is needed to achieve them. Key elements of S. 877 are
already covered by the February 22, 2013 memorandum from the Office of
Science and Technology Policy (OSTP) regarding ``Increasing Access to
the Results of federally Funded Scientific Research.'' Efforts are
already underway to coordinate governmentwide compliance with the OSTP
memorandum.
VA believes that transparency is most effectively accomplished
using PubMed Central, an archive maintained by the NIH. VHA Office of
Research and Development is negotiating with NIH with the objective of
disseminating published findings using this vehicle. Using this common
platform to disseminate VA funded research would be more cost-effective
and would better serve the needs of the Federal and non-Federal
research community.
VA estimates the costs associated with this bill to be $107,518 in
FY 2014; $1.46 million over five years, and $8.8 million over ten years
for the entire research program.
______
Response to Posthearing Questions Submitted by Hon. Mark Begich to
Robert L. Jesse, M.D., Ph.D., Principal Deputy Under Secretary for
Health, U.S. Department of Veterans Affairs
Question 1. A question about IHS/VA and Tribal agreements, as you
may know each year I have been here I have been pushing my Alaska
Hero's Card, and I want to commend the VA on getting the Tribes to see
veterans in rural areas where there are no VA facilities.
My question is, how do you think the agreements are doing and what
do you need from the Committee to ensure the continuity of the good
health care for Veterans closer to home?
Response. VA is implementing a national reimbursement agreement
with the Indian Health Service (IHS) and individual reimbursement
agreements with Tribal Health Programs (THP). As is the case now, the
reimbursement agreements with tribal health care programs preserve the
ability for eligible American Indian/Alaska Native (AI/AN) Veterans to
choose where to receive their care, at VA or the tribal health care
facilities. For IHS, we have one signed VA-IHS National Reimbursement
Agreement, with over 81 signed local implementation plans covering 106
IHS health care facilities. As of November 2013, there are 35 signed
THP reimbursement agreements. Of those, 26 are Alaska-based VA-THP
agreements. VA continues to work closely with individual THPs to
finalize more VA-THP reimbursement agreements. Currently, assistance
from the Committee is not required for VA reimbursement agreements with
IHS and THP facilities.
The Alaska-based VA-THP reimbursement agreements specifically allow
for non-AI/AN and AI/AN eligible Veterans to receive care at tribal
health care facilities. This helps to achieve the goals set forth in
the Alaska Hero's Card Act of 2011 (H.R. 2203, 112th Congress (1st
Session 2011)) as well.
In FY 2013, 2,000 eligible AI/AN Veterans have been treated under
the VA reimbursement agreements with IHS and THP accounting for
approximately $1.8 million in care.
VA looks forward to the continued growth of these agreements
enabling Veterans to have greater access to VA benefits.
Question 2. The recent reports and testimony I have heard on my
time on this Committee and SASC on the increase of Military Sexual
Trauma, (MST) is appalling. What steps is the VA taking to provide
services for those who have been assaulted and are dealing with the
trauma years later?
Response. Since 1992, when VA was first authorized to provide
counseling and care to Veterans who experienced Military Sexual Trauma
(MST), VA has dedicated significant resources and staff to ensure this
is, and remains, a robust treatment program, which continues to improve
and excel. VA surveys have shown that when Veterans are asked about the
quality of the care they have received from VA, overall ratings are
high for both men and women, with 78.5 percent of men and 72.3 percent
of women rating the quality of care received from VA as ``very good''
or ``excellent.'' Importantly, ratings of overall quality did not
significantly differ among Veterans who did and did not report MST,
after adjusting for patient characteristics.
The terms of 38 United States Code Sec. 1720D authorize VA to
provide Veterans with counseling, care, and services needed to overcome
psychological trauma which, in the judgment of a mental health
professional employed by VA, resulted from a physical assault of a
sexual nature, battery of a sexual nature, or sexual harassment which
occurred during their service on active duty or active duty for
training. In implementing this authority, the Veterans Health
Administration (VHA) has developed a number of initiatives to
facilitate provision of these services, including the following:
Services & Treatment
Screening. Recognizing that many survivors of MST do not
disclose their experiences unless asked directly, it is VA policy that
all Veterans seen for health care be screened for MST. Screening is
conducted in a private setting by qualified providers trained in how to
screen sensitively and respond to disclosures. Veterans who report
experiencing MST are offered a referral to mental health for further
assessment and/or treatment.
Free care. Health care services (inpatient, outpatient,
and pharmaceutical care) for physical and mental health conditions
authorized to be provided under section 1720D are provided free of
charge (i.e., no copayments apply). Eligibility for MST-related
treatment is also separate from and independent of the Veterans
Benefits Administration (VBA) disability claims process. That is to
say, eligibility for MST-related care does not require or depend on the
Veteran filing and/or obtaining adjudication from VBA that the
condition secondary to MST is service-connected. In addition, some
Veterans not generally eligible for VA services may still be able to
receive free care for conditions related to MST.
Access to care. Facility MST Coordinators serve as contact
persons for MST-related issues and can help Veterans find and access VA
services and programs. All Veterans seen in VHA who screen positive for
MST are offered a referral to mental health services.
Outpatient services. Every VA health care facility
provides MST-related mental health outpatient services, including
formal psychological assessment and evaluation, psychiatry, and
individual and group psychotherapy. Specialty services are also
available to target problems such as Post Traumatic Stress Disorder
(PTSD), substance abuse, depression, and homelessness. Every facility
has providers knowledgeable about mental health treatment for the
aftereffects of MST. Because MST is associated with a range of mental
health problems, VA's general services for PTSD, depression, anxiety,
substance abuse, and others are important resources for MST survivors.
In addition, many VA facilities have specialized outpatient mental
health services focusing specifically on sexual trauma. Many community-
based Vet Centers also have specially trained sexual trauma counselors.
Residential/inpatient care. For Veterans who need more
intensive treatment, many VA facilities have Mental Health Residential
Rehabilitation and Treatment Programs (MHRRTP), a resource that is rare
in the private sector. VA also has inpatient programs available for
acute care needs (e.g., psychiatric emergencies and stabilization,
medication adjustment).
Education of Staff
All VHA mental health and primary care providers are
required to complete mandatory training on MST.
VHA's national MST Support Team hosts monthly continuing
education calls on MST-related topics that are open to all VA staff and
available online afterwards.
Since 2007, the MST Support Team has hosted an annual,
multi-day, in-person training focused on provisions of clinical care to
MST Survivors and MST-related program development.
The MST Resource Homepage is a VA intranet community of
practice Web site where VA staff can access MST-related resources and
materials, review data on MST screening and treatment, and participate
in MST-related discussion forums.
Staff also has access to an online independent study
course on MST and other Web-based training materials.
Information about MST has been integrated into VA's
rollouts of empirically-supported treatments for PTSD, depression, and
anxiety. These conditions are strongly associated with MST, meaning
these national initiatives have been an important means of expanding
MST Survivors' access to cutting-edge treatments. Furthermore, several
of these treatments were originally developed in treatment of sexual
assault survivors and have a particularly strong research base with
this population.
Since 2008, the MST Support Team has engaged in national
activities to support and encourage facilities to host events as part
of Sexual Assault Awareness Month (SAAM) in April. These activities
include selection of a national theme, dissemination of support
materials, publication of information about SAAM in the VAnguard
magazine and other outlets, and, in April, hosting a special national
MST training call designed to be of general interest to VA staff.
At a facility level, MST Coordinators may host Grand
Rounds and other educational presentations, distribute informational
newsletters or fact sheets, and engage in other activities.
Outreach to Veterans
To help ensure information about MST-related services is
readily available to Veterans, VA's national MST Support Team developed
outreach posters, handouts, and educational documents for Veterans,
secured inclusion of information about MST on relevant va.gov Web
sites, and developed an MST-specific Internet Web site
(www.mentalhealth.va.gov/msthome.asp).
The MST Support Team identified Transitioning
Servicemembers and newly discharged Veterans as high priority groups
for outreach in fiscal year 2013. The team is collaborating with DOD's
Sexual Assault Prevention & Response Office and other national VHA
program offices to ensure that these Veterans are aware of MST-related
services available through VHA.
Facility MST Coordinators engage in local outreach efforts
to raise awareness about the availability of MST-related services. Tips
sheets from the MST Support Team help facilitate these efforts.
MST is included in ``Make the Connection''
(www.maketheconnection.net) and ``About Face'' (www.ptsd.va.gov/
aboutface) Web sites featuring Veteran's stories of recovery.
Question 3. I have introduced a bill to expand the definition of
homeless veterans to include victims fleeing domestic violence.
Do you have any numbers or sense of the problems for veterans
fleeing domestic violence and wind up homeless? Is there something else
we should be doing with homeless and domestic violence to help
veterans? Concerning the definition of Homeless, what if any problems
do you see from expanding this definition? Seems like a very small
change that would benefit many veterans.
Request: Do you have any numbers or sense of the problems for
veterans fleeing domestic violence and wind up homeless?
Response. VA does not specifically track this data, but we do have
a sense of the problem for Veterans fleeing domestic violence who are
at risk for homelessness.
VA recognizes that Veterans who experience past or present Domestic
Violence/Intimate Partner Violence (DV/IPV) face complex issues,
including, homelessness. There is evidence that IPV is among the
leading contributors to housing instability and homelessness among
women (Baker, Billhardt, Warren, Rollins & Glass, 2010; Hamilton, Poza,
& Washington, 2011) and likely contributes to risk for homelessness
through multiple pathways. For example, fleeing an abusive relationship
can be a contributing factor to homelessness among women (Baker, Cook,
& Norris, 2003; Baker, et al., 2010).
In addition, IPV leads to and exacerbates mental health conditions,
such as PTSD and substance use disorders that significantly increase
risk for homelessness among women Veterans (Hamilton, et al., 2011;
Washington, et al., 2010). Similarly, IPV is associated with other risk
factors for homelessness, such as MST. Among homeless women Veterans,
the prevalence of MST is 53 percent, compared to 26.8 percent among
non-homeless women Veterans (Washington, et al., 2010).
Although male Veterans also experience IPV, male-to-female IPV
results in greater severity of violence, number of injuries, and mental
health consequences relative to IPV experienced by men (Archer, 2002;
Carbone-Lopez, Kruttschnitt & Macmillan, 2006). Moreover, the link
between IPV and homelessness risk has not been as robustly established
for men as it has been for women. Thus, the need to address DV/IPV and
risk for homelessness is arguably most urgent for women. Yet, VA
programs that address DV/IPV will work hand-in-hand with homelessness
programs to address this health issue among all Veterans regardless of
gender.
An array of services, from crisis intervention to long-term
assistance, is needed for Veterans fleeing violent relationships.
Immediate crisis intervention may include attention to physical
injuries and assistance with food, shelter, child care (when needed),
and general safety. Long-term assistance may include ongoing medical
care and programs to help Veterans cope with lasting emotional and
psychological effects of IPV to regain or achieve economic and housing
stability.
Request: Is there something else we should be doing with homeless
and domestic violence to help veterans?
Response. Addressing complex DV/IPV issues will require a
coordinated, interdisciplinary approach. In 2012, a Domestic Violence
Task Force was chartered to develop a national plan to address issues
relating to the identification of domestic violence and access to
services for Veterans who experience DV/IPV. The Task Force's
recommendations involve collaboration and coordination of care between
all types of VA services, including, but not limited to, physical
health care, evidence-based mental health treatments, employment, and
supportive housing services.
In addition, available data suggest that many VA providers have had
limited training related to DV/IPV (Iverson et al., in press). Thus,
training and education of VA staff will be vital to the successful
implementation of comprehensive care for Veterans who experience DV/
IPV, and those who use DV/IPV. A Veteran who experiences violence is
the recipient of violent behavior and is traditionally referred to as
``victim'' or ``survivor'' of DV/IPV. A Veteran who uses violence
toward his or her partner is typically referred to as a ``batterer,''
``abuser,'' or ``perpetrator.'' VA is in a unique position to provide
care for both those who experience and those who use violence. Training
initiatives will include information about DV/IPV being a risk factor
for homelessness among the Veteran population and will provide specific
guidance for addressing these often co-occurring issues.
Effective intervention involves collaboration among many programs
and agencies working together to provide identification and assessment,
risk evaluation and provision of safety supports, treatment planning
and delivery, and coordination with law enforcement and other relevant
providers. In addition to ending violence and preventing further
violence, services in response to DV/IPV often address needs related to
healing from the physical, psychological, and social effects of
violence. VA has resources in place that can also address the long-term
health effects of DV/IPV.
Community partnerships/resources must be further developed and
maintained to ensure that Veterans and their family members have
adequate assistance to quickly and safely transition from unsafe
settings putting them at risk for DV/IPV. These partnerships will
assist in supplementing what VA can provide and address access to safe
homes for immediate shelter, transitional homes for newly displaced
Veterans and their family members, and assistance with permanent
housing.
Request: Concerning the definition of Homeless, what if any
problems do you see from expanding this definition? Seems like a very
small change that would benefit many veterans.
Response. Addressing DV/IPV is likely to lead to reductions in
homelessness since many individuals end up homeless trying to flee DV/
IPV. VA Homeless Programs do not currently track the data for this
subpopulation; hence, we are unable to estimate the impact of expanding
the definition of homeless. VA has a homeless continuum of care with
services ranging from emergency shelter to permanent supportive
housing. Veterans who are fleeing from DV/IPV and satisfy the current
definition of homeless are already served in VA's homeless programs
when it is clinically appropriate. Even when a VA homeless program is
not a clinically appropriate placement for a Veteran affected by DV/
IPV, VA works closely within the local community to identify resources
best suited to the clinical needs of the Veteran. To this end, VA's
programs that address homelessness may help prevent future DV/IPV by
assisting Veterans in finding alternative housing options so they can
safely exit abusive relationships. VA does not know the scope or the
true needs of the DV/IPV Veteran population and currently lacks a VA
domestic violence safehouse program. A safehouse provides shelter for
women and children fleeing imminent danger and can provide a spectrum
of life-saving, supportive, and educational services to help women and
children leave behind a life of domestic violence and begin a new life
of stability. Staff training and informational outreach are essential
components for DV/IPV-related programming. Medical and mental health
providers and staff will undergo recommended training which will be
tailored to the specific needs of clinical, non-clinical, and mental
health staff. Training content for providers and staff will include an
overview of the prevalence, risk factors, protective factors, and
specific issues related to Veterans including risk assessment, safety
planning, and procedures for situations where the Veteran is in
imminent danger. DV/IPV programming will work hand-in-hand with current
initiatives aimed at addressing homelessness among Veterans ensuring
Veterans get the care they need.
Question 4. I see you did not have time to comment on my research
bill (S. 877), but I would like the VA to weigh in. This bill would
allow public access to research of the VA. The VA budget (2013) for
medical and prosthetic research is about $1.9 Billion, access to the
results remain limited. For example, nearly $53 million on post-
deployment mental health and $7 million on Gulf War illness. The
information from this research is frequently inaccessible for
clinicians outside the VA system, a significant number of veterans
receive at least some of their health care from non-VA clinicians.
How could public access to VA research improve the care veterans
receive from those clinicians?
Response. VA Research's success in improving Veteran health care is
predicated on making its results publicly available. Information
generated by VA researchers needs to be known, translated, and
implemented in order for it to positively impact Veterans health care.
The VHA Office of Research and Development (ORD) continues to emphasize
the importance of publishing results and ensuring timeliness in
completion of its funded activities. Within VA, ORD disseminates
research results to groups involved in patient care, including Pharmacy
Benefits Management and distribution groups for Center for Information
Dissemination and Education Resources communications. Public access to
VA research primarily involves two aspects, access to publications and
access to data. Currently, VA has a group examining ways to improve
access to research results in conjunction with similar activities by
other research funding agencies. More specifically, VA is looking at
ways to partner with the National Institutes of Health's PubMed Central
repository for making its publications more widely accessible. Clinical
trials sponsored by ORD are also complying with Section 801 of the Food
and Drug Administration Amendments Act by submitting results for
posting on clinicaltrials.gov. Registration and posting results of
studies on clinicaltrials.gov also provides a mechanism to accessing
publications through links established by the National Library of
Medicine between a study profile and any subsequent publication.
Finally, VA is exploring mechanisms for how data from its multi-site
clinical trials can be made available after the publication of the
primary results manuscript. Altogether, these efforts can provide
state-of-the-art knowledge in those areas for which clinicians in VA
and throughout the Nation to better inform decisions in providing care.
Since a core requirement of VA research is to be Veteran centric,
publications and results have a direct relevance for informing VA care.
Even further, VA research is part of a more national effort to help
better inform patients about diseases, treatment, and options in such
care.
Question 5. S. 877 will enhance public access to findings from VA-
funded research; I believe that the access to research afforded by this
bill could serve as a tool to assess the return on investment of
research funding.
A. How could implementing a public access policy for VA research,
like the public access policy that is already in place for the National
Institutes of Health, help VA to assess return on investment?
Response. While discussions on biomedical research's return on
investment are beyond the economic expertise VA maintains, several
publications including a 2011 report issued by the National Academy of
Science, National Academy of Engineering and the Institute of Medicine,
are available on this topic. However, ORD is already considering public
access policies that are consistent with those used by the National
Institutes of Health (NIH). Any determinations of return on investment
would be likely similar. Currently, ORD uses NIH's Electronic Research
Administration (eRA) tool for handling proposal submissions and
scientific peer review. Additionally, VA has been among leading groups
committed to posting information on its clinical trials on the NIH/
National Library of Medicine's clinicaltrials.gov public registry and
has established relationships with them to enable communication and
execution of best practices. Further, VA is exploring more systematic
processes for uploading trial results across the system on
clinicaltrials.gov. While VA agrees in principle with NIH policies,
there are some notable differences that have to be taken into account.
Given that VA is part of an integrated health care system, protections
for patient data and data security, in general, is of the utmost
concern. There are considerations in that context that may not have
been addressed in NIH's policies. Implementing any public access would
also be contingent upon information technology (IT) systems and
resources. Since VA IT support comes from a separate appropriation with
no direct tie to research activities, VA research may face challenges
that NIH does not.
B. Do you see any problems, drawbacks in making information
publicly available that could improve the care of veterans? And will
you work with the DOD to merge data files to expedite important
research to help veterans?
Response. Making publications derived from VA research available
has many important benefits to clinicians and patients. In fact, VA
research has been a leader for decades in the area of comparative
effectiveness research which can enable clinicians and patients to be
better informed about differences between available treatment,
prevention, and/or screening options. Providing information about
active clinical research protocols that Veterans can participate in is
also of significant value to advancing care for Veterans and the
Nation. However, having research data publicly available should
consider safeguards and policies for appropriate use. Making research
data available allows for analyses or even combinations with other data
to enable more advances in the field. In this context, making research
data available allows for a greater return on investment. The major
drawback is that data that is too widely accessible to individuals who
may not have requisite knowledge or skills for using them could be
misinterpreted. For example, statistically, repeated analyses of a
dataset can generate positive results by chance. Such results, if
published, may actually misinform clinicians and patients by suggesting
benefits that may not be true. Further, use of data for which they were
not originally intended may result in inappropriate analyses or
conclusions. It potentially bypasses the well-established scientific
peer review process for vetting results for broader dissemination.
Finally, prior to publishing data obtained from clinical research
protocols, VA needs to also consider ethical principles behind informed
consent and the purposes for which study participants knowingly
contributed their information. A lack of consideration for these points
can potentially result in unintended consequences that inhibit moving
science and medicine forward.
VA and DOD worked together on a National Research Action Plan
(NRAP) in response to an Executive Order, ``Improving Access to Mental
Health Services for Veterans, Servicemembers, and Military Families,''
issued on August 31, 2012. The NRAP contains plans for future data
sharing between VA and DOD to improve research.
Question 6. Next week is VA Research Week calling attention to the
achievements of VA researchers and the role they play in advancing
medical science. I know that the VA's Research and Development division
does some very innovative work. The Million Veteran Program is
comprehensive and when finished will have a wealth of information for
the VA.
My question, do you see the advantage of sharing this kind of info?
And do you see the value in sharing this comprehensive data collecting
with non-VA clinicians?
Response. The Million Veteran Program (MVP) is a research program
created to be a resource that combines genetic information, self-
reported survey information, and health record information from over
one Million consenting Veteran users of the VA health care system.
Approved researchers will be able to access this information to carry
out studies to better understand the effects of genetics on health and
disease. Currently, this information is not returned directly to
participants or to their clinicians, as it is for research purposes
only. Initially, MVP data access will be restricted to approved VA
researchers on a small scale in order to test out the complex
infrastructure that will securely house Veterans' information. Once the
process is thoroughly vetted, the collected information could be made
available to approved researchers in other Federal agencies and
academic institutions. One advantage of making this information
available to approved non-VA researchers is the possibility of
leveraging resources, in the form of public-private partnerships,
particularly in the bioinformatics and computational fields, to advance
the analysis of complex genetic data and the pace of scientific
discovery.
______
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal
to Robert L. Jesse, MD, Ph.D., Principal Deputy Under Secretary for
Health, U.S. Department of Veterans Affairs
Question 1. Dr. Jesse, I would like to focus on the Chiropractic
Care Available to All Veterans Act, which I am proud to sponsor with my
colleague, Senator Moran. The most frequent medical diagnoses reported
among Iraq and Afghanistan veterans are musculoskeletal and connective
system issues. In fact, nearly 200,000 recent veterans who have sought
VA care since 2002 have been diagnosed with these conditions.
Chiropractic care can be an appropriate and effective means of
treatment for these individuals.
However, the VA currently provides chiropractic care at only a
fraction of its medical centers. As a consequence, many deserving
veterans who would benefit from chiropractic care are unable to access
the specialized medical attention they need. The Chiropractic Care
Available to All Veterans Act would require VA to provide chiropractic
care services at all of its medical centers by the end of 2016. All
veterans deserve access to these cost-effective chiropractic treatments
at VA facilities.
Your assessment of veterans' access to these services, that the
care is currently available to ``all veterans,'' does not line up with
the Veterans' Health Administration's own reporting that fewer than 50
medical centers currently offer these services. Even veterans taking
advantage of fee-based chiropractic care outside of the VA system may
not be able to readily access these services, depending on geographic
location. I am not convinced that these current options are sufficient
to meet veterans' increasing demand for chiropractic care.
How does VA currently accommodate these veterans, if at all, in
areas far away from a VA facility with chiropractic services and far
away from fee-based service options?
Response. The Department of Veterans Affairs (VA) provides
chiropractic services as part of the medical benefits package and
administers this service based on clinical need, similar to all other
medical care. Chiropractic services are provided on-station by VA
staff, or when not available through VA, services are provided through
the Non-VA Purchased Care program (Fee Basis). When chiropractic
services are obtained under the Non-VA Purchased Care program, VA works
to accommodate (to the extent possible) the Veteran's preference
regarding choice of community provider. In Fiscal Year 2013, VA spent
over $10.3 million on chiropractic services, including $5.5 million on
purchased chiropractic services. Even when VA seeks to procure this
service, the needed chiropractic services may not be available in the
Veteran's local community, especially in rural areas. This creates a
barrier to access that is outside of VA's control. Where VA cannot
procure the services locally, the only option may be for the Veteran to
travel to the distant VA Medical Center. Costs of such travel may be
offset if the Veteran is eligible for beneficiary travel benefits.
Chairman Sanders. Thank you very much. Dr. Jesse. As you
know, I have introduced legislation to expand VA's caregiver
program to veterans of all eras.
Dr. Jesse. Yes.
Chairman Sanders.While VA did not provide written testimony
on this particular bill, I would very much appreciate you
providing this Committee with information on the progress of
this program. My understanding is that it is filling a real
need.
Can you speak to that? For example, how many veterans and
their families have accessed the program to date?
Dr. Jesse. Sir, I do not have those numbers in front of me
but we will get them to you for the record. I will say that we
have briefed senior management on the progress of the program.
As you know, I think a report is due 2 years after the
implementation of the program which would be at the end of this
month.
Chairman Sanders. Can we expect to receive that report at
the end of this month?
Dr. Jesse. I can hope so but not promise. How is that?
Chairman Sanders. Sometimes this Committee has had a
problem with getting reports in a timely manner. So, please
ensure your leadership is aware that we expect the report at
the end of this month.
[Responses were not received within the Committee's
timeframe for publication.]
Dr. Jesse. I shall. I think the program is quite
successful. In terms of expanding the program, you, I think,
are well aware that the equity issue to all veterans of all
generations is important to us; and expanding this program I
think very much fits within that. Of course, the question is
the cost and the eligibility issues that would have to be well-
defined.
But these are important issues to us. We very much
appreciate the opportunity to have started off in this initial
view of the post-9/11 veterans and clearly can see the impact
of having this capability.
Chairman Sanders. In other words, what you are telling us
is you think that program is filling a real need.
Dr. Jesse. I believe so, yes.
Chairman Sanders. OK. And would you agree that it is hard
to argue from an equity standpoint why it is only available to
post-9/11 families?
Dr. Jesse. Yes.
Chairman Sanders. Senator Burr raised the point that he and
I are working together on the homeless issue. Let me applaud VA
for its work in this area. I know it is easy to beat up on the
VA but the VA has made some significant improvements under
General Shinseki and taken important steps in dealing with what
I consider a national embarrassment, and that is homelessness
among veterans.
VA has set an ambitious goal of ending homelessness among
veterans by 2015.
The VA's homeless programs serve a number of populations
with different needs. Senator Burr and I have introduced
legislation to make common sense improvements to some of VA's
programs for homeless veterans, including making transitional
housing programs more accessible to the growing population of
homeless women veterans.
Last December, the Interagency Council on Homelessness
released the report that detailed challenges around stable
housing for veterans in rural areas and tribal lands. The
report included several recommendations on how to improve
services for this population. My question is two-fold.
First, does VA believe we can continue to make significant
progress in dealing with the tragedy of homelessness in our
veterans' population and especially the growing needs of women
veterans?
Second, what actions is VA taking to address the needs of
homeless veterans in rural areas and on tribal lands?
Dr. Jesse. Senator, the first question is, are we making
significant progress? And I think the answer to that is simply
yes. We have in place a multitude of programs across both urban
and rural venues.
I will say that I think the homeless program in VA has
taught us an incredibly important lesson, and that is that the
success of programs like this are not necessarily predicated on
what we ourselves do, but our ability to partner with the
incredibly dedicated local, State, and other Federal agencies
that are addressing these issues.
I had the opportunity a couple of years ago to go to some
of the veteran homeless stand-downs that we were conducting and
was just thoroughly impressed that the comments from the local
government, faith-based, and NGO's about the role that the VA
was playing to supporting the communities.
Granted, our authority is to take care of the homeless
veteran but much of the capability to do that requires
interacting with all the local folks. I think the best comment
I had gotten was that they were very pleased whenever they
identified a homeless person as a veteran because they knew
that one phone call and that person would be engulfed with
services.
So, I think we are making great strides in those areas. I
went to the Point-in-Time count this year out in Los Angeles
and was equally impressed by the fact they were not necessarily
counting homeless people because they knew them all. And, that
is a far more important statement because when you know who the
homeless people are, you know how to serve them best and get
them the appropriate services.
Regarding rural and tribal areas, I confess I cannot speak
to the tribal areas. I can get that back for you for the
record. The rural areas, I think we are equally dedicated to
which is a matter of working in lower volume areas but, again,
supporting the local communities who are working in these
areas.
[Responses were not received within the Committee's
timeframe for publication.]
Chairman Sanders. Thank you. As I mentioned, Senator Burr
and I have introduced sound legislation, and we are going to do
our best to see that it is passed. We look forward to working
with you for its implementation.
Senator Burr.
Senator Burr. Thank you, Mr. Chairman.
Dr. Jesse thank you for being here. I have great affection
for the entire VA workforce----
Dr. Jesse. Thank you.
Senator Burr [continuing]. For what they commit to do; and
I appreciate that the VA supports my Camp Lejeune bill. I am
concerned, though, that the family members at Camp Lejeune and
the veterans are waiting to access benefits provided by the
current law.
In an explanation of the health care benefits provided by
Camp Lejeune Act, VA's budget justification indicated the VA
would start treating family members in fiscal year 2015.
Let me ask you. Why are these family members who are
fighting cancer and other devastating diseases being forced to
wait 18 months for the health care they need right now?
Dr. Jesse. So, part of that answer was embedded in the
initial legislation which required the authorization,
appropriation of the funding to do so. We have been engaging
with the family members. We have, I think, at this point
identified approximately 500, but in terms of actually
beginning to disburse money to pay for their health care----
Senator Burr. I need to cut you short. The authorization is
in this year's continuing resolution. It is in this year's. It
is in next year's. There is no explanation as to why it would
take to 2015 except that we have thrown a dart on a map and
that was the date that came up.
Dr. Jesse. I would like to get back to you for the record.
Senator Burr. I would ask only this of you; go back and
read the act.
Dr. Jesse. OK.
Senator Burr. It is now law. Go back and look at the CR.
The authorization is there. The Act, when it was adopted was
offset. The money was there.
I am just going to be real candid. There is no excuse. To
do this is to turn your back on individuals that are reliant on
the VA partnership to provide them health care.
And, let me just say to all my colleagues, we did not put
VA in the primarily spot; they are secondary. These people have
to turn to their own insurance first. VA is a backup. It is
there for any cost overage. It is there if they do not have
insurance. These are folks that, in many cases, are in terminal
illness. They may not make it to 2015.
Dr. Jesse, you testified that VA was reviewing the staffing
structure of the VISN headquarters to streamline and
standardize their operation and that you were going to go back
to determine, geographically, what the number was.
Now, I am not a bureaucrat. I am a business guy. It makes
sense to me that you would go in and figure out geographically
how many you needed before you looked at how to streamline it.
Have I got it backwards or do you?
Dr. Jesse. So, I am a cardiologist. I think the ability to
reconfigure the entire administrative organization of the VA is
complex and probably more than just determining what the right
number of VISNs is; and the ability go to in and look at the
efficiency and effectiveness of the existent VISN structure is
a relatively straightforward process.
What it really required us to do--and I think, frankly, was
very important--is to really speak to what is the role of the
VISN structure. It has changed over time from their original
conception back in 2008 when they were put together. And if you
are trying to understand why there was such a great variance
across the sizes of the VISNs regardless of the scope of size
of----
Senator Burr. Do you intend to sort of go back to the
original intent of the creation of the VISNs to use the
template to look at the current numbers?
Dr. Jesse. So, the original VISNs were built on the
structure geographic including referral patterns. I think
having done the first part which is: we said what we have done
and we briefed your staff on it; we have leaned down the size
of the VISNs. The next thing to do is really go look at the
referral patterns.
Frankly, there are a lot of people for care across VISN
lines which creates at some level of both confusion and
complication. If we can re-adjust them on what are the
contemporary VISN patterns, I mean, I think we can make some
significant changes in how the preferred VISN structures are
aligned. But I do not know if 12 is the right answer or 15 is
the right answer.
Senator Burr. VA's own testimony states that they are
unclear why VISNs 19 and 20 are consolidated and VISN 6 would
be untouched and stated VA would appreciate the opportunity to
review the Committee's criteria for determining these
boundaries. I am ready. I think we have been very specific.
Let me just, Mr. Chairman, ask one last question. Your
written testimony states that if this VISN Reorganization Act
were to become law, veterans could potentially, ``be forced to
travel to different locations for care because the space for
clinical operations would be used to comply with the provision
calling for VISN offices to be co-located within a medical
center.''
Since the bill outlines the process for VA to enter into
leases, how in the world would this provision change where a
veteran received their care?
Dr. Jesse. I think what that statement refers to is--let me
back that up and say one of the reasons why many of the VISN
headquarters are not on the grounds of a medical center is
because the space needs in those medical centers was to deliver
clinical care and it felt it was more appropriate to move an
administrative function that was not directly attached to that
medical center offsite and use the space for delivery of care.
The notion is if we then had to collapse the space to
deliver care, we would have to distribute that care somewhere
else. I think that is what it is referring to.
Senator Burr. I thank the Chair.
Chairman Sanders. Senator Begich.
STATEMENT OF HON. MARK BEGICH,
U.S. SENATOR FROM ALASKA
Senator Begich. Thank you, Mr. Chairman.
Thank you both for being here this morning. Let me ask you,
in reference to two bills that I have. One is S. 287, which is
a bill to amend Title 38 of the Code to expand the definition
of homeless veterans for the purpose of benefits under the
administration.
For purpose of eligibility or what it would change through
the VA, the bill includes veterans, families fleeing from
domestic or dating violence, sexual assaults, stalking and
other dangerous life-threatening events as well as children who
may be at risk or jeopardized. There is no other type of
residency. The idea is to expand the definition of
homelessness.
Last year, you all supported it but this year you have no
comment. Can you tell me where you are on this? Just give me
your thoughts on it.
Dr. Jesse. Sure. Ms. Blauert.
Ms. Blauert. Yes, sir. We did provide views in September of
last year; and to be honest, we were not really satisfied
coming back to you with essentially the same view this year. We
want a little bit more time to dig in and look at the issues
and exactly what the impact would be on our existing programs
with expanding who we capture with the term ``homeless
veteran.'' You can be assured that VA does not turn away a
veteran who is out on the streets and in need.
Senator Begich. I understand that. But what I guess I am
trying to--if that was September of last year, it is now May. I
battled this issue before with HUD because what they always
would say is we hear you, the definition of family, and some
other definitions. But what it would do is statically change
their numbers. In other words, it would show that you had more
homeless. Well, of course, because now you have increased the
definition. I hope that is not one of the reasons. That is now
one of the reasons, correct?
Ms. Blauert. No. Absolutely.
Senator Begich. OK. Then when can I see a response, because
it seems logical that we would want to make sure veterans and
families fleeing domestic violence or dating violence or other
situations of this nature that become homeless would be even at
higher risk because of the situations they were in, now they
are on the streets. So, is there philosophical opposition to
it?
Ms. Blauert. No, I do not believe there is philosophical
opposition to it. It is my understanding that there is interest
in making sure that we have clinicians and services available
to treat the needs of these persons. Some of them are going to
be different than the current population that we consider
homeless.
Senator Begich. I understand.
Ms. Blauert. I understand that VHA recently undertook a
task force to specifically look at the domestic violence issue.
Dr. Jesse. We could break a bit of the discussion away from
the definition of homeless and speak to our ability and frankly
our desperate need to attend to his very vulnerable population.
You know, we take the issue of domestic violence incredibly
serious. As you know, the women's health program in VA has been
doing some magnificent work over the past couple of years. They
have a task force which has just completed its report on
domestic violence.
Senator Begich. Does the task force, did they deal with the
issue of homelessness?
Dr. Jesse. I do not know that they specifically addressed
the issue of homelessness. What they are specifically
addressing is how we support and care for victims of domestic
violence, which would generally mean getting them out of the
living environment that they are in into some other
environment.
Senator Begich. I only have limited time here so I want to
get right to it.
Dr. Jesse. Yes.
Senator Begich. So, the task force is done. They have
prepared a report. When will that be public?
Dr. Jesse. That I do not know, but I know that the report
has been done and we would see the recommendations coming out
shortly. We can get that back to you.
Senator Begich. OK. That would be great.
[Responses were not received within the Committee's
timeframe for publication.]
Senator Begich. So, if you are subject to domestic violence
or sexual assault in a home environment, then you leave.
Dr. Jesse. Right.
Senator Begich. OK. So, they become couch-hoppers where
they are going from house to house or they are on the street.
This is not the population you want on the streets.
Dr. Jesse. No.
Senator Begich. So, I am hopeful, if that is a draft report
and it does not address this it should, and then refer to the
bill itself because the definition is what helps make sure
resources follow these individuals.
Dr. Jesse. Exactly.
Senator Begich. That is really important.
Let me quickly go to one last thing, and that is there was
another piece of legislation, S. 877, the Veterans Fair
Research Transparency Act. This is very simple.
The National Institute of Health does this now, and a lot
of the work that they do they can share; therefore, the data
helps with other research, et cetera.
Why can the VA not replicate what the National Institute of
Health does in the sense of creating a database and ability for
sharing of information? Of course, not individuals by names and
so forth. Why can we not do that if another Federal agency does
that now?
Dr. Jesse. Well, I do not think it is an issue that we
cannot. I think the issue is we just have not had the time to
look at exactly the best way to do this. I fully agree with you
that the NIH does this now. They require any NIH-funded study
to make that journal article available free of charge.
Senator Begich. So, let me ask you this. Again
philosophically, does the VA oppose this?
Dr. Jesse. No. No.
Senator Begich. So, really it is about looking at this
legislation and seeing how you can implement it?
Dr. Jesse. The simple answer might be just to tag on to the
NIH's role.
Senator Begich. Mr. Chairman, with the time we get, we have
all these bills; it is hard to get agencies to say, yea, nay,
or here are the five things we need fixed.
All I am asking for is--when I was mayor of a city, our
legislative body asked for something. We would respond by
saying we do not like it; we do like it; or we have problems
and here are the six things we need fixed. Can you do that with
this bill?
Dr. Jesse. We can.
Senator Begich. Thank you. That is all I have. My time was
up. I am sorry I had to rush you. I am respecting the Chairman
here, and I do not want to get in trouble.
Chairman Sanders. Senator Boozman.
STATEMENT OF HON. JOHN BOOZMAN,
U.S. SENATOR FROM ARKANSAS
Senator Boozman. Thank you, Mr. Chairman, and thank you for
being with us, Dr. Jesse.
Dr. Jesse. Yes, sir.
Senator Boozman. We have gotten behind in the backlog of
disability claims, and this and that. But I do think that we
have a really good story to tell in regard to homelessness. You
all have done a good job with that, which is something we need
to talk more about.
In the last 15 years--I have been on the VA Committee in
the House or the Senate now for a long time and just the
increase in veterans health care in general has improved
dramatically. We have still got a long way to go in the sense
of just fighting the battle but it really is much better.
We currently have just completed and are going to dedicate
a expansion in Fayetteville, AK, providing a lot more
outpatient services. That has become a large VA facility now
with a tremendous veteran population. It was very much needed,
and it truly is state-of-the-art.
I was out visiting our clinics. The advances that we are
using: telemedicine and things like that; those are good
things. So, those are things that we can be very proud of.
I also appreciate your comments about recognizing, in
regard to homelessness, the value of State, local, faith-based,
and other NGO's, the partnerships, which have been big factors
in pushing us forward in that regard.
I hope that we will do the same thing in regard to suicide
and some of these other challenges we have and really make a
concentrated effort.
I guess what I am interested in is things that work. I
think in homelessness at some point we kind of threw our hands
up and said the government has the want-to but they do not have
the heart to get this done and we allowed others to come in and
help. I hope that we will do that again with the suicide.
In a second, I would like you to comment about these
things. We have been working with Senator Begich on the bill. I
am an original cosponsor of the one that he mentioned. I guess
the thing there is, you know, going out to rural States like
ours you will have communities that do an excellent job helping
with people that are put in very difficult situations where
essentially the community provides. Then, you have other places
where there are no resources at all.
I am committed to getting this thing done as quickly as we
can, but until then, you mentioned the fact that you could
provide resources. Can we do this somewhat administratively in
the sense that when people are in this situation, does that
qualify them for homelessness in another way? Do you see what I
am saying?
Dr. Jesse. Yes, I see what you are saying. My gut answer is
I would sure hope so. If there is a technical reason we cannot,
I am not aware of it but I will try to find that out. I think
that one of the other brilliant parts of the homeless program
that is under-recognized is the prevention piece of it.
Senator Boozman. Right.
Dr. Jesse. VBA watches the mortgages real carefully. As
people look like they are defaulting, VBA has interventions.
They can keep people in their homes. Keeping people employed,
opening up the GI Bills to get people in school so at least
they are getting educated if they cannot get a job. All these
things contribute to the prevention of homelessness which I
think are part of the bigger story.
But in terms of that specific, I will have to get a
technical answer to that. I would sure hope that we do not deny
somebody there. Again, I think that providing a safe place to
live for a victim of domestic violence is absolutely key.
Whether they are called homeless or not is less important than
making sure that they are safe.
Senator Boozman. You know, short term until we can reach
agreement and get this thing sorted out officially, I think
that would be very helpful in trying to, because that is one of
the things that we all agree on needs to be done.
Dr. Jesse. Yes, we do.
Senator Boozman. The other thing is, you know, in doing
that these folks are going to be eligible for other things.
So if you can always head these things off at the pass,
invariably it costs a lot less money in the future because then
you do not get into destructive behavior and things like that
which are so difficult to deal with.
Dr. Jesse. That is a great statement because that applies
even to things like the transportation bills which getting
people to their appointments. While it is difficult to
quantitate the savings, we know from both the U.S. Health Care
and other national health care systems that people who do not
make their appointments that is what costs, because getting to
those appointments allows you to help patients manage their
chronic diseases best and is part of our commitment to the use
of telemedicine and all its derivatives to keep engaged with
patients rather than relying just on those point-to-point
visits.
Senator Boozman. Thank you. I have used all my time. The
only thing I would say, you do not have time to respond, but I
would hope that you support the Veterans' Drug Courts. I think
that is another solution that is a big deal.
Chairman Sanders. OK, panelists, thank you very much. And,
Dr. Jesse, remember again the law says we should get that
report at the end of this month.
Dr. Jesse. Yes, sir.
Chairman Sanders. We will be looking at our mailbox.
Dr. Jesse. OK. Thank you for having us. Thank you for your
support.
Chairman Sanders. I would like to welcome our second panel.
[Pause.]
Chairman Sanders. Clearly, if this Committee is to do its
job well, it is important that we hear not just from
representatives of the VA but from people on the ground who
will be impacted by legislation that this Committee considers.
So, we are delighted to have a wonderful panel with us. These
individuals have devoted years of their lives to the needs of
American veterans.
We are going to begin with Rick Weidman, Executive Director
for Policy and Government Affairs at Vietnam Veterans of
America.
We will then hear from Dr. Wayne Jonas, who is the
president and Chief Executive Officer of the Samueli Institute.
We will hear from Heather Ansley, Vice President for
Veterans Policy at VetsFirst; next, Matt Gornick, Policy
Director for the National Coalition for Homeless Veterans.
And finally Thomas Bowman, Former Chief of Staff of the
Department of Veterans Affairs. We thank all of you very much
for being with us.
Mr. Weidman, please begin.
STATEMENT OF RICK WEIDMAN, EXECUTIVE DIRECTOR FOR POLICY AND
GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA
Mr. Weidman. Mr. Chairman, thank you for inviting Vietnam
Veterans of America to share some of our views on the issues
before the Committee today.
The first issue I want to touch on is the issue of children
of Vietnam Veterans with spina bifida. With the help of your
staff and that of Senator Donnelly, we are finally making some
progress in that regard in terms of taking care of one case,
Honey Sue Newby, who had come to our attention.
Our concern, though, is with the other thousand children,
as nobody knows whether or not they are being taken care of. It
once again comes back to the same issue that you and your
colleagues have touched on this morning of accountability for
things that were clearly defined in the statute some time ago.
It is that accountability issue that we struggle with with
the Veterans Administration in all facets of it. In regard to
the Veterans' Health Equity Act, we think it is important for
the States that do not have any medical center and access to
care, whether it be in the State of Vermont or New Hampshire or
Wyoming or North Dakota, is very important and we thank Senator
Shaheen for that.
The Women Veterans and Other Health Care Improvements of
2013, introduced by Senator Murray, we are for this bill
strongly. In fact, we recognized one of your staff who worked
on this bill as Congressional Staffer of The Year for the 112th
Congress.
And, it provides many additional steps toward what was
envisioned by Senator Inouye 30 years ago when we started this
process of making the VA responsive to the needs of women
veterans and it is another important milestone.
We support Senator Begich's broadening the definition of
homeless veterans and would, for the record, make the point
that we have always defined, at Vietnam Veterans of America,
homeless veterans as those without a permanent home.
VA does not define it that way. They only define it if you
are on the street. Most people, before they hit the street,
have stayed on couches or in basements or in attics, friends'
houses, relatives, et cetera; and it is only when they have
exhausted all of those other opportunities that they end up on
the street. We need to catch them before they hit the street
and that is where VA often falls down.
I wanted to touch on the Reorganization Act because while
we applaud the effort, Senator Burr, to get at the
administrative overhead, we are not necessarily sure that this
is the way to get at it.
We were told when they reorganized into VISNs that it would
reduce administrative overhead and, in fact, it has gone
exactly the other way. There is more admin overhead at the
medical centers than there was before; and still, on top of
that, you have the admin overhead at the VISNs.
We have never quite figured out what the heck a nurse
executive is. Is that a person trained as a nurse who does not
work as a nurse anymore? All of those kinds of euphemisms
trouble us deeply.
And their new reorganization plan reminds some of us of a
certain age of the old Kelvinator washers, and it looks like a
big wash tub.
It is so confusing that even though we have tried to
understand it, we cannot. What they have done is divide
operations from policy, and anytime you divide that, what you
do is neuter the policy people--who really know what ought to
be done--from the operations people; and the operations people
will always trump the policy people.
So, we think that far too many people that have been hired
since 2006 by VHA have not been more clinicians who actually
directly serve veterans. And, that really is the heart of the
matter which we would encourage the Committee to look into
deeply and possibly request a GAO report about how this has
shaken out; what percentage of those new funds have actually
gone to care deliverers versus more people in the admin
overhead.
Regarding chiropractic, we thank very much Senator
Blumenthal for stepping forward on that one. This is yet
another case where Congress has spoken clearly, just like in
the case of physician assistants, and VA ignores it.
It was clear 10 years ago that Congress wanted chiropractic
care to be available to any veteran who needed it within the VA
and yet VA has dragged its heels.
So, it is really a question of VA not being responsive and
not fulfilling the will of the Congress. It is the
accountability issue that bothers us.
I see I am out of time but I would just mention that we are
strongly in favor of the Homeless Veterans' Prevention Act of
2013, and we have shared in our written statement some specific
ideas and concepts that we would appreciate your looking at
before that bill comes to markup.
Mr. Chairman, distinguished Senators on the Committee,
thank you very much for hearing our views.
[The prepared statement of Mr. Weidman follows:]
Prepared Statement of Vietnam Veterans of America, Submitted by Richard
F. Weidman, Executive Director for Policy and Government Affairs on the
National Staff
Mr. Chairman, Ranking Member Burr, and other distinguish members of
the Senate Veterans' Affairs Committee. We appreciate your giving
Vietnam Veterans of America (VVA) the opportunity to express our
thoughts on pending legislative proposals vital to veterans and their
families that are before this Committee today.
Mr. Chairman and members of the Senate Veterans' Affairs Committee,
VVA would like to go on the record in support of the Secretary of
Veterans Affairs, the Honorable Eric K. Shinseki, as well as the
Undersecretary for Benefits (USB), the Honorable Allison Hickey. We
know they have faced difficult challenges in their jobs. The easy
answer to the problems confronting the veterans' community are
difficult and thorny ones. VVA believes in much greater accountability
on the part of managers and supervisors within the VA system. However,
we have been pushing for a plan to ``fix'' the Veterans Benefits
Administration (VBA) for more than 15 years. We now have a
modernization plan, so we urge that all lower their voices and let the
top leaders do their job.
What VVA does urge is that VBA do a great deal more ``addition by
subtraction'' of key highly paid staff both at the headquarters and out
in the Regional Offices who are just doing ``business as usual the way
they have always done.'' In fact many of these are working almost as
hard on undermining Undersecretary Hickey as she is in trying to move
the transformation forward. Those who continue to be part of the
problem instead of party of the solutions need to be weeded out, and
afforded a chance to pursue other opportunities outside of the VA.
care for children of vietnam veterans with spina bifida
Mr. Chairman, Vietnam Veterans strongly urges you to ensure that
overall (non-medical) case management services be provided to the
almost 1,000 now adult children of those veterans who served in Vietnam
during the war and who now suffer from diabetes. VVA has been working
particularly with one such young woman, Ms. Honey Sue Newby, and her
parents for some time.
With assistance from your staff and that of Senator Donnelly, we
are finally making some progress. However, VVA is very concerned about
the other nine hundred plus children as to what quality of medical care
and services they are receiving (if in fact they are receiving such
care as needed). This is a problem that is upon us now, and it will
only intensify as to what happens to these severely disabled progeny of
veterans when their parents get too old and sick to take care of them
anymore, or they die before their time as so many Vietnam veterans
have.
We ask that you move a legislative fix to address Ms. Newby's
situation and that of the other most disabled sons and daughters with
Spina Bifida, as quickly as possible. VVA also urges that you and the
Committee take additional steps to ensure that there is a detailed
assessment of each and every disabled person and their family in this
program as to what care they have received until now, an assessment of
what they need today, and a means of ensuring that these unfortunate
victims of their parent's military service are cared for in the future
in a comprehensive manner. Obviously this assessment should assess both
quantity and quality of medical services rendered. VVA also urges that
you include custodial care in addition to the full range of medical,
remedial, rehabilitative, respite, home based care, and other services
that VA can should provide today.
While all of these services were supposed to be provided through
CHAMP-VA offices located in Denver Colorado, the governing rule book
was never shared with the parents. It was also not provided to VVA even
when we submitted a Freedom Of Information Act (FOIA) request for all
relevant documents. However, We were able to get a copy of this
handbook from another very competent veterans' advocate, and we are
submitting it as an Addendum to this statement, with your permission,
to get it on the record in a public way, so that all of the effective
families may go to your web site and see what they are supposed to be
getting for this disabled child.
S. 49--Veterans Health Equity Act of 2013, introduced by Senator
Jeanne Shaheen, requires the Secretary of Veterans Affairs, with
respect to each of the 48 contiguous states, to ensure that veterans
who are eligible for hospital care and medical services through the
Department of Veterans Affairs (VA) have access to: (1) at least one
full-service VA medical center in the state, or (2) hospital care and
medical services comparable to that provided in full-service VA medical
centers through contract with other health providers in the state.
This proposed legislation directs the Secretary to report to
Congress on compliance with such requirement, including its effect on
improving the quality and standards of veterans' care.
Vietnam Veterans of America (VVA) strongly favors this bill. For
too long veterans who live in low population density states have not
had proper access to tertiary medical care within a reasonable distance
from their home. Seven years ago VVA first testified that collectively
the veterans' community needed to develop a new paradigm or paradigms
of delivering health care because of the nature of the military today.
This is the most rural Army that the United States has fielded
since World War I. Almost 40% come from towns of 25,000 or less, yet
most of the VA medical centers are all located in or near major
metropolitan centers. Furthermore, the role of the National Guard and
the Reserves has changed dramatically. They are no longer regarded as a
strategic reserve force to be activated only in case of the direst
national emergency. Rather, they are being used as part of the
operational force. At this moment more than 52% of those serving on
active duty in the U.S. Armed Forces are mobilized National Guard and
Reserve forces. This percentage will only go up as the number of full
time active duty is drawn down, as is planned in the next few years.
The National Guard tends to come from rural areas, so as they get
wounded or hurt they naturally want to return to where their family and
friends support system is located. Yet that is not where the majority
of the medical centers are located, whether we are speaking of South
Dakota, Alaska, New Hampshire, or any other of the less populous
states.
VVA thanks Senator Shaheen for introducing S. 49, and urge early
enactment of this much needed step to ensure proper medical care for
veterans outside of major metropolitan areas.
S. 62--Check the Box for Homeless Veterans Act of 2013, introduced
by Senator Barbara Boxer, amends the Internal Revenue Code to: (1)
establish in the Treasury the Homeless Veterans Assistance Fund; and
(2) allow individual taxpayers to designate on their tax returns a
specified portion (not less than $1) of any overpayment of tax, and to
make a contribution of an additional amount, to be paid over to such
Fund to provide services to homeless veterans. This bill when enacted
into law will establish the Homeless Veterans Assistance Fund which
would provide additional funding sources for the Departments of
Veterans Affairs and Labor to enhance their current program to
assistant homeless veterans. VVA National Homeless Veterans Committee
fully supports S. 62 and would recommend that additional language in
the bill provide assistance to homeless veterans and their families.
VVA thanks Senator Boxer for her efforts in this regard.
S. 131--Women Veterans and Other Health Care Improvements Act of
2013, introduced by Senator Patty Murray, includes fertility counseling
and treatment within authorized Department of Veterans Affairs (VA)
medical services. Directs the Secretary of Veterans Affairs to furnish
such counseling and treatment, including the use of assisted
reproductive technology, to a spouse or surrogate of a severely
wounded, ill, or injured veteran who has an infertility condition
incurred or aggravated in the line of duty and who is enrolled in the
VA health care system, as long as the spouse and veteran apply jointly
for such counseling and treatment.
It has been thirty years since Senator Inouye led the effort to
start the process that is still ongoing of ensuring that the needs of
the women veterans are properly addressed and met by the Department of
Veteran Affairs. As always, we are grateful to Senator Murray for her
continued stalwart and thoughtful leadership as we move toward the goal
of parity in health care for women who have served their country well
in military service.
Furthermore the need to address fertility and procreation problems
has been apparent for many years, and this proposal in a good and
comprehensive approach to this problem for both male and female
veterans. VVA strongly supports this legislation.
S. 229--Corporal Michael J. Crescenz Act of 2013, introduced by
Senator Pat Toomey, Designates the Department of Veterans Affairs (VA)
medical center at 3900 Woodland Avenue in Philadelphia, Pennsylvania,
as the ``Corporal Michael J. Crescenz Department of Veterans Affairs
Medical Center.''
Corporal Michael J. Crescenz of West Virginia served in 4th
Battalion, 31st Infantry, 196th Infantry Brigade, Americal Division,
Rifleman Company A Hiep Duc Valley area, Republic of Vietnam,
20 November 1968. His bravery and extraordinary heroism at the cost of
his life are in the highest traditions of the military service and
reflect great credit on himself, his unit, and the U.S. Army and we are
proud that his legacy will live on and his bravery will not be
forgotten. The West Virginia State Council of VVA strongly supports
this legislation. VVA fully supports this bill.
S. 287--Introduced by Senator Mark Begich; a bill 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, and for other purposes, Includes as a homeless
veteran, for purposes of eligibility for benefits through the
Department of Veterans Affairs (VA), a veteran or veteran's family
fleeing domestic or dating violence, sexual assault, stalking, or other
dangerous or life-threatening conditions in the current housing
situation, including where the health and safety of children are
jeopardized, there is no other residence, and there is a lack of
resources or support networks to obtain other permanent housing.
Homelessness is hundreds of thousands of individual disasters
occurring side by side, unfortunately, the need to flee domestic
violence is one of those terrible conditions that lead to such
homelessness. VVA commends Senator Begich for leading on this issue.
VVA supports the bill as written.
S. 325--Introduced by Senator Jon Tester; a bill to amend title 38,
United States Code, to increase the maximum age for children eligible
for medical care under the CHAMPVA program, and for other purposes.
Makes a child eligible for medical care under the Civilian Health and
Medical Program of the Department of Veterans Affairs (CHAMPVA)
eligible for such care until the child's 26th birthday, regardless of
the child's marital status. Makes such provision inapplicable before
January 1, 2014, to a child who is eligible to enroll in an employer-
sponsored health care plan.
This proposed legislation corrects an ``unintended consequence'' of
the children of disabled veterans not being included under the
provisions of the Affordable Care Act when the requirement for
insurance companies to allow children to be carried on their parents'
medical insurance policy until the age of 26.
VVA strongly supports this legislation.
S. 412--Keep Our Commitment to Veterans Act, introduced by Senator
Mary Landrieu, authorizes the Secretary of Veterans Affairs (VA) to
carry out specified major medical facility leases in FY 2013-FY 2014 in
New Mexico, New Jersey, South Carolina, Georgia, Hawaii, Louisiana,
Florida, Puerto Rico, Texas, Connecticut, and Massachusetts. Reduces
lease amounts authorized in previous fiscal years for VA outpatient
clinics in: (1) Johnson County, Kansas; (2) San Diego, California; and
(3) Tyler, Texas.
VVA supports this authorization to move forward with needed leases
in the above noted locations.
S. 422--Chiropractic Care Available to All Veterans Act of 2013,
introduced by Senator Richard Blumenthal, amends the Department of
Veterans Affairs Health Care Programs Enhancement Act of 2001 to
require a program under which the Secretary of Veterans Affairs
provides chiropractic care and services to veterans through Department
of Veterans Affairs (VA) medical centers and clinics to be carried out
at: (1) no fewer than 75 medical centers by December 31, 2014, and (2)
all medical centers by December 31, 2016. Includes chiropractic
examinations and services within required VA medical, rehabilitative,
and preventive health care services.
VVA supports this bill, and thanks Senator Blumenthal for his
leadership on this issue. This is yet another case where the Veterans
Health Administration (VHA) has arrogantly ignored the will of the
Congress for some years, possibly because of a petty professional
``guild'' mentality. It is shameful that Congress has to enact yet
another law to try and force the VHA to do the right thing. It is
similar to the situation where VHA continues to discriminate against
Physician Assistants, no matter how often or how forcefully the
Congress revisits that issue or the one at hand regarding chiropractic
PR actioners.
S. 455--Introduced by Senator Jon Tester; A bill to amend title 38,
United States Code, to authorize the Secretary of Veterans Affairs to
transport individuals to and from facilities of the Department of
Veterans Affairs in connection with rehabilitation, counseling,
examination, treatment, and care, and for other purposes. Authorizes
the Secretary of Veterans Affairs to transport individuals to and from
facilities of the Department of Veterans Affairs (VA) in connection
with vocational rehabilitation, counseling, examination, treatment, or
care.
As noted elsewhere, Vietnam Veterans of America thanks Senator
Tester for his continued leadership to ensure that veterans in rural
and remote locales receive the support needed to ensure they are
afforded the same level of quantity and quality of medical care and
rehabilitative services as other veterans who are the city dwellers.
S. 522--Wounded Warrior Workforce Enhancement Act, introduced by
Senator Richard Durbin. VVA fully supports this bill, and thanks
Senator Durbin for bringing it forth in the Senate. The need for more
training opportunities for those who would learn and practice orthotics
is readily apparent for all who have looked at this situation. Our war
fighters are surviving grievous wounds and multiple amputations that
would have killed them on the battlefield even as recently as the Gulf
War in 1991. This only increases the need for more and better trained/
educated orthotics specialists. This legislation, if enacted, will
assist in that advancement of care.
S. 529--Introduced by Senator Richard Burr; a bill to amend title
38, United States Code, to modify the commencement date of the period
of service at Camp Lejeune, North Carolina, for eligibility for
hospital care and medical services in connection with exposure to
contaminated water, and for other purposes. Changes the commencement
for the period of military service at Camp Lejeune, North Carolina, for
purposes of eligibility for hospital care and medical services for
specified illnesses or conditions related to exposure to contaminated
water at such installation, from January 1, 1957, to either August 1,
1953, or an earlier date that the Secretary of Veterans Affairs (VA),
in consultation with the Agency for Toxic Substances and Disease
Registry, shall specify. Requires the Secretary to publish in the
Federal Register any earlier date chosen.
VVA supports the bills as written, and thanks Senator Burr for
continuing to champion the cause of the servicemembers and their
families who are still suffering adverse consequences as a result of
exposure to harmful toxic pollutants many decades ago at Camp Lejeune.
We do urge that there be continued strong oversight to ensure that the
intent of the law is being fulfilled, and if necessary that there be
additional enforcement measures taken to ensure that justice is done
for these veterans and their families.
S. 543--Reorganization Act of 2013, introduced by Senator Richard
Burr, directs the Secretary of Veterans Affairs to organize the
Veterans Health Administration (VHA) into 12 geographically defined
Veterans Integrated Service Networks (VISNs).
VVA supports the motivation behind this well-meaning proposal, in
that it seeks to greatly reduce the resources devoted to administrative
overhead, thus freeing additional resources to be invested in more
clinicians who actually provide hands on care to veterans. The enormous
increase in the appropriation for the Veterans Health Administration
(VHA) since 2006 was motivated by the desire of those on both sides of
the aisle to ensure that there were adequate resources available to
deliver quality medical care in a timely way to those who had served
our country well in military service.
In response to pressure from Capitol Hill the VHA has now decreased
the number of persons on the staff of the various VISNs to 55 each,
with any additional staff beyond this standard supposedly subject to a
rigorous justification process. Many feel that this number is still way
too high. Particularly in light of the fact that we have not seen the
great diminishment of administrative overhead at the individual VA
medical centers that were promised almost twenty years ago.
What is of even greater concern to VVA is the dividing of all
policy people into one ``stove-pipe'' and all of the ``operations''
managers into another ``stove-pipe.'' Not only does this result in many
more people who are performing tasks other than direct provision of
medical services to veterans, to separate policy from actual operations
is a dangerous effort which in many cases will result in operational
expediency prevailing over the best medical policy that is supposed to
be derived from evidence based medicine. Eliminating this dual chain of
command would free up many more resources than reducing the number of
VISN from 21 to 12. While we commend Senator Burr for attempting to
ensure that more resources actually go to having more actual care
deliverers, we are not sure that this is the best way to accomplish
that laudable goal.
S. 633--Introduced by Senator Jon Tester; a bill to amend title 38,
United States Code, to provide for coverage under the beneficiary
travel program of the Department of Veterans Affairs of certain
disabled veterans for travel in connection with certain special
disabilities rehabilitation, and for other purposes.
VVA supports this bill, and thanks Senator Tester for continuing to
be the champion of improved means for veterans in rural and remote
locations to have adequate access to vitally needed medical and
rehabilitation care.
S. 851--To amend title 38, United States Code, to extend to all
veterans with a serious service-connected injury eligibility to
participate in the family caregiver services program.
Many Vietnam veterans are alive today because their wives, or
sisters, or other relative have been taking care of them for decades.
Heretofore there was never any recognition of the fact that these
veterans would either have had to enter into long term care or would
have been on the street if not for the extraordinary efforts of these
family caregivers. Either way the additional cost to American society
would have been extremely large, whether in fiscal cost or the societal
cost of having many additional veterans among the homeless.
The Veterans Service Organizations (VSO) were basically asked by
The White House to support the bill as it was originally set to apply
only to the post-9/11 generation of veterans and their families. We did
this, but asked that the clause be inserted to require a report to the
Congress by May 2013 as a prelude to having this apply to veterans and
their families of every generation, based on need for such a program
regardless of when the veteran served.
Several years ago VVA did support legislation to assist family
caregivers of catastrophically wounded or injured warriors after 9/11.
Just as we saved badly desperately, horribly--wounded troops during our
war, troops who would have died during World War II or Korea, thanks to
the bravery and the tenacity of our medevac crews and military medical
personnel at evacuation hospitals, this new generation of medevac crews
and medical personnel have been saving catastrophically wounded
warriors who would surely have died in Vietnam. Heart-rending testimony
before congressional committees by some of these surviving veterans,
and by their wives and mothers, moved Congress to enact into law the
Caregivers and Veterans Omnibus Health Services Act of 2010 Public Law
111-163 to assist family caregivers of catastrophically wounded or
injured warriors after 9/11.
As noted above, there was a caveat in Public Law 111-163 that
requires the Secretary of Veterans Affairs to report to Congress by
May 2013 on how the caregiver program has been working, and what, in
his judgment, might be the efficacy of extending the program to embrace
family caregivers of veterans of Vietnam and Somalia and the first
fight with Saddam Hussein in the Persian Gulf.
VVA strongly supports S. 851.
S. 825--Homeless Veterans Prevention Act of 2013; VVA supports the
bill as written, however, would like for the Senate Committee on
Veterans to also consider adding the following homeless language to the
bill:
Legislation establishing Supportive Services Assistance Grants
for VA Homeless Grant & Per Diem Service Center Grant awardees
Under the VA HGPD program non-profits receive per diem at rates
based on an hourly calculation ($5.24 per hour) for the actual time
that the homeless Veteran is actually on site in the center. This
amount does not come close to paying for the professional staff that
must provide the assistance and comprehensive services that continue on
the Veteran's behalf, long after they leave the facility. As one can
well imagine the needs of these Veterans are great and demands an
enormous amount of time, energy, and manpower in order to be effective
and successful. We believe it is possible to create ``Service Center
Staffing/Operational'' grants, much like the VA ``Special Needs''
grants.
One of the most effective front line outreach operations funded by
VA HGPD is the Day Service Center, sometimes referred to as a Drop-In-
Center. These service centers are unique and indispensable as a
resource for VA contact with homeless Veterans. They reach deep into
the homeless Veteran population that are still on the streets and in
the shelters of our cities and towns. They are the portal from the
streets and shelters to substance abuse treatment, job placement, job
training, VA benefits, VA medical and mental health care and treatment,
homeless domiciliary placement, and transitional housing. They are the
first step to independent living. For many it is the first step out of
homelessness. In light of the Special Needs grants, passing the
legislation to establish this funding stream would not be setting a
precedent. ``Special Needs'' grants have been doing it for years. And
VVA believes that these service centers can't wait too much longer.
Agencies have been advocating for years for the VA to recognize a more
appropriate funding distribution process of HGPD resources for their
true operational activities. These agencies have been holding on to
survival by their fingertips for a very long time. Without serious and
speedy activation of staffing grants the result may well be the demise
of these critically needed services centers. We cannot lose these
valuable front line, ``on the streets,'' service center outreach
programs. They are the heartthrob of VA homeless Veteran programs; the
first hand up offered too many of the homeless Veterans who are on the
streets and in the shelter system of our cities.
VVA feels the cost of implementing these grants would be offset by
the benefit given to those Homeless Veterans still on the streets and
provide a vehicle by which the VA five year plan to end Veteran
Homelessness would be more achievable.
department of labor homeless veterans reintegration program (hvrp)
Once a Veteran has signed a lease he or she is no longer homeless
and cannot enter any HVRP program. Providers have been told that all
they need to do is enroll the Veteran into the HVRP program before they
sign the lease and then put them in the HVRP training program after
they are housed.
The Department of Labor (DOL) Homeless Veterans Reintegration
Program directly trains homeless Veterans in an effort to provide
skills and abilities leading to employment in order to maintain an
independent life-style. Recently housed Veterans should not be excluded
from this viable program (HVRP) because of an emphasis on the ``housing
first'' model. They are being penalized for following the direction of
their case managers, with housing placement being expedited at an
exceptionally fast pace. The defined HVRP eligibility criteria are at
the crux of the matter. The rub comes with the DOL requirement that the
assessed and enrolled Veteran must enter the training program within
the quarter they are enrolled. A ``fix'' to this situation may only
require DOL regulation but in all likelihood it may require legislative
action. Our position is that we believe it would best be accomplished
by a direct redefinition of the eligibility requirement and permit
recently housed Veterans to enroll into the HVRP training programs for
up to one year after housing placement. If we are to eliminate
homelessness among Veterans then we also are essentially being charged
to make sure that once housed they can remain in independent housing.
Ultimately, we further believe that if documentation can be provided
that proves that the Veteran is in imminent danger of becoming homeless
they should also be considered for eligibility in HVRP training
programs.
Legislation to amend the eligibility criteria for veterans in
enrolled in the Department of Labor Homeless Veterans Reintegration
Program (HVRP) so those veterans entering into ``housing first'' would
be able to access this training for a period of up to 12 months after
placement into housing.
special needs funding under the department of veterans affairs homeless
grants & per diem program is due to expire on september 30, 2013
In accordance with Title 38 of the US Code, Part II, Chapter 20,
Benefits for Homeless Veterans, Subchapter VII, Other Provisions, Sec.
2061, Grant Programs for Homeless Veterans with Special Needs, the
statute reads that the Secretary shall carry out a program to make
grants to health care facilities of the Department and to Grant and Per
Diem Providers in order to encourage development by those facilities
and providers of programs for homeless veterans with special needs.
These special needs veterans include women and women who have care of
minor dependents; frail, elderly; terminally ill; and chronically
mentally ill.
Many of the veterans falling out under special needs categories
require services above and beyond what the original grant was for.
Services such as Military Sexual Trauma counseling end of life and
bereavement counseling, or learning how to function with a severe
mental health condition. These services, many times, require
individuals with special training and certifications to act as
counselors. Many non-profit agencies do not have the funding
capabilities to sustain licensed practitioners on staff. Special Needs
grants provide additional funding to allow for those individuals to be
hired and to provide for additional services necessary for the veterans
to achieve the greatest level of self-sufficiency.
Vietnam Veterans of America will continue to aggressively advocate
for legislation forward that would extend the Homeless Veterans with
Special Needs due to expire on September 30, 2013.
I am happy to answer any questions, Mr. Chairman, and again thank
you and your distinguished colleagues for the opportunity to offer our
views here today.
Chairman Sanders. Thank you very much, Mr. Weidman.
Dr. Jonas.
STATEMENT OF WAYNE B. JONAS, M.D., PRESIDENT AND CHIEF
EXECUTIVE OFFICER, SAMUELI INSTITUTE
Dr. Jonas. Thank you very much, Mr. Chairman, Senator
Sanders, Members of the Committee. It dawned on me as I was
coming here actually last night that I am not only a veteran
that I am a fourth-generation veteran.
I had forgotten that my great-grandfather actually was in
the Philippines in the military and rode in the Rough Riders.
My grandfather was with Patton going across Germany, and my
father was a 30-year chaplain in three wars in the Army.
So, when I became a family physician after medical school,
there was no question I was going to be an Army doctor. I had
the great opportunity during those 24 years to also run the
Office of Alternative Medicine at the NIH, run a WHO
traditional medicine office that looked at traditional
practices from around the world; sit on the White House
Commission for Complementary and Alternative Medicine; and run
a research program at Walter Reed Army Institute of Research.
I now run an institute called the Samueli Institute which
is a non-profit 501(c)(3) research institute that examines the
inherent healing capacity of individuals with a scientific lens
in order to determine how they can be implemented into whole
systems, into large systems in these areas. We do a lot of work
with active duty, DOD, and with veterans.
I fully support the integration of evidence-based, whole
person health promotion, and complementary medicine practices
into veterans' care.
After 10 years of wars, we have tremendous suffering of
which only the tip of the iceberg is seen when people walk into
the clinic in the veterans' area.
Right now when someone walks into a clinic anywhere,
whether it is veteran or non-veteran clinic, military clinic,
because of the structure of medicine, you get divided up.
If you have psychological issues, PTSD, you go see the
behavioral medicine person. If we were told you got hit in the
head or you claimed you were exposed to trauma, you go see the
neurologist. If you lost a leg or had surgery, you go see the
orthopod.
Yet, people do not experience this suffering that way.
People experience this suffering as whole persons, from the
physical pain to the psychological injuries to the cognitive
difficulties to the energetic problems to the spiritual and
moral injuries that have occurred in war. That spreads into the
social and family areas then they experience the suffering
also.
We need a whole system, whole person approach to dealing
with these things the way people experience them, not a
divided, disintegrated system. Thus, we need practices that can
help them reset, reheal, tap into their inherent healing
processes and, more importantly, teach them the skills that
they need in order to build resilience for the long run.
Many of the folks from the current wars are young and they
may have a lifetime of suffering. We do not want that to be a
lifetime of dependency. We want it to be a lifetime of optimal
healing and functioning.
These practices have the potential, if they are properly
evaluated and integrated, not simply to treat a disease but, in
fact, to provide that resetting.
One of our grant recipients just published the first
randomized controlled trial published in the journal Spine of
low back pain with chiropractic, demonstrating that
chiropractic, when added on to standard medical care,
significantly decreased pain and increased functionality in
active duty populations who had carried big loads for many
years.
We have just completed a study at Walter Reed in
partnership with Walter Reed looking at the use of acupuncture
for Post Traumatic Stress Syndrome.
One month of eight treatments of acupuncture reduced Post
Traumatic Stress Syndrome by 56 percent and improved all the
other symptoms of the trauma spectrum including pain, improved
sleep, reduced medication, and even to my surprise, improved
cognitive function.
On a study published about 4 or 5 months ago that we did in
conjunction with Scripts and Camp Pendleton Marines in Post
Traumatic Stress Syndrome took a very simple relaxation, self-
care practice taught by nurses to include relaxation skills
training program an individual's Post Traumatic Stress
Syndrome, added on to usual behavioral care significantly
reduced PTSD.
Then that was followed up, as was the acupuncture study.
After those were finished, 3 months later they continued to
maintain improvement. In other words, it was not a one-off
treatment. It was actually a reset, a rehealing through those
practices.
Those types of self-care practices can be taught to
families and become a normal part of recovery, not requiring
the system. These practices should be a main part of the
integration into the system but they have to be done and
evaluated in a careful way in order to determine how the
benefits can be properly induced.
What are the economic drivers? There are no economic
drivers for these self-care practices. They are not a device.
They are not a new drug. They do not have a new company behind
them throwing millions of dollars trying to get them into the
system.
Thus, they incrementally and slowly creep into the system
only to the extent that veterans pay attention to them. That
requires a coordinated and concerted effort in those areas. I
think that kind of a coordinated, concerted effort can be done.
There are several blue prints to do that.
I want to highlight this book that was just completed by
the Institute of Medicine on chronic multi-symptom illness with
veterans. They actually show a blueprint for bringing healing-
oriented processes and systems into the Veterans'
Administration, and I would urge the Veterans' Administration
to pay close attention to that.
Thank you very much for your time and attention.
[The prepared statement of Dr. Jonas follows:]
Prepared Statement of Wayne B. Jonas, M.D., President and CEO,
Samueli Institute
Thank you, Senator Sanders and Members of the Committee for the
invitation to testify on the pending health care legislation, and in
particular to voice my support for your efforts to promote greater
integration of complementary and alternative approaches into the
provision of veterans' health. My name is Wayne Jonas. I am a veteran
and retired Army family physician. I see patients weekly at a military
medical center, and am President and CEO of the Samueli Institute of
Alexandria, Virginia, and Corona Del Mar, California. I have formerly
served as Director of the Office of Alternative Medicine at the
National Institutes of Health, a Director of the World Health
Organization Collaborating Center of Traditional Medicine, the Medical
Research Fellowship and Walter Reed and a member of the White House
Commission on Complementary and Alternative Medicine Policy.
Samueli Institute, a 501(c)(3) non-profit scientific research
organization, investigates healing processes and their application in
promoting health, wellness and human flourishing, preventing illness,
and treating disease. The Institute is one of few organizations in the
Nation with a track record in complementary and integrative medicine,
healing relationships, and military and veteran medical research. The
Institute has extensively investigated the health conditions routinely
presented by our servicemembers, veterans and their families.
I state my strong support for greater integration of complementary
and alternative approaches into veterans' health care based on the
clinical and outcomes evidence for their effectiveness for a wide array
of conditions presented every day by our veterans. These approaches are
also low cost and have few negative side effects.
In more than ten years of armed conflicts, a large number of the
Nation's veterans are exhibiting what I term the trauma spectrum
response--an array of symptoms, including pain, anxiety, depression,
sleeplessness, excessive drug use and social isolation resulting from
multiple deployments or a battlefield insult, like an explosion or
other trauma. These symptoms often progress to chronic conditions, like
Post Traumatic Stress Disorder and chronic pain; and most of these
people and families are young, with a long battle for recovery in front
of them. More and more, our Nation is faced with the weighty imperative
not only to attempt cure of our veterans' combat wounds, but to help
them to heal for the rest of their lives. The pilot programs described
in the draft Veterans' Health Promotion Act will help veterans to heal,
because it will provide patient-centered approaches that restore them
to personal and social wholeness.
Recent research by Samueli Institute, and other leading national
and international researchers, has shown the effectiveness of drugless,
self-care and integrative practices for treatment of these prevalent
conditions and for healing. Our research on acupuncture, mind-body,
nutrition and self-care approaches has demonstrated that these
practices can help heal and reset veterans to optimal well-being and
function. For example, recent studies on acupuncture and relaxation
approaches have demonstrated marked improvements (as large or larger
than the best drug or behavioral treatments) in PTSD with additional
benefits on pain, cognitive function, energy, sleep and anger. The
Institute's research has shown the growing use of complementary and
alternative medicine (CAM) practices by veterans, and favorable
outcomes for individuals who receive CAM in addition to standard care.
VA practitioners are attempting to secure these practices for their
patients, but encounter institutional barriers, limited availability
and the tyranny of the status quo.
To appropriately address the policy and operational issues related
to the transition of complementary and alternative medicine approaches
into the VA's health care operations and infrastructure, I recommend a
centralized, coordinated, rapid translational program to inform the
VA's decisions on benefits, manpower, infrastructure and management.
The provisions of the draft Veterans' Health Promotion Act and, in
particular, its support for a Center of Innovation for complementary
and alternative medicine, a pilot program on the establishment of
complementary and alternative medicine within VA medical centers, and
the study of barriers encountered by veterans to receive complementary
and alternative care, are laudable and considerable first steps in the
right direction. Without this program we will not know how to make
these practices more widely available to our veterans who need and
deserve them.
While that legislation uses the term ``complementary and
alternative medicine (or CAM)'' freely, I feel the use of the term
``integrative health care'' is more appropriate as it more clearly
describes the process of integrating CAM practices into the
conventional care provided widely across the Nation and by the VA. The
ultimate goal is to improve health and health care for veterans through
the seamless integration of the best of conventional medicine and CAM.
The pilot program will benefit from the work of early champions in the
VA system who have introduced such things as acupuncture, guided
imagery, meditation, mindfulness and other CAM practices through
research and innovative programs. The proposed pilot program will
create the necessary infrastructure and process for wide adoption of
these practices, such that they become mainstream options for treating
symptoms and promoting well-being, in combination with the best of
conventional care.
Such a centralized, coordinated and rapid translational program
would provide a cornerstone for the VA's top priority of providing P4
(personalized, predictive, preventive and participatory) medicine for
all vets.
I appreciate the opportunity to appear before this Committee and I
look forward to any questions. Thank you.
Chairman Sanders. Thank you very much, Dr. Jonas.
Ms. Ansley.
STATEMENT OF HEATHER ANSLEY, ESQ., MSW, VICE PRESIDENT FOR
VETERANS' POLICY, VETSFIRST
Ms. Ansley. Chairman Sanders, 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 before the Committee this morning.
My oral testimony will focus on S. 131, S. 324, S. 455,
S. 633, and S. 851.
First, we support the Women Veterans and Other Health Care
Improvements Act of 2013. After more than a decade of war, many
severely disabled veterans who have experienced trauma-related
improvised explosive devices and other conditions of warfare
may experience infertility.
For many of these same veterans having the ability to start
or grow their families represents an important part of moving
forward with their lives.
S. 131 takes important holistic steps toward 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.
Importantly, this legislation also provides the opportunity for
veterans to grow their families through adoption.
VetsFirst also supports the efforts of S. 131 to improve
access to VA services for women veterans. To ensure that women
veterans have full access to medical services, VA must continue
to improve efforts to address the unique needs and concerns of
women veterans.
Increasing the avenues for women to receive information
through portals such as VA's new women veterans hotline, which
is a requirement of S. 131, is an important step forward.
We also support increasing access to mental health and
readjustment counseling by providing opportunities for child
care for all veterans.
Second, VetsFirst supports S. 325, which would increase the
maximum age for children eligible for medical care under the
CHAMPVA program. Children who are CHAMPVA beneficiaries
typically lose their coverage at age 18 unless they are full
time students in which case they can maintain their benefits to
age 23.
The Affordable Care Act or the ACA allows children to
remain on a parent's health insurance until age 26. However,
TRICARE and CHAMPVA beneficiaries were not covered by this
provision. TRICARE has since been brought into alignment with
the ACA but CHAMPVA has not. S. 325 would correct this
injustice by allowing those beneficiaries to receive health
care benefits until age 26.
Third, we support S. 455 which would provide VA with the
authority to provide transportation for veterans who need
assistance to and from VA facilities. Lack of transportation
options remains a barrier for some veterans who need to travel
to VA facilities for health care services. For many veterans
riding with family members and friends, using public
transportation, or driving themselves allows them to travel to
a VA facility when needed.
For veterans who do not have a network of friends and
family, they are not able to drive. They do not live near
public transportation. They have to seek other options.
In January 2013, the President signed the Dignified Burial
and Other Veterans' Benefits Improvement Act of 2012, which
authorized VA to transport individuals to and from VA
facilities for these purposes. This authority will expire in
2014. We support S. 455, which would extend it to ensure most
importantly that no veteran is left without the ability to
access critical VA services.
Fourth, VetsFirst supports S. 633, which provides
beneficiary travel benefits for all veterans who have spinal
cord injuries, vision impairments, and multiple amputations,
and need to travel to receive inpatient rehabilitation
services.
For those veterans who need these services but are not
eligible for travel benefits, the ability to pay for travel,
which may include traveling a great distance, can be very
burdensome, so every effort must be made to reduce the barriers
that limit access to these services, primarily because without
those, that assistance, a veteran can lose their independence
and may end up in a higher cost care somewhere.
Last, VetsFirst supports the Caregiver Expansion and
Promotion Act of 2013. Many families of disabled veterans play
a crucial role in providing needed services and supports that
allow veterans to return to and remain in their homes.
Spouses and family members, however, often must leave the
work force to assist their husbands, wives, adult children in
their efforts to rehabilitate and reintegrate into their
communities. That sacrifice may include lost income and other
benefits, including health insurance. S. 851 would extend
enhanced caregiver benefits originally provided to family
caregivers of post-9/11 veterans with serious injuries to
caregivers of veterans of all eras who have serious service-
connected disabilities.
Many of these caregivers have sacrificed for decades in
order to be able to provide assistance to their veterans and
gladly have done so.
But we would hope that this would be an opportunity to
recognize their significant contributions that they have made
for, in several cases, many years to keep those veterans
independent, working, and living in their communities.
Again, thank you for the opportunity to share VetsFirst's
views of the legislation today. This concludes my testimony.
[The prepared statement of Ms. Ansley follows:]
Prepared Statement of VetsFirst, a Program of United Spinal
Association, Submitted by Heather L. Ansley, Esq., MSW, Vice President
of Veterans Policy
Chairman Sanders, 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, a program of United Spinal Association, represents the
culmination of over 60 years of service to veterans and their families.
We provide 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, we are not only
a VA-recognized national veterans service organization, but also a
leader in advocacy for all people with disabilities.
women veterans and other health care improvements act of 2013 (s. 131)
After more than 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.
This legislation also provides the opportunity for veterans who are
severely wounded, ill, or injured to grow their families through
adoption. VA's assistance would be available for the adoption of up to
three children or one cycle of in vitro fertilization, whichever is of
lesser cost. VetsFirst believes that providing the option for disabled
veterans to adopt is a critical recognition of the many paths to
parenthood.
This legislation also requires VA to facilitate collaborative
research with the Department of Defense 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 this legislation to improve
access to VA services for women veterans. Women make up an increasing
percentage of the veteran population. By 2040, VA projects that women
will make up nearly 18 percent of the veteran population. As of 2012,
360,000 women veterans were using VA health care. VA must continue to
improve efforts to address the unique needs and concerns of women
veterans.
As part of these efforts, VA recently launched the Women Veterans
hotline. The purpose of the hotline is to provide a single portal for
women veterans to receive information about VA benefits and services.
The call center staff will work collaboratively with other VA hotlines,
including VA's crisis line. The Women Veterans and Other Health Care
Improvements Act would complement and build upon these efforts by
ensuring that the Women Veterans hotline is able to connect women
veterans with needed services not provided by VA.
One of the services that many veterans, women and men, need to be
able to fully access VA health care and readjustment counseling is
affordable, convenient childcare. This legislation also provides
veterans who are the primary caretaker of their children the
opportunity to receive childcare assistance from VA when receiving
mental health care services, readjustment counseling, or other
intensive health services. This assistance may include stipends for
licensed childcare services and VA provision of childcare services.
VetsFirst supports the Women Veterans and Other Health Care
Improvements Act. This comprehensive legislation is needed to ensure
that veterans are able to begin or expand their families and receive
the health care assistance they need following their military service.
to increase the maximum age for children eligible for medical
under the champva program (s. 325)
The Civilian Health and Medical Program of the Department of
Veterans Affairs (CHAMPVA) is a robust health care program for the
spouses and dependent children of veterans who are permanently and
totally disabled, died while on active duty, or died due to a service-
connected disability. For the families of these veterans, CHAMPVA
provides critical physical and mental health care benefits. Children
who are CHAMPVA beneficiaries typically lose coverage at age 18 unless
they are full-time students, in which case they maintain benefits until
age 23.
The Affordable Care Act (ACA) allows children to remain on a
parent's health insurance until age 26. However, TRICARE and CHAMPVA
child beneficiaries were not covered by this provision. The National
Defense Authorization Act (NDAA) for FY 2011 brought TRICARE into
alignment with the ACA provision by extending coverage to age 26 for
TRICARE beneficiaries. CHAMPVA child beneficiaries, however, were not
included in the NDAA.
Consequently, CHAMPVA child beneficiaries are prohibited from
receiving benefits provided to other adult children in our Nation.
S. 325 will correct this injustice by allowing child beneficiaries to
continue to receive health care benefits under the CHAMPVA program
until age 26. This legislation will ensure parity for the children of
permanently and totally disabled veterans and those who died in service
to our Nation.
VetsFirst supports S. 325 because it will ensure that the children
of men and women who have sacrificed greatly for our Nation are able to
finish educational opportunities and begin careers without having to
forgo access to critical health care benefits. We urge swift passage of
this critical legislation.
to authorize va to transport individuals to and from va facilities in
connection with rehabilitation, counseling, examination, treatment, and
care (s. 455)
Lack of transportation options can present significant barriers to
disabled veterans in their efforts to actively participate in their
communities. VetsFirst has been an active supporter of efforts to make
public transportation, taxis, and other modes of transportation more
accessible to wheelchair users and other people with disabilities. We
also support and promote travel training to help people who have
acquired disabilities learn how to navigate their community's
transportation options.
Despite these efforts, transportation remains a barrier for some
veterans who need to travel to VA medical services for health care. For
many veterans, riding with family members and friends, using public
transportation, or driving themselves allows them to travel to VA
facilities when needed. For veterans who do not have a network of
family and friends who can drive them to appointments, or who live in
areas without public transportation or widespread assistance from
volunteer organizations, they must seek other options.
To address unmet needs, VA launched the Veterans Transportation
Service (VTS) initiative in 2010. The VTS initiative provides funding
for mobility managers, transportation coordinators, and vehicles at
local VA facilities. Although volunteer drivers are an integral part of
transporting many disabled veterans to and from VA facilities, the need
for drivers is greater than the number of volunteers. In addition, some
veterans who need transportation have significant medical needs or are
unable to ambulate, and volunteer drivers may be hesitant to transport
these veterans.
In January 2013, the President signed the Dignified Burial and
Other Veterans' Benefits Improvement Act of 2012 (Public Law 112-260).
Section 202 of this legislation authorized VA to transport individuals
to and from VA facilities for vocational rehabilitation, counseling,
and for the purpose of examination, treatment, or care. This authority
will expire in 2014.
S. 455 will extend VA's authority to ensure that no veteran is left
without the ability to access critical VA services. VetsFirst supports
this legislation and urges swift passage.
to provide coverage under va's beneficiary travel program for the
travel of certain disabled veterans for certain special disabilities
rehabilitation (s. 633)
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 can be very burdensome.
In addition, few of these services are available locally, particularly
to veterans who live in rural areas.
All disabled veterans who need to travel to receive in-patient care
at special disabilities rehabilitation programs should be eligible to
receive travel benefits from VA. 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.
VetsFirst supports S. 633 because it will improve access to
rehabilitation services for all veterans who have spinal cord injuries
or disorders, vision impairments, or double or multiple amputations.
caregiver expansion promotion act of 2013 (s. 851)
Many families of disabled veterans play a crucial role in providing
needed services and supports that allow veterans to return to, and
remain in, their homes. The sacrifice of family caregivers not only
supports veterans, but also VA's mission. Spouses and family members
often must leave the workforce to assist their husbands, wives, and
adult children in their efforts to rehabilitate and reintegrate into
their communities. The sacrifice of these caregivers, however, may
result in lost income and other benefits, including health insurance.
Although the commitment of the caregivers of our Nation's veterans
has been evident for many decades, a study released in November 2010 by
the National Alliance for Caregiving provides statistical evidence
supporting the depth of the commitment that these caregivers have made
to our veterans. For instance, the study report titled, ``Caregivers of
Veterans-Serving on the Homefront,'' noted that 70 percent of
caregivers for our Nation's veterans are spouses. For all populations,
only 6 percent of caregivers are spouses. Clearly, immediate family
members have an important role in caregiving for our Nation's veterans.
An even higher number of caregivers, 80 percent, live with the
veteran for whom they are providing care. Nationwide, only 23 percent
of caregivers of all adults live with the care receiver. Consequently,
68 percent of caregivers of veterans report a high level of emotional
stress due to caregiving which is more than double the level of stress
endured by caregivers of all adults.
The lifelong commitment made by caregivers of our Nation's veterans
is clearly represented by the 26 percent of parents who are providing
care for their sons and daughters who are veterans of the wars in Iraq
and Afghanistan. The long-term caregiving relationship of our Nation's
veterans with disabilities and their caregivers exceeds that of other
caregiving relationships. According to the National Alliance for
Caregiving, 30 percent of caregivers of veterans from all eras give
care for 10 years or longer, as opposed to only 15 percent of
caregivers nationwide.
In May 2010, the President signed the VetsFirst supported
Caregivers and Veterans Omnibus Health Services Act of 2010 (Public Law
111-163), to provide critical supports for caregivers of veterans with
disabilities. Caregivers for all eligible veterans who are enrolled in
the VA's health care system are to have access to education sessions,
support services, counseling, mental health services, and respite care.
The law also provides certain caregivers of veterans who have a serious
injury, such as a Traumatic Brain Injury, that was incurred or
aggravated in the line of duty on or after September 11, 2001, with a
monthly stipend and access to medical care.
The expansive services provided through Title I of Public Law 111-
163 provided hope for many caregivers who as the National Alliance for
Caregiving study demonstrates provide care for a longer period of time
and have a higher stress level than other types of caregivers. In order
to receive assistance under the program of comprehensive assistance for
family caregivers, a caregiver must be providing care to an ``eligible
veteran.'' According to 38 U.S.C. Sec. 1720G(a)(2),
[A]n eligible veteran is any individual who (A) is a veteran or
member of the Armed Forces undergoing medical discharge from
the Armed Forces; (B) has a serious injury (including Traumatic
Brain Injury, psychological trauma, or other mental disorder)
incurred or aggravated in the line of duty in the active
military, naval, or air service on or after September 11, 2001;
and (C) is in need of personal care services because of (i) an
inability to perform one or more activities of daily living;
(ii) a need for supervision or protection based on symptoms or
residuals of neurological or other impairment or injury; or
(iii) such other matters as the Secretary considers
appropriate.
Under the comprehensive program, family caregivers are eligible to
receive training, technical support, counseling, and lodging and
subsistence. For the family caregiver who is chosen as the primary
provider of personal care services additional benefits are available.
These benefits include mental health services, respite care of not less
than 30 days annually, medical care, and a monthly personal caregiver
stipend. As identified by the National Alliance for Caregiving, these
benefits are desperately needed by the caregivers of disabled veterans.
Public Law 111-163 requires VA to submit a report to Congress
regarding the feasibility of expanding comprehensive caregiver benefits
for veterans who have a serious service-connected injury that was
incurred or aggravated before September 11, 2001. To date, VA has not
released this report.
The Caregiver Expansion and Improvement Act of 2013 (S. 851) would
build on Public Law 111-163 by extending these enhanced caregiver
benefits to the caregivers of veterans of all eras who have serious
service-connected disabilities. Many of these caregivers have
sacrificed for decades to serve their seriously injured disabled
veterans. We must recognize the significant contributions made by these
caregivers by ensuring that they have full access to all VA caregiver
benefits. The determination for which caregivers receive comprehensive
caregiver benefits should be based on a veteran's level of need,
particularly as those with serious injuries, including spinal cord
injuries, age.
VetsFirst strongly supports the expansion of comprehensive
caregiver assistance to family caregivers of all veterans with a
serious service-connected disability. We urge swift pass of S. 851.
to provide for certain requirements relating to
the immunization of veterans (draft)
For veterans who have spinal cord injuries and disorders or other
significant disabilities, contracting influenza or pneumonia can lead
to severe, debilitating health problems, or even death. Since focusing
on the need for veterans with spinal cord injuries and disorders to
receive influenza vaccinations due to their high-risk of influenza
related complications, VA has seen an increase in the vaccination rate
for these veterans from 28 percent in 2000 to 79 percent in 2010.
Similarly, VA saw an increase in vaccination rates for pneumococcal
pneumonia from 40 percent in 2000 to 94 percent in 2010.
Receiving every recommended immunization as suggested is critical
for all veterans. This draft legislation would ensure that veterans
have access to immunizations against infectious diseases in accordance
with the recommended adult immunization schedule. The legislation
requires VA to include information about immunizations in VA's annual
report to Congress on preventive health. Importantly, this legislation
also requires VA to develop and implement quality measures and metrics,
including targets for compliance, to ensure that recommended
immunizations are delivered in accordance with the schedule.
VetsFirst fully supports legislation to establish requirements for
immunizations and metrics for their delivery. Veterans, particularly
those who are at high-risk for contracting diseases that vaccines can
prevent, must receive those immunizations. As efforts to address
influenza and pneumonia have proven, concerted efforts to increase
immunizations can increase the number of veterans who are offered and
accept those vaccines.
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 Sanders. Thank you very much, Ms. Ansley.
Mr. Gornick.
STATEMENT OF MATT GORNICK, POLICY DIRECTOR, NATIONAL COALITION
FOR HOMELESS VETERANS
Mr. Gornick. Chairman Bernard Sanders, Ranking Member
Richard Burr, and distinguished Members of the Senate Committee
on Veterans' Affairs, I am honored to appear before this
Committee as the policy director of the National Coalition for
Homeless Veterans.
On behalf of the 2,100 community- and faith-based
organizations NCHV represents, we thank you for your steadfast
commitment to serving our Nation's most vulnerable heroes.
My testimony today will focus on three bills currently
before this Committee: S. 62, the Check the Box for Homeless
Veterans Act of 2013; S. 287, a bill to expand the definition
of homeless veteran for purposes of benefits under the laws
administered by the Secretary of Veterans Affairs; and S. 825,
the Homeless Veterans Prevention Act of 2013.
Since their inception, Federal assistance programs for
homeless veterans have received overwhelming bipartisan support
from Congress. While critical, some of these investments have
been modest in consideration of the full range of problems
associated with veteran homelessness.
Sen. Barbara Boxer's Check the Box for Homeless Veterans
Act would help address some of the shortfalls by establishing a
national Homeless Veterans Assistance Fund, supported through
designated tax overpayments and other direct contributions.
This fund would be used for two purposes: one, to develop
and implement new and innovative strategies to prevent and end
veteran homelessness; and two, to provide services through any
homeless veteran program administered by the VA, HUD, and
Labor.
This fund's primary purpose should be to help close gaps in
service delivery systems for veterans. It would be
counterproductive to reduce appropriations for homeless veteran
assistance simply due to this fund's establishment.
The next bill I would like to discuss is S. 287. Over the
past few years, VA's homeless programs have evolved to
accommodate the growing number of homeless women veterans and
single veterans with dependent children.
Unfortunately, the Department still defines homeless
veteran based on an incomplete citation of the McKinney-Vento
Homeless Assistance Act. The full definition of ``homeless''
under this act includes individuals and families who are
fleeing, or attempting to flee, domestic violence, dating
violence, sexual assault, stalking, or other dangerous or life-
threatening conditions in their housing situation.
Senator Mark Begich's S. 287 serves a straightforward
purpose: to include this provision in VA's definition of a
homeless veteran.
Although some veterans who meet this expanded definition
may already qualify for VA homeless assistance due to the
nature of their circumstances, we must ensure that they are not
denied the help that they need.
The last bill that I would like to discuss is Chairman
Sanders and Ranking Member Burr's S. 825, the Homeless Veterans
Prevention Act of 2013.
The breadth of this bill is a testament to this Committee's
leadership in the effort to prevent and end veteran
homelessness. Among its many important provisions, S. 825 would
reauthorize competitive grant programs for community- and
faith-based veteran service providers.
These programs include the Grant and Per Diem Program,
Homeless Veterans' Reintegration Program, and Supportive
Services for Veteran Families Program.
NCHV concurs with VA in its fiscal year 2014 Budget
Proposal on the following items, which are not reflected in
this bill. The Grand Per Diem Program should be permanently
authorized at $250 million. This program has the capacity to
serve 30,000 homeless veterans each year and is vital to VA's
mission to end veteran homelessness.
The Supportive Services for Veteran Families Program should
be permanently authorized at $300 million. This program will
serve as the foundation of VA's strategy to prevent veteran
homelessness well beyond 2015.
Last, the Grant Program for Homeless Veterans with Special
Needs should also be permanently authorized. Therefore, NCHV
recommends that the Homeless Veterans Prevention Act be amended
to accommodate these proposals. Without these extensions, VA
cannot adequately plan for these programs' future.
Additionally, while this bill would provide increased per
diem payments for service providers implementing a Transition-
in-Place housing model, the need to reform the per diem payment
method remains.
This Committee helped pass legislation that became Public
Law 112-154, which requires VA to study all matters relating to
the per diem payment method, including anticipated changes in
the cost of providing services to homeless veterans.
VA must report to Congress on its findings less than 3
months from today. Anything short of a proposal to thoroughly
modernize this outdated reimbursement policy from a flat per
diem rate to a flexible, cost-of-services payment method should
be deemed insufficient.
In closing, thank you for the opportunity to present this
testimony. It is a privilege to work with this Committee to
ensure that every veteran in crisis has reasonable access to
the support services they earned through their service to our
country.
Thank you.
[The prepared statement of Mr. Gornick follows:]
Prepared Statement of Matt Gornick, NCHV Policy Director,
National Coalition for Homeless Veterans
Chairman Bernie Sanders, Ranking Member Richard Burr, and
distinguished members of the Senate Committee on Veterans' Affairs: I
am honored to appear before this Committee as the policy director of
the National Coalition for Homeless Veterans (NCHV). On behalf of the
2,100 community- and faith-based organizations NCHV represents, we
thank you for your steadfast commitment to serving our Nation's most
vulnerable heroes.
This testimony will focus on our support for three bills currently
before this Committee:
S. 62, the ``Check the Box for Homeless Veterans Act of
2013;''
S. 287, a bill ``to expand the definition of homeless
veteran for purposes of benefits under the laws administered by the
Secretary of Veterans Affairs;'' and
S. 825, the ``Homeless Veterans Prevention Act of 2013.''
Additionally, this testimony will recommend ways to improve
effective service delivery to homeless veterans.
background
For decades, the veteran service provider community represented by
NCHV has worked arduously toward the goal of ending veteran
homelessness. The announcement of Secretary of Veterans Affairs Eric
Shinseki's Five-Year Plan to End Veteran Homelessness in
November 2009--fully incorporated into the ``Federal Strategic Plan to
Prevent and End Homelessness''--demonstrated the Federal Government's
solidarity in making that goal a reality.
Congress has seen the promise of this plan and, through fiscal year
(FY) 2013, has increased funding for successful community-based
programs to end veteran homelessness. These investments have fueled
consistent decreases in the number of homeless veterans on a given
night--down 17.2% since 2009, according to the latest Point-in-Time
Report from the U.S. Department of Housing and Urban Development (HUD).
As the maturity date of the Five-Year Plan approaches, NCHV
maintains that our Nation is on a path to ensure that no veterans,
regardless of their personal haunts and challenges, are ever left to
fend for themselves on the streets.
The legislation currently before this Committee would help keep our
Nation on this path.
s. 62, ``check the box for homeless veterans act of 2013''
Since their inception, Federal assistance programs for homeless
veterans have received overwhelming bipartisan support from Congress.
While critical, some of these investments have been modest in
consideration of the full range of problems associated with veteran
homelessness.
Sen. Barbara Boxer's S. 62 would help address some of the
shortfalls by establishing a national Homeless Veterans Assistance
Fund, supported through designated tax overpayments and other direct
contributions. The fund would be used for two purposes:
1. To develop and implement new and innovative strategies to
prevent and end veteran homelessness; and
2. To provide services through any homeless veteran program
administered by the Department of Veterans Affairs (VA), the Department
of Labor-Veterans' Employment and Training Service (DOL-VETS), and HUD.
This fund's primary purpose should be to help close gaps in service
delivery systems for veterans. It would be counterproductive to reduce
appropriations for homeless veteran assistance programs simply due to
this fund's establishment.
The Homeless Veterans Assistance Fund should help organizations
that cannot compete for Federal grants under limited programs--such as
those in highly rural areas--provide support to veterans in crisis. The
fund should also support nontraditional, high-demand activities such
as:
Contracting with veteran service providers to administer
case management for veterans in permanent supportive housing in
underserved communities.
Providing child care assistance for veterans in employment
assistance programs.
Helping veterans make security deposits and pay utility
hook-up fees for housing placements.
All of the above activities are already authorized in some form. By
focusing on these areas of service delivery, S. 62 would serve a vital
role in both eliminating and preventing veteran homelessness.
s. 287, a bill ``to expand the definition of homeless veteran for
purposes of benefits under the laws administered by the secretary of
veterans affairs''
Over the past few years, VA's homeless programs--such as the
Supportive Services for Veteran Families (SSVF) and HUD-VA Supportive
Housing (HUD-VASH) Programs--have evolved to accommodate the growing
number of homeless women veterans and single veterans with dependent
children. Unfortunately, the department still 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 provision:
``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. Mark Begich's S. 287 serves a straightforward purpose: to
include this provision in VA's definition of ``homeless veteran.''
Although some veterans who meet this expanded definition may
already qualify for VA homeless assistance due to the nature of their
circumstances, we must ensure that we do not deny any of these veteran
families the help that they need.
s. 825, ``homeless veterans prevention act of 2013''
The breadth of this bill is a testament to this Committee's
leadership in the effort to prevent and end veteran homelessness.
Introduced by Chairman Bernie Sanders and Ranking Member Richard Burr,
S. 825 would--among many important provisions--reauthorize competitive
grant programs for community- and faith-based veteran service
providers. These programs include the Grant and Per Diem (GPD) Program,
Homeless Veterans' Reintegration Program (HVRP), and SSVF Program.
Along with the continued buildup of the HUD-VASH Program, expansion of
these programs has contributed to the steady reduction in veteran
homelessness over recent years.
NCHV concurs with VA in its FY 2014 Budget Proposal on the
following items, which are not reflected in this legislation:
The GPD Program should be permanently authorized at $250
million. As currently written, S. 825 would allow the program's
authorization to drop to $150 million after FY 2014.
The SSVF Program should be permanently authorized at $300
million. As currently written, S. 825 would allow the program's
authority to expire after FY 2014. This program will serve as the
foundation of VA's strategy to prevent veteran homelessness well beyond
2015, and its permanent authorization is critical to sustain the
national priority to end veteran homelessness.
The grant program for homeless veterans with special needs
should be permanently authorized. As currently written, S. 825 would
allow the program's authority to expire after FY 2014.
Therefore, NCHV recommends that S. 825 be amended to accommodate
these proposals. Without these extensions, the Department of Veterans
Affairs cannot adequately plan for these programs' future.
Additionally, while this bill would provide increased per diem
payments for service providers implementing a ``Transition in Place''
housing model, the need to reform the per diem payment method remains.
This Committee helped pass legislation that became Public Law 112-154,
which requires VA to:
``Complete a study of all matters relating to the method used
by the Secretary to make per diem payments under section
2012(a) of title 38, United States Code, including changes
anticipated by the Secretary in the cost of furnishing services
to homeless veterans and accounting for costs of providing such
services in various geographic areas.''
The law requires VA to report to Congress on its findings no later
Aug. 6, 2013. Anything less than a proposal to thoroughly modernize
this outdated reimbursement policy--from a flat per diem rate to a
flexible, cost-of-services payment method--should be deemed
insufficient.
in summation
Thank you for the opportunity to present this testimony for today's
hearing. It is a privilege to work with the Senate Committee on
Veterans' Affairs to ensure that every veteran in crisis has reasonable
access to the support services they have earned through their service
to our country.
Chairman Sanders. Thank you very much, Mr. Gornick.
Mr. Bowman.
STATEMENT OF THOMAS BOWMAN, FORMER CHIEF OF STAFF, U.S.
DEPARTMENT OF VETERANS AFFAIRS
Mr. Bowman. Chairman Sanders, Ranking Member Burr, and
distinguished Members of the Committee, it is a pleasure to be
here and offer my comments on S. 543, the VISN Reorganization
Act of 2013.
I believe the proposed legislation is both timely and
necessary to ensure that the VA with predictable regularity,
reviews, reorganizes or right sizes, as appropriate, its VISN
organizational structure and operation to more efficiently and
effectively oversee and manage the budgetary and planning
responsibilities for the respective networks.
At the outset, I believe it important to state that I
receive all my health care through the VA at the Bay Pines VA
Medical Center in St. Petersburg, FL. Although I have many
other health care options available to me, I choose the VA
because I believe in its mission and its people.
My comments have been influenced most particularly by my
last 3-1/2 years experience as an employee of VA, day to day,
as the senior advisor to the VISN 8 network director.
There has been no serious review or right-sizing of the
VISN geographic boundaries in approximately 18 years until
prompted by the proposed legislation.
The legislation reduces the number of VISNs from 21 to 12
by combining existing geographic boundaries and eliminating
excess VISN headquarters, and assisting the transfer or
reassignment of affected personnel to nearby VA medical centers
or other VA facilities. Many could fill existing vacancies at
these facilities based upon their exceptional skill sets.
With the closure of 9 VISN headquarters under the
reorganization, the funding saved could be provided to other VA
medical centers to support their clinical needs, other capital
asset upgrades, and maintenance, as needed.
I have provided the Committee a map reflecting the proposed
realigned boundaries. The map also reflects the current
location of existing VA medical centers, community-based
outpatient clinics and VISN headquarters.
The geographic combinations result in a re-balancing across
VA of the aggregate number of today's veteran beneficiaries
under one VISN director instead of two or possibly, in one
case, three separate VISN headquarters.
Some might argue that despite smaller unique or enrolled
patient numbers, you need to separate VISNs because of the
challenge presented by the number of VA medical centers or the
expansion of geographic areas that the combinations would
entail.
VA medical centers are not all the same complexity level or
size. The same management process and procedures for budgeting
and planning can be applied by a VISN director whether the
number of medical centers is 8, 14, or in the largest proposed
VISN combination--VISNs 1, 2 and 3--would be 20.
The management tools, reports, information technology
capability, tele and video communications venues, and site
visits available to a VISN director and staff are significant
and effective, if appropriately utilized.
It should be noted that the realignment of the VISN
geographic boundaries would not adversely impact individual
veteran patient referral patterns as they exist today. They
would continue as before.
Patients would still be cared for by their VA medical
center staff or wherever they may be referred for care. The
VISN headquarters does not currently, nor under the proposed
restructuring, provide direct patient care.
What would change is that the VA medical center directors
in realigned VISNs would have a new VISN director to which they
will be accountable, and a new boss.
The proposed legislation states, in essence, that a VISN
headquarters is to be located on the grounds of a VA medical
center. At the same time, however, it provides that the
Secretary can justify keeping the VISN headquarters in a leased
location off campus by justifying his decision in a report to
appropriate Congressional oversight committees.
The Secretary, in providing that report, then is offering
his justification for keeping a lease that may be in existence
or to possibly move into an offsite location.
In the absence of an unanticipated exigent circumstance--
natural disaster or other unforeseen emergencies--there is very
little justification for not being able to balance the VISN
books at the end of the fiscal year.
VISNs begin to plan for the closure of their books, and VA
Central office is generally well aware of any deficiencies well
in advance of the end of the fiscal year. VA Central Office has
the ability to transfer reserve funds held at their level to
cover the deficiencies in VISN accounts in advance of the end
of the fiscal year where and when they propose to do so.
In addition, the Under Secretary for Health has a number of
means and methods by which to hold VISN directors accountable
for year-end budget deficiencies.
Mr. Chairman, this concludes my comments; I offer others in
my written statement.
[The prepared statement of Mr. Bowman follows:]
Prepared Statement of Thomas G. Bowman, J.D., Colonel USMC (Ret.),
Former Chief of Staff, U.S. Department of Veterans Affairs
Chairman Sanders, Ranking Member Burr, Distinguished Members of the
Senate Committee on Veterans Affairs, Thank you for the opportunity to
appear before you and offer my comments on S. 543, ``VISN
Reorganization Act of 2013.'' I believe the proposed legislation is
both timely and necessary to ensure that the Department of Veterans
Affairs with predictable regularity, reviews, reorganizes or right
sizes, as appropriate, its VISN organizational structure and operation
to more efficiently and effectively oversee and manage the budgetary
and planning responsibilities for veteran healthcare in the respective
networks.
By way of personal background, I retired from the Marine Corps in
September 1999 after 30 years having served as both an infantry officer
and Judge Advocate; my last assignment as the Senior Military Assistant
to the Under Secretary of Defense for Personnel and Readiness. Upon
retirement, I joined the Committee on Government Reform and Oversight,
U.S. House of Representatives as a Senior Counsel and served there
until February 2002 when I joined the Department of Veterans Affairs. I
served in various positions at VA headquarters which included Acting
Assistant Secretary for Public and Intergovernmental Affairs, Deputy
Chief of Staff and Chief of Staff. I departed VA Central Office in
January 2009 and assumed the position of Senior Advisor to the Director
of the VA Sunshine Healthcare Network (VISN 8) in St. Petersburg,
Florida. I retired from the VA in June 2012.
In 1995, Dr. Kenneth Kizer, then the Under Secretary for Health for
VA implemented a plan for the reorganization of both the field
operations and its central office management. It was called Vision for
Change: A Plan to Restructure the Veterans Health Administration,
March 17, 1995. Under the plan the basic budgetary and planning unit of
healthcare delivery in the field was moved from individual medical
centers into integrated service networks providing care for veteran
beneficiaries in pre-determined geographic areas. Dr. Kizer stated:
``These network service areas and their veteran populations are
defined on the basis of VHA's natural referral patterns;
aggregate numbers of beneficiaries and facilities needed to
support and provide primary, secondary and tertiary care; and
to a lesser extent, political jurisdictional boundaries such as
states.''
visn geographic boundaries
Although 22 VISN's were part of the original implementation plan,
two of the smallest VISN's were combined to better justify and
accommodate staffing, funding and patient population leaving 21 VISN's
to initiate Dr. Kizer's plan. The VISN staffing level was to be 10 FTE.
There has been no serious review and right sizing of the VISN
geographic boundaries in approximately 18 years until prompted by the
proposed legislation.
The proposed legislation reduces the number of VISN's from 21 to 12
by combining existing geographic boundaries and eliminating excess VISN
headquarters, and assisting the transfer or reassignment of affected
personnel to nearby VA medical centers, or other VA facilities. Many
could fill existing vacancies at these facilities based upon their
exceptional skillsets. With the closure of 9 VISN headquarters under
the reorganization, the funding saved could be provided to other VA
medical centers to support clinical needs and other capital asset
upgrade and maintenance, as needed. Attached is a map reflecting the
proposed realigned boundaries identifying affected VISN's. The map also
reflects the current location of existing VA medical centers, community
based outpatient clinics (CBOC) and VISN headquarters locations.
The geographic combinations result, across the VA, in a re-
balancing and closer standardization of the aggregate number of today's
veteran beneficiaries under the budgetary and planning management of
one VISN director instead of spread across two or, in one case, three
separate VISN headquarters with its associated staff. In essence, the
combining of the selected VISN's is analogous to what Dr. Kizer found
appropriate to do for roughly similar reasons in the very beginning
when he combined two VISNs.
By way of an example below, I am using approximate 2011 VA data for
VHA unique patient/veteran enrollee numbers. Combining VISN 1 (232,490/
353,911), VISN 2 (129,815/140,415) and VISN 3 (167,172/183,382) would
result in approximately 529,477/677,708 total unique patients/veteran
enrollees would result in one VISN director and associated staff
managing them, instead of the VISN headquarters budget and FTE overhead
of three VISN. Those numbers compare more favorably to what one VISN,
VISN 8, had as numbers for the same categories at the same time--
505,133/714,755. Another example is combining VISN 17 (261,560/394,110)
and VISN 18 (240,044/363,209) would result in one VISN director
managing 501,604/757,319. A further example is combining VISN's 19 and
20. VISN 19 (170,608/261,736) combined with VISN 20 (243,872/375,968)
results in 414,480/637,704 total unique patients/veteran enrollees;
numbers still smaller than those of VISN 8.
Some might argue that despite smaller unique and enrollee patient
numbers, you need separate VISN's because of the challenge presented by
the number of VA medical centers or the expansion of geographic areas
that the combinations would entail. VA medical centers are not all the
same complexity level or size. The same management process and
procedures for budgeting and planning can be applied whether the number
of medical centers is 8, 14, or in the largest proposed VISN (combining
VISN's 1, 2 and 3) would be 20. The management tools, reports, IT and
tele and video communications venues available to a VISN director and
staff are significant and effective, if utilized appropriately. Much of
the intended mission of the VISN operation is accomplished through data
analysis and ``dashboards'' All too often in recent years the immediate
response to any additional tasking or expansion of responsibility at
the VISN headquarters level has is a request for more FTE instead of
working with what staff already exist. Doing so underestimates the fact
that current VISN staff are individually and collectively more capable
of assuming more responsibilities if asked, especially in the
restricted budget environment that VA will be challenged with in future
years.
It is important to note that the realignment of the VISN geographic
boundaries would not adversely impact individual veteran patient
referral patterns. They would continue as before. Patients would still
be cared for by their VA Medical Center staff, or wherever they may be
referred for care. The VISN headquarters does not currently, nor under
the proposed restructuring, provide direct patient healthcare. What
would change is that VA Medical Center directors in realigned VISN's
would have a new VISN director to which they will be accountable * * *
a new boss.
visn staffing
The current review by VHA into the VISN headquarters FTE staffing
numbers seems to be consistent in its results (55-65 FTE) with VISN
staffing levels recommended by the proposed legislation--not more than
65 FTE. However, the current VHA review was done assuming 21 VISN's. I
believe the review started with approximately 1720 adjusted VISN FTE
staff, and VHA is in the process of reducing VISN staffing to a total
of 1230 FTE, a reduction of approximately 490 FTE. With the proposed
realignment, VISN staffing could be further reduced by approximately
520 FTE. The budgetary savings and FTE benefit could be moved to
support operations at the VA medical centers.
In conjunction with the reorganization of the number of VISN's, I
would strongly urge that the position of VISN Deputy Director be
upgraded to SES level at all VISN headquarters. VA medical centers are
healthcare systems and each health system has a director that is an
SES. They are accountable to the VISN director (an SES) in the chain of
command. As the term Deputy Director is currently applied, it is a
misnomer. If a VISN director retires; is replaced for cause; or, absent
for a significant period of time, VA has to identify an SES level
individual to replace him or her for the duration of the absence or
vacancy. Usually that replacement is through detailing a current
sitting medical center director within the VISN, or seeking someone
from another VISN to assume the director responsibilities until a
replacement is appointed. At the present time, that recruitment and
appointment process can be rather time consuming.
An SES Deputy Director can immediately assume the Acting Director
role with current understanding of the VISN issues; no ``learning
curve'' would be necessary. Medical center directors will be more
inclined to see the SES Deputy Director as more of a ``peer'' and
interact with that person more completely and confidentially on
business and other related issues that they usually reserve for
conversations with the VISN director. Additionally, upgrading the
position can be an excellent succession planning venue for potential
medical center director candidates allowing them to gain significant
experience and insight into executive planning and decisionmaking. SES
allocations for these positions can possibly come from SES positions
that become available through the VISN consolidations if retirements
occur or from those currently available within VA Central Office.
location of visn headquarters
The proposed legislation states, in essence, that a VISN
headquarters is to be located on the grounds of a VA medical center. At
the same time, however, it provides that the Secretary can justify
keeping the VISN headquarters in a leased location off campus by
justifying his decision in a report to appropriate Congressional
oversight committees. The preference for colocation upon a VA medical
center campus is in keeping with what Dr. Kizer recommended. Colocation
on a VA medical center campus provides for veteran and medical center
situational awareness for the VISN staff by witnessing their budget
policy and planning being implemented at the operational level. If the
Secretary ultimately directs the movement on campus, there would
possibly be some associated costs, but that would be the decision of
the Secretary.
visn balanced budget
In the absence of an unanticipated exigent circumstance (natural
disaster, or other unforeseen emergencies), there is very little
justification for not being able to balance at the end of the fiscal
year. VISN's begin to plan for the closure of their books, and VA
Central office is generally well aware of any deficiencies in advance
of the end of the fiscal year. VA Central Office has the ability to
transfer reserved funds held at their level to cover the deficiencies
in VISN accounts in advance of the end of the fiscal year where and
when they want to do so. In addition, the Under Secretary for Health
has a number of manner, means and methods of holding VISN directors
accountable for year-end budget deficiencies.
triennial review of visn structure
A review and report to Congress every three years will provide
appropriate ``checks and balances'' for VA leadership as it plans and
programs for VISN field operations; preclude unnecessary FTE increases;
and, facilitate and enhance appropriate Congressional oversight of VISN
operations.
Mr. Chairman, this concludes my statement. I am pleased to answer
any questions that you or other Members may have.
[Included in Mr. Bowman's testimony:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Sanders. Mr. Bowman, thank you very much. Each of
you provided excellent testimony. You all have made an
important contributions to the discussion on how we should go
forward.
Dr. Jonas, let me start with you. As you may know, your
statement is fairly revolutionary. As I understand it, what you
are suggesting is that complementary or alternative medicine
should be integrated into our health care system. What you are
suggesting is that if we move aggressively in areas like
meditation, acupuncture, chiropractic care, and other areas, we
can ease the suffering of veterans and we can save the system
substantial sums of money.
Is my characterization correct? If so, what would you
suggest that we do with VA to increase access to these
therapies? How aggressive should we be? The VA has already made
efforts in all of these areas and may even be ahead of the
curve compared to the private sector.
Dr. Jonas. I think your characterization could be correct
provided these practices are integrated in the proper way. They
are not simply tagged on as if they were another treatment
system for another condition and a specialty is created.
So, my first suggestion is that the VA--and they have made
a lot of progress in these areas--get outside help. And what I
mean by that is that by definition, these things are not part
of the mainstream system. That is why they are called
complementary and alternative medicine. They are outside of the
way things normally are done.
That means the skills in terms of the delivery of them are
not things that are normally part of the educational part of
practitioners that are in the VA. They are integrated into
medical records, for example. They are not part of the benefits
system. They are not tightly linked to the priorities such as
the personalized person-centered care center.
So, we will go into a patient-centered medical home. In the
VA version, it is a pact, and we will look for whether these
practices are even on the radar screen; and in most cases they
are not or they are on the side. They are not fully integrated.
We will go into the distribution system for primary care
enhancements, for example, called the Scan System. That
infrastructure is there to do it but you do not see integrative
practices as part of that.
There needs to be a retraining program and an evaluation
and quality assurance program that is coordinated with current
existing practices so that they are systemically designed and
evaluated as they are put in to the system.
Chairman Sanders. Are there any health care systems in this
country which are doing a better job than the VA that we can
learn from?
Dr. Jonas. In this area there are, and I suggest the VA
really look at some of those care systems that have
demonstrated improvements in pain, improvements in function,
and reduction of costs in those areas.
There are a number of them. The Allina System up in
Minnesota, for example, has a wonderful inpatient example of
how to integrate complementary practices into mainstream in a
systematic way.
Chairman Sanders. And the results have been positive?
Dr. Jonas. Very positive, yes, reductions in pain, anxiety,
cost, length of stay in the hospital, this type of thing.
There are some examples within the VA also but they tend to
be champion driven meaning that if you have a passionate person
who is organized in the VA, it is done. Salt Lake City had a
wonderful one, for example, that showed, documented, and
published major improvements in outcomes, reductions in costs,
including impact on homelessness and that type of thing through
a whole-person integrated practice.
But when the medical director of that VA retired and left,
it largely went away. It was not embedded into the system, into
the benefits, or into the training and education of the entire
system.
So, these are the kinds of things that need to be
coordinated.
Chairman Sanders. My impression is that people are
gravitating more to these type of procedures. My impression
also, having visited a number of VA centers, is that many
veterans look forward to and want to access these types of
alternative treatments. Is that accurate?
Dr. Jonas. That is absolutely right. Surveys done on the
DOD side, and also on the VA side, show that the use of these
practices tends to be even higher in those populations than
they are out in the civilian population, especially for stress-
related pain and those types of conditions, mental health
conditions.
Chairman Sanders. All of us are wrestling the epidemic of
PTSD.
Dr. Jonas. Right.
Chairman Sanders. It is a huge problem. You touched on it
in your testimony. You think there are treatments,
complementary and alternative treatments, that can help?
Dr. Jonas. Well, I mentioned two. One is a relaxation
treatment that we tested out at Camp Pendleton which was
delivered by nurses. It induced a deep relaxation. It actually
involved training skills; in other words, training veterans and
their families how to do that. We are doing another one of
those programs down at Fort Hood and at some VAs that show
improvements in that.
Those are the kinds of practices. They are skill-based
training. They are not treatments per se. They are not
something where you have a pill or you have even a needle or a
manipulation where you require a professional. It is self-care
practice.
Chairman Sanders. You have done that within the DOD. Am I
correct that there is no reason why that could not be done
within VA, as well?
Dr. Jonas. There are mind, body, and relaxation practices
going on in the DOD. Few of them have been evaluated. There
have been some that have had impact in those areas.
They need to be designed with experts from the outside that
get involved, subject matter experts, and done in coordination
with the VA practitioners so they learn how to actually deliver
them because they are the implementation experts.
So, that is why a team approach is required in those areas.
Chairman Sanders. Thank you very much. My time has expired.
Senator Burr.
Senator Burr. Mr. Chairman, thank you, and to the panel. I
found it to be fascinating. I will probably need another round
just to let you know now because I want to cover as much ground
as I can today.
Tom, thank you for being here and retirement looks like it
is treating you well.
The VISN Reorganization Act would create regional support
centers, and they were set up to measure the efficiency and the
effectiveness of the VISNs.
Now, the VA has testified that these centers would likely
increase staffing, are not the best functions to be moved to a
regional level, and could produce conflicting oversight
programs.
Let me ask you. Do you believe that this function could be
carried out without additional staff?
Mr. Bowman. Senator, I do. And, by way of background, the
functions that have been identified in the legislation--
finance, compliance, outreach, women veterans, homelessness,
and could be others. In each VISN, there are individuals that
are responsible for those tasks and responsibilities of
analysis and oversight of what is occurring in the medical
centers within the respective VISN.
If you were to move forward with the regional support
centers, what you are doing is taking what would be a number of
personnel. Now, it could be a one, two, or three personnel
office that would be looking at a larger number of VA medical
centers. It would not be an expansion or an explosion of
additional FTE.
And in fact, in the legislation, the approach that is taken
is that you would attempt to move individuals who had those
responsibilities in VISNs where there were a closure of the
VISN headquarters and move them into the regional support
center.
An important point to remember is that at the VISN level,
the individuals who are conducting those responsibilities,
those analysis and assessment responsibilities are accountable
to the VISN director.
If their functions are moved to a regional support center
and they are looking at more VISNs, you gain the ability to
assess good practices, good implementation across a larger
number of headquarters.
I am aware that there has been some comments about a
confusion in the chain of command. So, if you create a regional
support center, do you now blur the chain of command, the
answer is no, because as the legislation is discussed, the
regional support center would be looking at a predetermined
number of VISNs as determined by the Under Secretary or the
Secretary.
Then, they would take a look at whether or not they are
performing, those medical centers are performing. If they are
not performing, the VISN director is going to be made aware of
it by reports and information that would come down from VA
central office. The regional support centers would be a field
entity where accountability by the VISNs can be taken to the
VISN level of accountability back up to VA central office.
Senator Burr. So, to some degree, some VISNs or some
directors might look at this as a threat because there would
actually be data that they could not influence what it said
that makes its way to central office.
Mr. Bowman. Yes, there would be a concern there.
Senator Burr. You know, Tom, I noticed in your written
testimony you mentioned the lack of succession planning, and
specifically you state that VISN deputy directors should be at
the SES level to match the VA medical center directors.
I am wondering. Can you expand on that to some degree?
Mr. Bowman. At the present time, the way VISNs are
constructed and the way medical centers are constructed, you
have an SES as a VISN director and you have an SES as a medical
center director. At the present time and by exception in one
case, VISN 8, the deputy network director is not an SES.
Now, from an operational standpoint that I witnessed for 3-
1/2 years is that when a deputy director is not a VISN, if
there is a gap or an absence on the part of the VISN director,
either they were relieved for cause or they retire or for some
other reason are going to be gone for a long period of time, VA
has to pull in either an existing medical center director to
act temporarily as the VISN director. This means he or she is
no longer managing the business of the medical center from
which they came or they are going to be the VISN director until
the personnel process of replacing the VISN director occurs.
And, as we know, that is not a very quick process.
The other point is that if you have the deputy network
director as an SES, it becomes a position that career
employees--as they advance in their rank within the VHA
structure--it will be a position that they look to compete for
because of the advantage of experience to be gained.
It becomes part of a succession planning venue because, if
you have individuals who have served as deputy network
directors, they then become good candidates to be looking at or
to be considered for medical center directors because they have
gained the advantage of the experience and background of what a
VISN operation is like as they oversee medical centers.
It would, at the same time, allow the medical center
directors to feel more comfortable in bringing to the attention
of a deputy network director issues sensitive in nature,
whether they be business or personal as it relates to
happenings within the VISN much more so than somebody who is
not at the SES level.
Senator Burr. Great. Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Mr. Bowman.
Senator Boozman.
Senator Boozman. Thank you, Mr. Chairman.
Rick, you mentioned and Dr. Jesse alluded to it earlier of
the sense of having HUD look at in preventing--sometimes we do
not talk about the prevention of homelessness which again are
very, you know, are so beneficial.
I think you make an interesting point if you have the--it
might be an intervention there. If that does not resolve it,
then the next step is that you are sleeping on somebody's
couch. That is another opportunity to intervene before the bad
things happen where you are physically out on the street.
So, I think you make a really good point there. Perhaps,
you know, there is something that we can do to figure out how
we can do that step. I certainly would like to work with you in
that regard.
I just want to thank all of you. We really can be proud of
a lot of things that have happened in the last several years
and your advocacy in different ways really has made a huge
difference, working with the VA. And so, we really do
appreciate it.
The other thing is you mentioned spina bifida and that is
something that I would like to look at.
The Vietnam era is my era. I can recall somebody that was
just a wonderful employee whose husband died very, very young
that was up to his eyebrows in Agent Orange. They had two
children who had multiple problems, you know, as a result of
this.
So, we all know of those kind of stories. But like I said,
I would like to be involved in that and I will get with you on
that.
Mr. Bowman, I think you have got some great ideas. I
appreciate your service and have enjoyed working with you now
for the last several years.
And again, you know, we have got a great story to tell in
regard to making changes. I guess good ideas were there for
quite a while. I am sure that you are frustrated in the sense
of getting some of those ideas done then, as we all are.
I have been on the Committee for a long time. We have all
been working in these areas. What is your recommendation? How
do we actually get those good ideas that you had implemented?
What is the next step in actually getting some of this
stuff done in regard to perhaps looking at reorganization,
looking at, I guess--what I would like to know is how do we get
that done?
And then the other question is what is the low hanging
fruit out there that you think that the Committee, the VSOs,
the nonprofits, what are some of the low hanging fruit that we
can get at to help VA? I think a lot of this stuff, probably
the vast majority VA wants to be helped to implement.
What are the things we need to address that we could
actually get done fairly quickly?
Mr. Bowman. Well, sir, in the area of veterans' health and
the operation at the field level, I think the one thing that
needs to occur to be able to kind of pave the way for ideas to
be immediately identified as beneficial is that the more
opportunity that senior officials in the VA central office have
to go into the field and spend time in the field, a 2-day visit
down to a particular medical center is not going to gain a
senior official an opportunity to fully understand or grasp
what may be an issue. They can get that based upon a briefing
in their office.
When senior officials come down, they are going to then be
able to see what is being commented upon as needs. I believe
that the collaboration and close coordination with veteran
service organizes and their state-level entities is
exceptionally important because of lot of the day-to-day
adjustments and practice of outreach, of information flow is
accomplished by and through and with the veteran service
organizations and what I saw in my 3-1/2 years down at the VISN
8 area was the community- and faith-based organizations were
more interested in what was happening through the process of
conveyance of information.
The low hanging fruit I believe----
Senator Boozman. So, in regard to the other, some of that
is just the tyranny of the urgent that you are dealing with
that prevents you from--it is interesting. I think, you know,
the advice that you are giving is good advice for us.
I mean, we are in the same position as senior officials in
having oversight and getting out in the field, you know,
spending time. We just simply do not do enough of that, yet I
am not being critical. We are the people who are actually
interested in spending a lot of time but I think that is good
advice for all of us.
Mr. Bowman. The follow-up comment is that with my time in
central office and then down in the field in VISN 8 that the
impact of a visit by a senior official or a Member of Congress
on the morale of the employees at the operational level in the
medical center is tremendous--oftentimes it may go overlooked--
because the mere fact you have taken the time to go down there
sends a very clear signal that you are interested and that you
are aware.
And then, what will happen is I think there is doing to be
an exchange of information through staff because they believe,
I mean, if you were to come down an say, what do you need here?
Intuitively and institutionally, it will either find its
way into the vapor, you know, the higher it goes up through the
chain of command, now some of it has to go up through the chain
of command and should because senior officials within the VA
chain of command should be made aware.
However, if a Members of Congress comes down and talks to a
medical center director and says, is there anything that I can
do for you; and if that medical center director has already,
you know, expressed that, I believe there should be the
latitude, the internal belief that he could be candid with the
Member of Congress.
That is not the feeling, and I think that the morale out
there in tough times can be significantly enhanced by very
small events and that is by ``small'' I mean it could be 1 or 2
days but the fact that you have oversight individuals, whether
they be senior officials at the headquarters level but
especially Members of Congress.
Senator Boozman. Thank you.
Chairman Sanders. Thank you, Senator Boozman.
Senator Boozman, at one of our recent hearings, you raised
an issue that I want to pick up on now with Dr. Jonas. I think
you raised a concern that many of us have heard about, which is
the over medication of many of our veterans. We have heard that
time and time again. Dr. Jonas, let me ask you about that
issue. Is it fair to assume that by increasing the availability
of complementary and alternative medicine we could address, at
least to some degree, the problem of over medication?
Dr. Jonas. Overmedication is a large problem. We spend less
than .01 percent of our research budget on pain treatments, for
example, that are not some type of intervention or medication
aspect, the vast majority of that. We wonder why that is the
tool that the physicians have to use to do that.
Sir, I know you saw Escape Fire. I would recommend it to
the rest of you. There was a servicemember there who gets the
typical kinds of medical treatment for multiple problems. Each
of these practitioners that I mentioned that you go to has
their own special medication that they treat for sleep, for
anxiety, for depression, for pain, et cetera.
Part of the trauma spectrum is medication addiction used
for treating pain and these other aspects. So, many of these
things, in fact, can substitute for that and can lower that. In
fact, some of the demonstration projects that I mentioned to
you have all demonstrated that as ways of substituting for
medications in many of these areas.
Chairman Sanders. Thank you very much.
Rick, we have introduced legislation to expand the
Caregivers Expansion and Improvement Act. I think you heard
from the VA today that the program has been a success with the
families of post-9/11 veterans.
Is there any reason, in your judgment, why we should not
expand the program to Vietnam-era veterans, their families, as
well as those veterans from other eras?
Mr. Weidman. Senator, when the bill was first advanced in
the Congress, people asked, what is your contribution in
getting this law enacted? I said, our contribution at Vietnam
Veterans of America is we are going to be quiet.
In other words, our folks, a lot of our members who are
alive today because their spouse has been taking care of them
for 40 years and without any assistance from the government and
saving the government over that period of time billions of
dollars that otherwise would have had to go into custodial care
or long-term care of one form or another.
We had always hoped that, and the White House at that point
assured us, that they would follow on with expanding it to all
generations based on medical needs or life situation needs.
Yet, that has not happened from there. We are very pleased that
it is coming from the Committee and we are strongly in favor of
expanding it to every generation.
Chairman Sanders. Thank you.
Mr. Weidman. May I say one thing, sir?
Chairman Sanders. Sure.
Mr. Weidman. Senator Boozman, you asked the question about
what can VA do that is low hanging fruit? What VA can do is
implement the executive order that was issued on January 21,
2009, having to do with open government, transparency, and
participation of stakeholders.
It is not followed anywhere in VHA. They give lip service
to it. They have a quarterly meeting, as an example, at the
VISN level that is mostly what we used to call a ``dog and pony
show'' where they fill the air with talk for 2 hours and 45
minutes of a 3-hour session. Then, you have 15 minutes to ask
questions and then everybody has got to go.
That is not participation in our view and it is not either
the letter or the spirit of that executive order. Might I
suggest, Mr. Chairman and Ranking Member, that you even
consider taking that and enacting that into statute so it will
live beyond this presidency.
Chairman Sanders. Mr. Bowman, as I understand the essence
of your testimony, regarding Senator Burr's legislation is that
we should not support bureaucracy but put our resources into
providing care to veterans. That is certainly a noble goal, one
which I support.
How many years have you worked with the VA?
Mr. Bowman. Almost 11 before I retired.
Chairman Sanders. OK. And you worked at the national level
and the local level.?
Mr. Bowman. Yes, sir.
Chairman Sanders. You began your testimony by saying to get
your health care the VA. Overall, understanding that every
health care system has its share of problems, including VA,
does VA do a fairly good job for our veterans, do you think, in
terms of providing quality health care?
Mr. Bowman. In the delivery of health care to veterans at
the medical center level, I would say yes, they do. My concern
would be, as I look at my experience in VISN 8, is that there
are more veterans out there who belong in the VA system and
they are not there because of an outreach deficiency.
Chairman Sanders. Let me pick up on that point. You know,
we had a hearing just on that issue.
Mr. Bowman. Yes, sir.
Chairman Sanders. So, what you are telling me, and excuse
me. VISN 8 is where?
Mr. Bowman. VISN 8 is essentially of all Florida except for
a little chunk of the panhandle.
Chairman Sanders. OK. And a lot of veterans live there?
Mr. Bowman. Yes, sir.
Chairman Sanders. So, what you are telling this Committee
is there are veterans who are eligible for and need care who do
not know how to access the system?
Mr. Bowman. Yes, sir; and I know it may sound strange with
all of the publicity that has been----
Chairman Sanders. No, it does not sound strange to me. All
of us here, no matter what our political views may be, share
one understanding.
You do not get elected unless you figure out how to
communicate with the people in your State, right? And sometimes
bureaucracies do not do that. What I am hearing you say just
confirms why we held that hearing.
Mr. Bowman. Yes, sir.
Chairman Sanders. I want to see every veteran in this
country who is entitled to benefits to get them or at least
know about them. You agree with that?
Mr. Bowman. Yes, sir.
Chairman Sanders. You are telling me that this is a problem
in Florida?
Mr. Bowman. I believe it is a problem in the Florida area,
and from my time in Washington, I believe that it is a problem
across the country that there needs to be more aggressive
outreach.
Chairman Sanders. Good. I very much share that concern.
Senator Burr.
Senator Burr. Dr. Jonas, you mentioned that there is recent
research that has shown the effectiveness of complementary and
alternative medicines. In standard research studies, they
include experimental groups and control groups. Did any of that
research that was done adopt this standard of two different
groups?
Dr. Jonas. Yes, sir, all the studies that I mentioned in my
testimony were done in what is called randomized controlled
trials which is not only two different groups but they are
equally distributed into the comparison and the control group
so that they start at the same level when they are looking for
comparative benefits, yes.
Senator Burr. If there is an executive summary to that
research out there, I hope you will provide it for the
Committee. If it is in your testimony I apologize, or is it in
the book?
Dr. Jonas. So, we just supplied the IOM. I was on the
Committee for the IOM, and we just supplied them with a
comprehensive analysis of complementary medicine and guidelines
and what are called ``meta analysis'' which is where you look
at these kinds of studies and look for the quality and the
quantity of them into this book. So, they are available,
especially Chapter 6, which really talks about that.
Senator Burr. In your professional opinion, is the
reluctance to utilize more alternative treatment unique to the
VA or is it across medicine as a whole?
Dr. Jonas. This is across medicine as a whole. This is not
unique at all to the VA. In fact, as Senator Sanders said, the
VA tends to be ahead of the curve in the use of these compared
to a civilian population where these things do not get paid
for.
Senator Burr. So, is this an ignorance of understanding
that your research is out there or a disregard for its
conclusion?
Dr. Jonas. It is partly ignorance and it is partly the
squeaky wheel. When you have billions and billions of dollars
dumped into technologies that are then advertised and pushed on
the system--and I get them in my medical bag as a primary care
practitioner and I have .01 percent of the research dollars
going into my medical bag--going into drugless approaches like
this, it is no wonder I cannot find them in the bag. They are
buried underneath other types of things.
There is actually no economic driver to deliver these low-
cost self-care types of practices. That is a large part of it.
So, I never learned about them. I did not learn about
nutrition, for example, in my medical school, and yet I know it
is a very important part of brain function, of cardiovascular
disease, hypertension, you know, depression, et cetera.
Senator Burr. So, when you talked earlier about evidence-
based, you would not be highlighting that VA or the health care
system in this country should adopt anything that there is not
clinical reason to implement.
Dr. Jonas. Absolutely. This has to be evidence-based. If we
do not do this, then we end up doing things that not only are
wrong but they may actually harm people. So, it has to be that
way.
Senator Burr. Good. Mr. Gornick, in your testimony, you
talked about shortfalls that exist that would be solved by
establishing a national assistance fund. Detail for me, if you
would, what these shortfalls are that exist?
Mr. Gornick. Thank you for that question.
Some of the different things that I laid out in my written
testimony include providing child care assistance for veterans
in employment assistance programs, and helping veterans make
security deposits and pay utility hook-up fees for housing
placements.
The latter could be addressed by the SSVF program, but
generally with a limited amount of funds; that is not where the
dollars go.
For a veteran that receives a HUD-VASH voucher, for
instance, that veteran now has a rental subsidy indefinitely so
long as Congress provides funding for that. But that does not
pay for the bed. That does not pay for the couch. That does not
pay for the down payment that he or she needs to make on an
apartment. Therefore, that veteran could continue being
homeless without these additional forms of help.
Senator Burr. So, we have a lot of different pieces out
here. We are hopeful because we say we have got a homelessness
program and they all come together to fill the need of an
individual, whatever that gap is.
But what you are saying is there is still--if everything
came together perfectly--there are still some shortfalls out
there that are relatively inexpensive but that blow up the
whole model if we do not address them. Is that an accurate
statement?
Mr. Gornick. Undoubtedly.
Senator Burr. Well, you know, Dr. Jonas talked about a
holistic approach and I think I share this with the Chair. We
do have a lot of programs, and I think we have got a passionate
commitment on the part of the Secretary and Members and
everybody within the VA to end homelessness for veterans.
What we do not do is a good job of holding accountable and
verifying that all these pieces come together. I think there is
a tendency that when the roof goes over somebody's head, we
walk away and we sleep well that night because we know that
they are no longer under a bridge.
I would suggest to you that our goal should not be to end
there. It is to make sure that the complementary, wraparound,
holistic services come to that veteran so that the mental
health treatment is there, substance abuse treatment is there.
Our goal cannot be temporary relief from veterans'
homelessness. It has to be constructed for permanent
transition. So, Mr. Gornick, I hope if there are more gaps than
what you have listed in your testimony, you will provide those
to the Committee so that we can begin to work with VA to see if
there are ways to fill them.
I thank all of you.
Chairman Sanders. Thank you very much Senator Burr. And let
me thank all of our witnesses. I have enjoyed your testimony
very much and I thank you for being here. We will continue our
discussion of pending legislation with a new panel next week.
Again, thank you all very much. This hearing is adjourned.
[Whereupon, at 11:53 a.m., the Committee was adjourned.]
A P P E N D I X
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Prepared Statement of Hon. Barbara Boxer, U.S. Senator from California
s. 62, the check the box for homeless veterans act of 2013
Chairman Sanders, Ranking Member Burr: Thank you for considering
S. 62, the Check the Box for Homeless Veterans Act of 2013 at today's
hearing.
I am so grateful to you both for your longstanding commitment to
our Nation's veterans and particularly for your tireless efforts to
eliminate the epidemic of veteran homelessness.
Ending veteran homelessness is one of the most critical challenges
facing our Nation today. It is also an issue that brings Americans
together because we all agree it is simply unacceptable that more than
60,000 veterans are homeless on any given night.
I strongly believe that if we work together as a Nation, we can end
veteran homelessness once and for all. And I know so many Americans are
looking for ways to give back to our veterans who have sacrificed so
much for us.
That is why I introduced S. 62, the Check the Box for Homeless
Veterans Act of 2013. This straightforward bill would create a ``check-
off box'' on the annual Federal tax return form and allow taxpayers to
make a voluntary contribution in the amount of their choice to support
programs that prevent and combat veteran homelessness.
Taxpayer contributions would be deposited and safeguarded in a new
Homeless Veterans Assistance Fund established in the U.S. Treasury.
These funds would be available to the VA--in consultation with the
Departments of Labor and Housing and Urban Development--solely to
provide services to homeless veterans, including developing and
implementing new and innovative strategies to end veteran homelessness.
My bill would also authorize the transfer of funds between these three
agencies to support programs that assist homeless veterans.
To ensure transparency and accountability in how these taxpayer
dollars are spent, my bill requires the President's annual budget
submission to include proposed uses of funds from the Homeless Veterans
Assistance Fund. Additionally, my bill stipulates that Congress must be
notified 60 days in advance of any expenditure of such funds.
The Check the Box for Homeless Veterans Act of 2013 would provide
additional necessary resources to help end the cycle of homelessness
for men and women like Air Force veteran Mike Hofler. After completing
his military service, Mike struggled with Post-Traumatic Stress and hit
rock bottom when he was hospitalized in a VA mental health unit.
The VA eventually referred Mike to the non-profit organization
Swords to Plowshares, where he got the support he needed to get his
life back on track. Within months, Mike found his own apartment and
began pursuing his bachelor's degree in social work. Today, Mike is a
recent graduate of the Columbia University School of Social Work's
Master of Science program and is working with returning veterans in New
York.
I am proud that this bill has strong support from our military and
veteran communities and has been endorsed by the National Coalition for
Homeless Veterans, the American Legion, the Veterans of Foreign Wars,
AMVETS Department of California, the Center for American Homeless
Veterans, the California Association of Veteran Service Agencies, and
Swords to Plowshares.
According to the National Coalition for Homeless Veterans, ``The
simple act of checking a box would enable taxpayers to prevent and end
homelessness for those who have served this country in a way
increasingly few Americans ever will. By supplementing proven Federal
programs, the `Check the Box for Homeless Veterans Act' will have a
strong and lasting impact in communities nationwide.''
I look forward to working with my colleagues to see this important
legislation enacted into law.
______
Prepared Statement of Hon. Joe Donnelly, U.S. Senator from Indiana
s. 832, improving the lives of children with spina bifida act of 2013
Chairman Sanders, Ranking Member Burr, Members of the Committee,
Thank you for the opportunity to submit a statement on behalf of
S. 832, the Improving the Lives of Children with Spina Bifida Act of
2013. This bill requires the Secretary of Veterans Affairs to carry out
pilot programs on furnishing case management services and assisted
living for children of Vietnam veterans and certain Korea service
veterans suffering from spina bifida.
Currently, the Department of Veterans Affairs (VA) provides
monetary allowances, vocational training and rehabilitation, and VA-
financed health care benefits to certain Korea and Vietnam veterans'
birth children who have been diagnosed with spina bifida. As of 2008,
Public Law 110-387, Section 408, outlined changes to the program,
providing comprehensive health care for spina bifida beneficiaries.
I first became aware of this program from a constituent whose step-
daughter suffers from spina bifida, and is a beneficiary of the VA
program. My constituent has worked for years to get the comprehensive
care services needed for his step-daughter and family, and has
struggled every step of the way. For several months, I have been
working in coordination with the Committee, the Vietnam Veterans of
America, and the VA to resolve his concerns, and I appreciate the
Committee's support during this process. We are beginning to make
progress in the VA's compliance with providing the services required by
law.
Earlier this year, the Committee conducted oversight activities on
implementation of the VA's spina bifida program, its outreach to spina
bifida beneficiaries, and options for improving the program. My office
was briefed on the conversations, and two key conclusions emerged: (1)
spina bifida patients are in need of comprehensive case management to
coordinate services, provide follow-up and follow-through support, and
help patients work in their home to resolve problems. Case management
is allowed for in the existing law, but has not been utilized; and (2)
as spina bifida beneficiaries and their caretakers age, beneficiaries
will need lifelong management of their health issues. Assisted living
facilities may enable these beneficiaries to maintain their
independence, and may be a better option than nursing home care.
Based on these conclusions, I worked with the Committee to develop
S. 832 calling for two pilot programs to address case management and
assisted living care. A key component of the pilot programs is a
requirement for the VA to inform all covered individuals of the
services available under the pilot programs. This can help narrow the
gap between the number of eligible beneficiaries, and those actually
utilizing the services provided by the VA. Additionally, this bill
relies on funding already appropriated or otherwise made available
within the spina bifida program to furnish case management and nursing
home care. We are not seeking to increase the benefits provided to
spina bifida beneficiaries, but rather to improve their access to care
and VA implementation of the services required under the law.
I believe this bill can make a meaningful difference in the lives
of spina bifida children, and encourage VA to live up to its
obligations under the law. I am grateful for the support of the
Committee in developing this legislation, as well as for the support of
Vietnam Veterans of America and Veterans of Foreign Wars.
Thank you for your consideration of the bill, and for your support.
______
Prepared Statement of The American Legion
s. 49, veterans health equity act of 2013
To require the Secretary of Veterans Affairs, with respect to each
of the 48 contiguous states, to ensure that veterans who are eligible
for hospital care and medical services through the Department of
Veterans Affairs (VA) have access to: (1) at least one full-service VA
medical center in the state, or (2) hospital care and medical services
comparable to that provided in full-service VA medical centers through
contract with other health providers in the state; and directs the
Secretary to report to Congress on compliance with such requirement,
including its effect on improving the quality and standards of
veterans' care.
The American Legion has no position on this bill.
s. 62, check the box for homeless veterans act of 2013
To offer taxpayers the opportunity to help keep those who have
served our country off the streets by making a voluntary contribution
on their annual Federal income tax return to support programs that
prevent and combat veteran homelessness.
On any given night in January 2013 over 60,000 veterans were
homeless in the United States. As such, The American Legion strongly
believes, in accordance with Resolution No. 306, Funding for Homeless
Veterans, passed at National Convention 2012, that homeless veteran
programs should be granted sufficient funding to provide supportive
services such as, but not limited to, outreach, healthcare,
rehabilitation, case management, personal financial planning,
transportation, vocational counseling, employment and training, and
education.
Resolution 306 states that The American Legion ``seek[s] and
support[s] any legislative or administrative proposal that will provide
medical, rehabilitative and employment assistance to homeless veterans
and their families.'' This bill would help do that by establishing a
Homeless Veterans Assistance Fund in the Treasury Department which
would supplement proven Federal programs for homeless and at-risk
veterans and their families. Additionally, this bill would provide
funding for innovative and relevant programs/services that would
improve and expand services available to homeless veterans. The
Department of Veterans Affairs (VA) Five-Year Plan to eliminate veteran
homelessness by 2015 is past the halfway mark. By helping to provide
the necessary resources to reach this obtainable, and worthy, goal,
this Nation can finally end the scourge of veteran homelessness.
The American Legion supports this bill.
s. 229, corporal michael j. crescenz act of 2013
To designate the Department of Veterans Affairs (VA) medical center
at 3900 Woodland Avenue in Philadelphia, Pennsylvania, as the
``Corporal Michael J. Crescenz Department of Veterans Affairs Medical
Center.''
The American Legion has no position on this bill.
s. 287, a bill 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, and for other
purposes
To include as a homeless veteran, for purposes of eligibility for
benefits through the Department of Veterans Affairs (VA), a veteran or
veteran's family fleeing domestic or dating violence, sexual assault,
stalking, or other dangerous or life-threatening conditions in the
current housing situation, including where the health and safety of
children are jeopardized, there is no other residence, and there is a
lack of resources or support networks to obtain other permanent
housing.
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.''
The expansion of the ``homeless veteran'' definition proposed by
S. 287 would align VA and HUD, making their partnership at the state
level more efficient. The bill would include as homeless veterans those
getting emergency shelter or other services as a result of their being
victims of domestic violence.
According to Resolution No. 306 Funding for Homeless Veterans,
passed at the 2012 National Convention, The American Legion is
committed to assisting homeless veterans and their families, continues
to support the efforts of public and private sector agencies and
organizations with the resources necessary to aid homeless veterans and
their families; and, supports any legislative or administrative
proposal that will provide medical, rehabilitative, and employment
assistance to homeless veterans and their families.
The American Legion supports this bill.
s. 325, a bill to amend title 38, united states code, to increase the
maximum age for children eligible for medical care under the champva
program, and for other purposes
To make a child eligible for medical care under the Civilian Health
and Medical Program of the Department of Veterans Affairs (CHAMPVA)
eligible for such care until the child's 26th birthday, regardless of
the child's marital status, and to make such provision inapplicable
before January 1, 2014, to a child who is eligible to enroll in an
employer-sponsored health care plan.
The American Legion has no position on this bill.
s. 412, keep our commitment to veterans act
To authorize the Secretary of Veterans Affairs (VA) to carry out
specified major medical facility leases in FY 2013-2014 in New Mexico,
New Jersey, South Carolina, Georgia, Hawaii, Louisiana, Florida, Puerto
Rico, Texas, Connecticut, and Massachusetts, and to reduce lease
amounts authorized in previous fiscal years for VA outpatient clinics
in: (1) Johnson County, Kansas; (2) San Diego, California; and (3)
Tyler, Texas.
The American Legion has no position on this bill.
s. 422, chiropractic care available to all veterans act of 2013
To amend the Department of Veterans Affairs Health Care Programs
Enhancement Act of 2001 to require a program under which the Secretary
of Veterans Affairs provides chiropractic care and services to veterans
through Department of Veterans Affairs (VA) medical centers and clinics
to be carried out at: (1) no fewer than 75 medical centers by
December 31, 2014, and (2) all medical centers by December 31, 2016,
and to include chiropractic examinations and services within required
VA medical, rehabilitative, and preventive health care services.
The American Legion has no position on this bill.
s. 455, a bill to amend title 38, united states code, to authorize the
secretary of veterans affairs to transport individuals to and from
facilities of the department of veterans affairs in connection with
rehabilitation counseling, examination, treatment, and care, and for
other purposes
To authorize the Secretary of Veterans Affairs to transport
individuals to and from facilities of the Department of Veterans
Affairs (VA) in connection with vocational rehabilitation, counseling,
examination, treatment, or care.
The American Legion's Resolution No. 294, Department of Veterans
Affairs Rural Healthcare Program, passed at the 2012 National
Convention, states that one out of every three veterans that receive
their health care at VA facilities live in rural communities and that
veterans residing in these areas have been underserved due to a lack of
access to health care, which can be attributed to greater travel
barriers and a lack of public transportation in these areas.
During The American Legion's 2012 System Worth Saving site visits,
which focused on Rural Veterans Health Care, it was recommended to the
Undersecretary of VHA for the Department of Veterans Affairs and the
Office of Rural Health that VA medical centers fully implement a
Veterans Transportation Service (VTS) Department to coordinate all
veteran transportation programs for the hospital, i.e. staff to conduct
transportation catchment area analysis, VTS program initiatives,
volunteer transportation drivers/scheduling and beneficiary travel
programs.
The American Legion believes that the provisions in this bill would
be extremely beneficial to veterans who reside in rural and/or highly
rural areas of the country where public transportation is less frequent
and/or unavailable. This bill would also assist veterans who cannot
utilize public transportation as a result of their existing medical
condition and/or disability.
The American Legion believes that no veteran should be penalized
based on where they chose to live and that the VA has an obligation to
provide veterans across the country access to the medical center and/or
community based outpatient clinic closest to them in order to receive
care.
The American Legion supports this bill.
s. 522, wounded warrior workforce enhancement act
To direct the Secretary of Veterans Affairs (VA) to award grants to
eligible institutions to: (1) establish a master's or doctoral degree
program in orthotics and prosthetics, or (2) expand upon an existing
master's degree program in such area; to require a grant priority for
institutions in partnership with a medical center administered by the
VA or a facility administered by the Department of Defense (DOD); to
provide grant amounts of at least $1 million and up to $1.5 million.
Defines as eligible institutions those either accredited by the
National Commission on Orthotic and Prosthetic Education or
demonstrating an ability to meet such accreditation requirements if
receiving a grant; and to require the Secretary to award a grant to an
institution with orthotic and prosthetic research and education
experience to: (1) establish the Center of Excellence in Orthotic and
Prosthetic Education; and (2) improve orthotic and prosthetic outcomes
for veterans, members of the Armed Forces, and civilians by conducting
orthotic- and prosthetic-based research.
Due to an aging population, increased rates of diabetes and
cardiovascular disease, and advances in military medicine, more
Americans will continue to need the skills of prosthetists and
orthotists in the coming years. Newer models of orthotics and
prosthetics improve the lives of many Americans but are hard to fit and
require highly skilled professionals at the same time that many
orthotists and prosthetists are retiring.
Currently, only five universities offer O&P master's programs
accredited by the Commission on Accreditation of Allied Health
Education Programs; the University of Hartford is among those five
programs.\1\ Only ten educational institutions offer any kind of
currently accredited O&P program, but five will have to adapt their
programs in order to meet the new master's degree requirement.
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\1\ http://www.caahep.org/Find-An-Accredited-Program/
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The proposed bill would devote $5 million per year for three years
to award competitive grants to institutions that prove their ability to
create or expand an accredited master's or doctoral program in O&P. The
grants would be between $1 million and $1.5 million and could be used
to build new programs, expand existing programs, further faculty
development, supplement salaries, fund faculty research projects, or
construct O&P facilities.
The second part of this bill appropriates $5 million for the VA to
establish a second Center of Excellence in Prosthetic and Orthotic
Education to provide evidence-based research in the knowledge, skills
and training most needed by clinical professionals in the field. The
first Center of Excellence is in Long Beach, CA. The legislation
directs the VA Secretary to consider joint applications from a VA
medical center and an academic institution with an established
orthotics and prosthetics program.
The bill also establishes DOD grants to research best practices for
the use of O&P, including for wounded warriors. The legislation calls
on the Defense Department to work in coordination with the VA, use data
from peer-reviewed sources, and draw on the expertise of individuals
and institutions outside of the Federal Government. $30 million is
appropriated for the grants.
Resolution No. 108: Request Congress Provide the Department of
Veterans Affairs Adequate Funding for Medical and Prosthetic Research,
passed at the 2012 National Convention states that The American Legion
``supports adequate funding for VA biomedical research activities,''
and requests that ``Congress and the Administration encourage
acceleration in the development and initiation of needed research on
conditions that significantly affect veterans--such as prostate cancer,
addictive disorders, trauma and wound healing, Post-Traumatic Stress
Disorder (PTSD), Traumatic Brain Injury (TBI), rehabilitation, and
others--jointly with the Department of Defense, the National Institutes
of Health, other Federal agencies, academic institutions and the
Department of Veterans Affairs.''
The American Legion supports the bill.
s. 529, a bill to amend title 38, united states code, to modify the
commencement date of the period of service at camp lejeune, north
carolina, for eligibility for hospital care and medical services in
connection with exposure to contaminated water, and for other purposes
To amend title 38, United States Code, to modify the commencement
date of the period of service at Camp Lejeune, North Carolina, for
eligibility for hospital care and services in connection with exposure
to contaminated water, and for other purposes.
For a period of over thirty years, servicemembers in the Marine
Corps and other branches of service, as well as their families, were
exposed to contaminated ground water at the Marine Corps Base at Camp
Lejeune, North Carolina. In response to this, the government has acted
to provide medical care to those affected by this terrible
contamination.
This bill, S. 529, would extend the affected period under the law,
expanding the period from its current onset of January 1, 1957 back to
an onset date of August 1, 1953. Should the Secretary of Veterans
Affairs, in consultation with the Agency for Toxic Substances and
Disease Registry determine the need for an earlier effective onset
date, the earlier date should be set after a proper publication of such
a date in the Federal Register.
Since at least the early 1980s, The American Legion has been at the
forefront of advocacy for veterans exposed to toxic, environmental
hazards such as Agent Orange, Gulf War related hazards, ionizing
radiation, and others, by pushing for epidemiological studies based on
DOD records, in order to address environmental exposure issues. The
American Legion's Resolution 95\2\ thoroughly supports vigorous
research into the effects of environmental exposures on servicemembers,
and the expansion of benefits and treatment to ameliorate such
exposures when research determines those benefits are merited. The
American Legion supports this expansion of effective dates, to reflect
the most accurate knowledge of the periods of exposure at Camp Lejeune.
Furthermore, continued monitoring of the period to determine the full
extent of damage done to those who served and their families is
essential to ensure this country fulfills its obligations to those who
have served.
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\2\ Resolution 95: Environmental Exposure, Indianapolis, IN
August 2012.
The American Legion supports this bill.
s. 543, visn reorganization act of 2013
To direct the Secretary of Veterans Affairs to organize the
Veterans Health Administration (VHA) into 12 geographically defined
Veterans Integrated Service Networks (VISNs), and for other purposes.
According to The American Legion's Resolution No. 162, Department
of Veterans Affairs Veterans Integrated Service Networks (VISN's),
passed at the 2012 National Convention, ``The American Legion urges
Congress to direct the Government Accountability Office (GAO) and
Department of Veterans Affairs (VA) Office of the Inspector General
conduct a comprehensive study to include purpose, goals, objectives and
budget and evaluation of the effectiveness of the 21 Veteran Integrated
Service Networks (VISNs),'' and ``urges the Veterans Health
Administration (VHA) leadership conduct an internal review and develop
an action plan to address VISN management, staffing and its current
geographic boundaries/catchment areas concerns, in order to better
provide timely access and quality health care for veterans.''
Department of Veterans Affairs (VA) Veterans Health Administration
is organized into a national central office and 21 VISN's (or regions)
which oversee several VA medical facilities and Community Based
Outpatient Clinics (CBOC's). The concept of VISN's was established by
Dr. Kenneth Kizer, former Undersecretary for Health for VHA, in order
to decentralize the medical centers and associated CBOC's from the
central office. VISN's were established to promote best practices,
innovation, and be responsible for all financial and operational
activities for the medical facilities within their jurisdiction.
Since the model was developed, however, there has been no official
documentation from VHA leadership on the overall effectiveness of the
current structure. Therefore, before any comprehensive restructuring of
the VISNs, of the type required by this legislation, is implemented,
The American Legion believes that Congress should direct the GAO and VA
Office of Inspector General conduct a comprehensive study to include
purpose, goals, objectives and budget evaluation of the effectiveness
of having 21 VISNs, and that the VHA leadership conduct an internal
review and develop an action plan to address VISN management, staffing
and its current geographic boundaries/catchment areas concerns, in
order to better provide timely access and quality healthcare for
veterans.
The American Legion does not support this bill.
s. 633, a bill to amend title 38, united states code, to provide for
coverage under the beneficiary travel program of the department of
veterans affairs of certain disabled veterans for travel in connection
with certain special disabilities rehabilitation, and for other
purposes
To authorize payment under the Department of Veterans Affairs (VA)
beneficiary travel program of travel expenses in connection with
medical examination, treatment, or care of a veteran with vision
impairment, a spinal cord injury or disorder, or double or multiple
amputations whose travel is in connection with care provided through a
VA special disabilities rehabilitation program, if such care is
provided: (1) on an inpatient basis, or (2) while a veteran is provided
temporary lodging at a VA facility in order to make such care more
accessible and to require a report from the Secretary to the
congressional veterans committees on the travel program.
The American Legion has no position on this bill
s. 800, treto garza far south texas veterans inpatient care act of 2013
To require the Secretary of Veterans Affairs to ensure that the
South Texas Department of Veterans Affairs Health Care Center at
Harlingen, located in Harlingen, Texas, includes a full-service
inpatient health care facility of the Department of Veterans Affairs,
to redesignate such center, and for other purposes.
The American Legion has no position on this bill.
s. 825, homeless veterans prevention act of 2013
To amend title 38, United States Code, to improve the provision of
services for homeless veterans, and for other purposes.
In order to fully implement VA's pledge to end homelessness among
veterans by 2015, Congress must continue making responsible investments
in affordable housing and supportive services programs that move
veterans and their families off the streets and into stable housing.
These homeless assistance programs should be intended to serve all
groups of low-income veterans--veterans at risk of becoming homeless,
veterans who are homeless for a short time, and veterans and their
families who have spent years without a place to call home. To make
this seamless system of care work, funding must be provided for a broad
range of appropriate and effective interventions. Funding that prevents
veterans from becoming homeless or quickly re-house veterans who need
nothing more than short-term rental assistance and limited case
management in order to get back on their feet could be used effectively
by community organizations and other stakeholders. These funds could
also be used to pay for employment services, utility assistance, child
care costs, legal services, and other housing-related expenses.
Additionally, there is still a need for funding that can provide short-
term housing to help homeless veterans get stabilized, along with
allowing them to get connecting with jobs, supportive services, more
permanent housing, and ultimately to become self-sufficient.
With the affects of the wars in Iraq and Afghanistan, it is widely
known that psychological stress, such as PTSD, TBI and other mental
illnesses play a significant role in pushing a certain population of
veterans into homelessness. Funding, along with grants that go to
homeless veterans programs and organizations that assist this
vulnerable demographic, are needed more than ever. Due to our work with
homeless veterans and their families, The American Legion understands
that homeless veterans need a sustained coordinated effort that
provides secure housing and nutritious meals; essential physical
healthcare, substance abuse aftercare and mental health counseling; as
well as personal development and empowerment. Veterans also need job
assessment, training and placement assistance. The American Legion
believes all programs to assist homeless veterans must focus on helping
veterans reach their highest level of self-management.
Furthermore, The American Legion has provided housing for homeless
veterans and their families as well (i.e., Departments of Pennsylvania,
North Carolina and Connecticut). One of the goals of The American
Legion is to help bring Federal agencies, non-profit organizations,
faith-based communities and other stakeholders to the table to discuss
best practices, along with funding opportunities, so homeless veterans
and their families can obtain the necessary care and help in order for
them to properly transition from the streets/shelters into gainful
employment and/or independent living.
Last, The American Legion strongly believes that with more
collaboration and civic engagement, access to stable and affordable
housing, and economic security to prevent and end homelessness, the
goal of eliminating veteran homelessness is well within reach.
According to Resolution No. 306, Funding for Homeless Veterans,
passed at the 2012 National Convention, The American Legion is
committed to assisting homeless veterans and their families, continue
to support the efforts of public and private sector agencies and
organizations with the resources necessary to aid homeless veterans and
their families, and, support any legislative or administrative proposal
that will provide medical, rehabilitative, and employment assistance to
homeless veterans and their families.
The American Legion supports this bill.
s. 832, improving the lives of children with spina bifida act of 2013
To require the Secretary of Veterans Affairs to carry out pilot
programs on furnishing case management services and assisted living to
children of Vietnam veterans and certain Korea service veterans born
with spina bifida and children of women Vietnam veterans born with
certain birth defects, and for other purposes.
The effects of Agent Orange and other herbicides on veterans of the
Vietnam conflict appear to be ongoing. Recent changes regarding the
expansion of presumptive conditions reveal that the medical community
has yet to realize the full effects of herbicide exposure. Considering
the manifestation of some conditions by children of Vietnam veterans,
it would stand to reason that the medical community has yet to
determine the long term effects of Agent Orange upon the children of
Vietnam veterans.
Through the awarding of benefits associated with herbicide exposure
to children of Vietnam veterans, VA has conceded a chronic condition
was caused by herbicide exposure and passed from parent to child. We
encourage VA to provide the necessary resources to ensure the highest
quality of life possible for these children of Vietnam veterans.
Additionally, we ``seek legislation to amend title 38, United States
Code, Chapter 18, to provide entitlement to spina bifida benefits for
the child or children of any veteran who was exposed to Agent Orange as
the result of service in the Republic of Vietnam or in other locations
where Agent Orange was tested, sprayed, or stored.''\3\ The American
Legion, as one of the longest standing advocates for veterans exposed
to environmental hazards, will continue the push to ensure that all
those who have been affected and continue to suffer as a result of this
exposure are cared for.
---------------------------------------------------------------------------
\3\ Resolution No. 199: Agent Orange
The American Legion supports this bill.
s. 845, a bill to amend title 38, united states code, to improve the
department of veterans affairs health professionals educational
assistance program, and for other purposes.
To extend Department of Veterans Affairs Health Professional
Scholarship Program until December 31, 2019; To repeal the cap on the
amount of Education Debt Reduction Payments Under Department of
Veterans Affairs Education Debt Reduction Program, and to stipulate
that the maximum amount--the total amount payable to a participant in
the Education Debt Reduction Program for any year may not exceed the
amount of the principal and interest on certain loans paid by the
individual during such year.
The nation is facing an unprecedented health care shortage that
could potentially have a profound impact on the care given to this
Nation's veterans. Shortages in health care staff threaten the Veterans
Health Administration's (VHA's) ability to provide quality care and
treatment to veterans. These shortages also influence VHA's ability to
provide timely access to quality care and, in some instances, its
ability to provide certain types of care.
The American Legion supports comprehensive efforts to establish VA
as a competitive force in attracting and retaining health care
personnel, especially nurses, essential to the mission of VA health
care. The Federal Government estimates that, by 2020, nurse and
physician retirements will create a shortage of about 24,000 physicians
and almost 1 million nurses nationwide. The American Legion strongly
believes that what happens at the Department of Veterans Affairs
Medical Centers (VAMCs) often reflects the general state of affairs
within the health care community as a whole.
The Health Professionals Educational Assistance Program (HPEAP) and
the VA Learning Opportunities Residency are the major education related
programs currently in use to promote nurse recruitment and retention.
HPEAP is comprised of the Employee Incentive Scholarship Program (EISP)
and the Education Debt Reduction Program (EDRP). The EISP authorizes VA
to award scholarships to employees pursuing degrees or training in
health care disciplines for which recruitment and retention of
qualified personnel is difficult. EISP awards cover tuition and related
expenses such as registration, fees, and books. The academic curricula
covered under this initiative include education and training programs
in fields leading to appointments or retention in Title 38 or Hybrid
Title 38 positions. The specific health care professions include:
physician, dentist, podiatrist, pharmacist, licensed practical/
vocational nurse, expanded-function dental auxiliary, registered nurse,
certified registered nurse anesthetist, physician assistant,
optometrist, physical therapist, occupational therapist, certified
respiratory therapy technician, and registered respiratory therapist.
The Education Debt Reduction Program (EDRP) authorizes VA to
provide education debt reduction payments to employees with qualifying
loans who are recently appointed to positions providing direct-patient
care services or services incident to direct-patient care services for
which recruitment and retention of qualified personnel is difficult.
The EDRP has been a powerful recruitment incentive for registered
nurses.
The American Legion is appreciative of the many contributions of
VHA nursing personnel and recognizes their dedication to veterans who
rely on VHA health care. Every effort must be made to recognize, reward
and maximize their contributions to the VHA health care system because
veterans deserve nothing less.
The American Legion supports this bill.
s. 851, caregivers expansion and improvement act of 2013
To amend title 38, United States Code, to extend to all veterans
with a serious service-connected injury eligibility to participate in
the family caregiver services program
Currently under title 38, only veterans who receive a serious
injury (including Traumatic Brain Injury, psychological trauma, or
other mental disorder) incurred or aggravated in the line of duty in
the active military, naval, or air service on or after September 11,
2001 are eligible for the family caregiver benefits. This bill would
amend the law and afford all veterans with a serious injury, as
defined, to be eligible to participate in the family caregivers service
program.
According to The American Legion's Resolution No. 126, Veterans
Receive Same Level of Benefits, passed at National Convention 2012,
``The American Legion urge[s] Congress to direct the Department of
Veterans Affairs to provide the same level of benefits for any veteran,
regardless of the dates or theater of operations during their military
service.'' This legislation would ensure that veterans of every era
receive the benefits they earned through their service. This would
recognize that, for the purpose of receiving care for serious injuries
incurred or aggravated in the line of duty, all service is equal. The
American Legion, as the voice of America's wartime veterans, believes
this is the right thing to do.
The American Legion supports this bill.
s. 852, veterans' health promotion act of 2013
To improve health care furnished by the Department of Veterans
Affairs by increasing access to complementary and alternative medicine
and other approaches to wellness and preventive care, and for other
purposes.
While modern medicine has proven immensely powerful in finding
treatments and cures for a host of health issues, there remain some
areas in which so-called ``alternative'' medicine has proven just as,
and at times perhaps more, effective. The Department of Veterans
Affairs has been exploring Complementary and Alternative Medicine (CAM)
since 2002. While a number of VA medical centers offer some sort of
CAM, it is not currently offered in any uniform manner.
The American Legion developed a Traumatic Brain Injury (TBI) and
Post Traumatic Stress Disorder (PTSD) Ad Hoc Committee in 2010 to look
to ``investigate the existing science and procedures, as well as
alternative methods for treating TBI and PTSD currently being employed
by the DOD and VA.'' The primary treatment of both agencies for TBI and
PTSD were treatment of the symptoms, and in many cases, overuse or
misuse of medications such as Risperidone, an anti-psychotic medication
that had no therapeutic benefit to veterans. The evidence based
treatments defined by DOD/VA's joint clinical practice guidelines are
cognitive processing therapy, prolonged exposure therapy and
antidepressants.
The American Legion's TBI and PTSD Ad Hoc Committee's was concerned
with the lack of research studies on new and innovative treatments such
as Virtual Reality Therapy, Hyperbaric Oxygen Therapy and other
complementary and alternative therapies. To this end, the Committee
worked with the Veterans Affairs and Rehabilitation Commission to adopt
American Legion Resolution No. 108, passed at the 2012 National
Convention that stated that The American Legion recommends ``Congress
and the Administration encourage acceleration in the development and
initiation of needed research on conditions that significantly affect
veterans--such as prostate cancer, addictive disorders, trauma and
wound healing, PTSD, TBI, rehabilitation, and others--jointly with the
Department of Defense, the National Institutes of Health, other Federal
agencies, academic institutions and the Department of Veterans
Affairs.''
Unfortunately, most of the existing research for the last several
years has validated the current evidence-based treatments being used.
In addition, there seems to be no fast-track mechanism to employing
innovative or novel therapies in a standardized way. This legislation
would make important strides toward the implementation of alternative
medicine by requiring VA to establish a minimum of one center of
innovation for complementary and alternative medicine in health
research, education, and clinical activities in each Veterans
Integrated Service Networks (VISN). This legislation would also require
the initiation of a pilot program to assess the feasibility and
advisability of establishing complementary and alternative medicine
centers within VA medical centers in order to promote the use and
integration of complementary and alternative medicine services for
mental health diagnoses and pain management. Finally, this legislation
would require the VA to conduct a comprehensive study of the barriers
encountered by veterans in receiving complementary and alternative
medicine from the Department of Veterans Affairs.
The American Legion believes that all possibilities should be
considered in the attempt to find treatments and cures for these
conditions which affect significant numbers of veterans, including
alternative medicine, if it be shown to be effective, and that these
treatments and cures should be available to all veterans, once they are
verified.
The American Legion supports this bill.
s. xxx, the veterans affairs research transparency act
To require the Secretary of Veterans Affairs to allow public access
to research of the Department, and for other purposes.
The mental health issues facing veterans, particularly with regard
to Traumatic Brain Injury and Post Traumatic Stress Disorder, require
collaboration between the Department of Veterans Affairs (VA), the
Department of Defense (DOD), medical health professionals, The American
Legion and Veteran Service Organizations (VSOs) in order to find cures
and best-practice solutions. Therefore, it makes sense that the
research efforts of VA and DOD should be available to VSOs and others
in order to facilitate the necessary collaboration.
The American Legion believes that the provisions in this bill would
be beneficial by allowing for communication of what the VA and DOD have
accomplished in their research efforts. This would allow The American
Legion, along with other VSOs, and any other interested parties, to
track and analyze the activities associated with the research in order
to understand how the VA and DOD are working to solve issues related to
veterans and servicemembers.
The American Legion's Resolution No. 285 Traumatic Brain Injury and
Post Traumatic Stress Disorder Programs, passed at National Convention
2012, calls for direct collaboration between VA& DOD and the
compilation of research of the two agencies in one location (including
an office). Resolution No. 44 Decentralization of Department of
Veterans Affairs Programs, passed in the Fall of 2012 by the National
Executive Committee of The American Legion, calls for the
decentralization of programs, especially IT, which will allow the VA
Office of Research & Development to improve their IT technology in
order to create the warehouse of research studies. The American Legion
believes that this bill makes strides toward these ends.
The American Legion supports this bill.
______
Prepared Statement of Diane M. Zumatto,
National Legislative Director, AMVETS
introduction
Chairman Sanders, Ranking Member Burr and distinguished members of
the Senate Veterans' Affairs Committee, it is my pleasure, on behalf of
AMVETS, to offer this testimony on pending health care legislation.
I would like to begin today by commending the Committee for all of
its work on behalf of American veterans everywhere, especially its
dedication to improving efficiencies by eliminating redundant and/or
counterproductive programs and its unwavering commitment to all of the
men and women whose job it is to protect and defend this country.
As the United States absorbs the aftereffects of more than a decade
of continuous war and in the face of the planned draw-down of military
personnel, the VA health care system will be severely stressed to
adequately meet the physical and mental health care needs of this
Nation's veterans. Thanks to improvements in battlefield medicine,
swift triage, aeromedical evacuations and trauma surgery, more combat-
wounded than ever before are surviving horrific wounds and will be
needing long-term rehabilitation, life-long specialized medical care,
sophisticated prosthetics, etc. Your committee has a responsibility to
ensure that the VA and our Nation live up to the health care
obligations imposed by the sacrifices of our veterans.
It is encouraging to acknowledge at this time that, despite the
extraordinary sacrifices being asked of our men and women in uniform,
the best and the brightest continue to step forward to answer the call
of our Nation in its time of need. I know that each of you is aware of
and appreciates the numerous issues of importance facing our military
members, veterans, retirees, families, and survivors, therefore this
testimony will be, following these introductory remarks limited to
specific health care legislation.
I would also like to delineate several general issues that AMVETS
would like the Committee to monitor and enforce as it goes about its
work:
ensure that the VA provides a continuity of health care
across all the service branches and for all individuals who were
wounded or injured in the line of duty including those who are ill due
to their service;
ensure that member of our Reserve Components not only have
adequate access, but timely and appropriate treatment, for all of their
physical and mental healthcare needs;
continue to press the VA to work collaboratively with the
DOD in creating and implementing a completely operational and fully
integrated electronic medical records system;
continue the strictest oversight to ensure the safety,
physical and mental health and confidentiality of victims of military
sexual trauma;
ensure that the VA continues to provide competent,
compassionate, high quality health care to all eligible veterans; and
ensure that the VA continues to receive sufficient, timely
and predictable funding for VA health care.
specific health care legislation
S. 131: AMVETS fully supports this legislation which seeks to
improve VA health care options for women veterans to include fertility
counseling and treatment. Thanks to the proliferation of improvised
explosive devices (IEDs) in Iraq and Afghanistan, the issues of
urotrauma and infertility have become a growing concern among active
military personnel and veterans.
IEDs, which are generally detonated on the ground, can cause severe
trauma to the sexual organs and genitourinary system. These
debilitating injuries can have devastating impacts--not only to urinary
and sexual function, but also on fertility. If the issue of infertility
is not adequately addressed for the young men and women, it will be
adding insult to injury. Thanks to the horrific wounds received in
battle on behalf of our country, many servicemembers have entirely lost
or had their reproductive capabilities severely compromised.
This legislation also requires the VA to provide reproductive
counseling and treatment, including the use of assisted reproductive
technology, to a spouse or surrogate of a severely wounded, Ill, or
injured veteran who has an infertility condition incurred or aggravated
in the line of duty. AMVETS believes that this aspect is of critical
importance to the intent of this legislation.
Another important aspect of this bill the requirement to facilitate
research conducted by DOD and HHS with the intent of improving VA's
ability to meet the long-term reproductive health care needs of
veterans who have incurred service-connected uro-trauma or other line
of duty injuries that affect a veterans' ability to reproduce.
AMVETS fully supports all of the provisions of this legislation and
feels strongly that these disabilities are not merely health issues;
they are quality of life issue as well.
S. 325: AMVETS supports this legislation which seeks to amend title
38, United States Code, to increase the maximum age for children
eligible for medical care under the CHAMPVA program. AMVETS sees this
as an equity issue since the expansion of eligibility for CHAMPVA for
eligible children up to age 26 is in line with provisions in both the
Patient Protection and Affordable Care Act (ACA) and the TRICARE Young
Adult benefit.
According to a new GAO Report on the relationship of TRICARE and VA
care to the ACA, ``[the] ACA requires that if a health insurance plan
provides for dependent coverage of children, the plan must continue to
make such coverage available for an adult child until age 26. This
requirement relating to coverage of adult children took effect for the
plan years beginning on or after September 23, 2010. Under ACA, both
married and unmarried children qualify for this coverage. The
authorizing statute for CHAMPVA currently does not conform to this
requirement.''
AMVETS appreciates the concern expressed in this legislation for
the sacrifices of children who have had their lives negatively impacted
by:
the loss of a veteran-parent's mobility;
the battlefield death of a veteran-parent; and/or
the loss of a veteran-parent due to a chronic, service-
connected condition.
S. 852: AMVETS supports this legislation which seeks to improve
health care provided by the VA by increasing access to complementary/
alternative medicine and innovative approaches to wellness/preventative
care. This is a multi-part piece of legislation with several important
and specific requirements including:
the designation and operation of centers of innovation for
complementary/alternative medicine;
a pilot program on the establishment of complementary/
alternative medicine centers within VA medical centers;
a pilot program on the use of wellness programs;
a pilot program on health promotion for overweight/obese
veterans;
a pilot program on health promotion for veterans through
the establishment of VA fitness facilities; and
a study on the barriers veterans face in receiving
complementary/alternative medicine
Considering the stress being put on the VA's traditional clinical
services, AMVETS believes that this legislation, by promoting wellness
and preventative medicine, will both improve timely access to services
and provide cost-effective treatment options for all participants of
the VA's health care system.
AMVETS believes that veterans should be afforded the opportunity to
utilize alternative medical therapies to help ameliorate the effects of
any chronic or residual mental and/or physical distress they may be
experiencing. The term ``alternative therapy'' covers a wide variety of
treatments, which would vastly expand the health care options available
to veterans including:
exercise therapy;
acupuncture;
group experiential activities;
chiropractic therapy; and
other forms of unorthodox medical treatment.
These alternative health care options might provide stand alone or
coordinated treatment options which could not only provide better
results but would be more cost effective too.
______
Prepared Statement of Anthony A. Wallis, Legislative Director/Director
of Government Affairs, The Association of the United States Navy
Regarding Consideration of S. 629, The Honor America's Guard and
Reserve Retirees Act
introduction
Chairmen, Ranking Member and Members of the Senate Veterans'
Affairs Committee, the Association of the United States Navy (AUSN)
would like to thank you and the Committee for the work that you do in
support of our Navy, retirees and Veterans, as well as their families.
Your hard work has allowed significant progress in creating legislation
that has left a positive impact on our military community. AUSN
supports legislation seeking the classification of certain affected
groups of our Navy Reservists as Veterans of the Armed Forces.
the problem
Currently, a problem exists whereby a Reserve Component member can
successfully complete a military career, 20 plus years, but not earn
the title of ``Veteran of the Armed Forces of the United States,''
unless he or she served on Title 10, U.S. Code, Active Duty for other
than training purposes for a period consisting of over 180 consecutive
days of Active Duty service. Drill training, annual training, Active
Duty for training and Title 32 duty are not deemed qualifying service
to qualify for ``Veteran'' status under the current definition. For
instance, the service of our Guard and Reserve members in Operation
Noble Eagle (ONE) would not qualify to earn the status of ``Veterans of
the Armed Forces,'' because it is technically a ``training'' status.
The same goes for those Guard and Reserve members who served in
Southern Border Security missions, as well as those who served in
Hurricane Sandy, Hurricane Katrina and other disaster relief missions.
Reserve Component members in the aforementioned operations have
performed countless tasks that contribute to the overall well-being of
the populace. In addition, the U.S. Navy has orders often written for
``training'' due to funding reasons. However, the fact may be that the
mission could be considered Active Duty, further excluding Navy
Reservists from qualifying under the current definition of ``Veteran.''
Section 101(2) of Title 38, U.S. Code provides the basic definition
of the term ``Veteran'' for purposes of benefits under laws
administered by the Department of Veterans Affairs (VA). The term
``Veteran'' is used repeatedly in Title 38, U.S. Code, to identify an
individual, ``who is eligible for benefits by virtue of his or her
service.'' The Section 101(2) definition establishes a standard
regarding the quality of active service which dictates eligibility for
Veterans' benefits. (www.va.gov/ogc/docs/1991/PREC_61-91.doc)
Many of these affected Reserve Component members, despite never
being called to Title 10, U.S. Code, Active Duty, already receive many
of the same benefits as their full-time counterparts, placing them
within the thinking behind the current definition of ``Veteran.''
However, these affected Reserve Component members, classified as
retirees but not Veterans due to the consecutive service day
parameters, are already eligible for benefits such as TRICARE, GI Bill
benefits and Reserve Retirement Pay. Current Veterans that fulfill the
180 consecutive days are eligible for these same benefits, leaving
these Retirees in `limbo', not knowing if they are classified to be a
Veteran.
According to the Defense Manpower Data Center (DMDC), currently
over 280,000 Reservist Component members and, in particular, nearly
46,000 Navy Reservists across the country could be affected by this
problem.
solution
AUSN applauds the Senate for the introduction of S. 629, the Honor
America's Guard and Reserve Retirees Act, which would rightfully grant
full Veteran status to members of the Reserve Component who have served
at least 20 years but have not been called for the Active Duty
parameters required under the current definition. AUSN was pleased to
see that the bill was introduced earlier this year by Senator Mark
Pryor (D-AR) and is continuing to garner support from a bipartisan list
of cosponsors including Senators John Boozman (R-AR), Mark Begich (D-
AK), Al Franken (D-MN), Chuck Grassley (R-IA), Tom Harkin (D-IA) Tim
Johnson (D-SD), Patrick Leahy (D-VT), Jon Tester (D-MT), and Ron Wyden
(D-OR), Kirsten Gillibrand (D-NY), Jeff Sessions (R-AL), Amy Klobuchar
(D-MN), Mazie Hirono (D-HI) and Mike Crapo (R-ID). S. 629 would
authorize Veteran status under Title 38 for Guard and Reserve members
of the Armed Forces who are entitled to a non-regular retirement under
Chapter 1223 of 10 U.S.C. but were never called to active Federal
service during their careers through no fault of their own. In the
112th Congress, the bill passed through the House in the form of H.R.
1025 by Unanimous Consent. Now, having passed through the House
Veterans' Affairs Committee (HVAC), Subcommittee on Disability
Assistance and Memorial Affairs (DAMA) last month and on its way to
Full Committee consideration, currently in the form of H.R. 679, AUSN
hopes the Senate will approve S. 629 as well.
unwarranted concerns
Critics have suggested that this bill is not needed since these
Reserve Component members already receive many of the same benefits.
Reserve military service opens eligibility to certain benefits provided
the member meets the specific criteria established in law. As
previously noted, Reservists already can qualify for certain Veterans'
benefits, such as educational benefits under Chapter 1606, 10 U.S.C.
for an initial enlistment of 6 years in the Selected Reserve; VA-backed
home mortgage loans upon completion of 6 years' Reserve service;
Servicemembers Group Life Insurance (SGLI) managed by the VA while
serving in the National Guard or Reserve Burial in a national cemetery
if qualified for a Reserve retirement at age 60. Ironically, however,
20+ year career Reservists who have earned specified Veterans' benefits
but never served on Active Duty orders are not ``Veterans of the Armed
Forces.''
Critics have also suggested that expanding the definition of
``Veteran'' to include these Reserve Component members could lead to
bestowing additional benefits they currently do not receive. This
argument is not sound, as Section 2(b) of the bill states stronger
language than similar legislation in previous years with a provision of
``Clarification Regarding Benefits,'' which states ``No person may
receive any benefit under the laws administered by the Secretary of
Veterans Affairs solely by reason [of passage of this act].'' As a
result, the Congressional Budget Office (CBO) has scored this bill at
zero cost. Concerns about Congress passing legislation to bestow
additional benefits as a result of this change in the future would be
even more difficult if S. 629, and H.R. 679, passes as the anti-
benefits language would be codified. Thus, it is in the best interest
of critics to have this bill passed so as to not confer additional
benefits in the future.
All said, there are three main reasons for this legislation. First,
honor. Honor is important to those who have volunteered to serve the
Nation in uniform. Second, for decades Guard and Reserve Component men
and women have performed military missions at home and overseas but
because of accounting technicalities, including funding sources and
duty codes, their military missions were not considered valid active
duty work; i.e., they performed the mission, but the orders did not
credit the work as Active Duty. Thus, their very real contributions to
the national security appear underappreciated, leaving them in a no-
man's land of ``non-Veteran'' status. Third, the bill simply provides
statutory and public recognition that a full career of service in
uniform qualifies a person with recognition as a Veteran. Career
reservists have earned specific military retirement and Veterans'
benefits but technically are excluded from being recognized as Veterans
under the law.
However, if the arguments stated above are not evidence enough,
there is another positive impact that passage would have.
potential economic impact
This zero-cost bill has the potential to help combat high levels of
unemployment among the Reserve Component community, including the
approximately 101,000 Gulf War era Reservist and National Guard
personnel who are currently unemployed in this country. The Reserve
Component currently suffers from rather high unemployment, as stated in
data from a recent House Veterans' Affairs, Subcommittee on Economic
Opportunity hearing on 14 March 2013.
During the hearing, according to Ronald D. Young, Director of
Family and Employer Program and Policy for the Department of Defense,
overall Guard and Reserve unemployment stood at 13.1% for
February 2013. For E-1s and E-4s, according to Young, the unemployment
rate soared to 23%. However, the overall Guard and Reserve figures
following the latest status of force survey, now stand at 11%, with
junior enlisted at 18% compared to the original 23%. Also testifying
was Major General Terry M. Haston, Adjutant General for the Tennessee
National Guard and Major Ty Shepard, Director of the California
National Guard Employment Initiative, who provided state-level
perspectives on Guard and Reserve unemployment. Major General Haston
described returning deployed units as suffering from a 25-30%
unemployment rate, while, Major Shepard noted that units returning from
deployment had even suffered in the past from ``unemployment rates well
over 50%.''
With such high unemployment rates among the Reserve Component one
may conclude that by providing ``Veteran'' status to affected
Reservists, employment opportunities may be available for them to be
hired by employers that actively seek Veterans in the workplace.
summary
In conclusion, S. 629 would not bestow any benefits other than the
honor of claiming Veteran status for those who honorably served and
sacrificed as career Reserve Component members. AUSN believes that our
Reserve Component deserve nothing less. We look forward to hearing of
the progress of this legislation and welcome any questions or concerns
you or your staff may have.
AUSN continues to stand ready to be the Voice for America's
Sailors, abroad and upon their return home, and looks forward to
working with Congress and the VA on serving our Veterans. Thank you.
______
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 68 years. On behalf of
BVA, thank you for this opportunity to submit for the record on the
current legislation before the Committee on VA Health Care Programs.
Chairman Sanders, 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. 633 and S 455 both 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) and authorize local VA personnel to transport
veterans who are unable to use volunteer vans for transportation.
Beneficiary Travel for Blinded Veterans: S. 633
BVA thanks Senator Tester for introducing S. 633 and S. 455. We
also express appreciation to Congresswoman Brownley for H.R. 1284 the
companion House legislation for disabled SCI and blinded veterans who
are currently ineligible for travel benefits. This bill would assist
mostly low-income and catastrophically 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, non-service-connected 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 this financial
assistance analysis 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 very rural regions. In fact,
almost all private blind outpatient agency services such as Lighthouse
for Blind are all located in large urban cities and majority are
established as all outpatient visits again barrier for rural veterans
traveling long distances every day to get training verses VA
rehabilitation centers. With the current economic problems with state
budgets clearly in view, we expect further cuts to these types of state
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 [email protected]
---------------------------------------------------------------------------
Vision loss is a leading cause of falls in the elderly.
One study found that visual field loss was associated with a six-fold
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 and Medicaid
direct costs of $11 Billion per year.\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 VA BRCs and SCIs provide. BVA requests that private agencies
demonstrate peer reviewed quality outcome measurements that are a
standard part of VHA Blind Rehabilitative Service and they must 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).
S. 455, Proposed Program Change in Law:
Current Law or Practice: Under 38 U.S.C. 111A, the Secretary has
the authority to transport any Veteran to or from a VA facility or
other place in connection with vocational rehabilitation, counseling,
or for the purpose of examination, treatment, or medical care. Last
session 112th Congress this Committee passed Public Law 112-260,
section 202 that revised VA's transportation authority's providing VA
the authority to supplement volunteer drivers with VA staff to drive
VTS vehicles which BVA supports. The clarifying authority established
under Public Law 112-260 expires on January 10, 2014 unless Congress
acts though and must be changed.
BVA supports proposed legislation to extend this recently enacted
provision, change Title 38 U.S.C. Sec. 111A that authorized VA to
transport any person to or from a VA facility or other place in
connection with vocational rehabilitation or counseling required by the
Secretary pursuant to chapter 34 or 35 of Title 38, or for the purpose
of examination, treatment, or care. This authority was enacted in
January 2013 under Public Law 112-260, Section 202, of the Dignified
Burial and Other Veterans' Benefits Improvement Act of 2012 and expires
one year after the data of enactment. This proposal would extend the
authority for an additional five years.
VA launched a Veterans Transportation Service (VTS) initiative in
2010 to enhance, support, and organize transportation efforts for
Veterans by VA health care facilities to improve access. Through the
VTS program, VA provided funding to local VA facilities for mobility
managers, transportation coordinators and vehicles to complement the
existing access to care that volunteers already provide. The service
provides Veterans with the ability to be transported to and from their
VA health care appointments. Between October 2011 and May 2012, VTS
transported more than 43,000 Veterans door to door, making more than
50,000 trips that totaled more than 2.1 million miles.
The average length of a trip is almost 60 miles--a considerable
distance in some rural communities, and a prohibitive distance for
those with poor health if transportation was not available. However,
with increasing numbers of transportation-disadvantaged Veterans, there
simply are not enough volunteers in all regions of the country to
sustain the current level of service. Furthermore, volunteer drivers
generally do not transport Veterans who are not ambulatory, require
portable oxygen, have undergone a procedure involving sedation, or have
other clinical issues.
Additionally, some volunteers, for valid reasons, are reluctant to
transport nonambulatory or very ill Veterans. We have had reports of
volunteer drivers not assisting blinded veterans in walking out to find
the vans when parked in various locations, whereas VA employees will
assist the veteran. Section 111A allows VA to supplement volunteer
drivers with VA staff to drive the VTS vehicles for one year and VHA
has stated its full support for this law. Without the proposed
extension, it is possible that VTS will need to be significantly
reduced or curtailed in January 2014, particularly in rural areas of
the country.
S. 325: BVA supports this bill to amend title 38 U.S.C., to
increase the maximum age for children eligible for medical care under
the CHAMPVA program that would allow same coverage mandated in other
current Federal programs. Dependent children who currently turn age 21
have loss of coverage under CHAMPVA and have difficulty finding and
being able to afford health insurance.
S. 522: BVA supports Senator Durbin's bill to require the Secretary
of Veterans Affairs to award grants to establish, or expand upon,
master's degree or doctoral degree programs in orthotics and
prosthetics, and for other purposes. The VA population of disabled
veterans requires more advanced degree specialists in the area of
prosthetics as technological advances are made in these devices. VA
must have the ability to provide support for these orthotics and
prosthetic specialists.
S. 845: BVA supports extension of the Department Veterans Affairs
Health Professional Educational Assistance Program. This program is
valuable as recruiting and retention tool for allied health care
professionals and allows VA to be competitive in assisting employees in
advancing in their college degrees.
S. 851: Chairman of the Senate Veterans' Affairs Committee Bernie
Sanders introduced S. 851, the Caregivers Expansion and Improvement Act
of 2013.
BVA strongly supports this bill as it would expand eligibility for
comprehensive benefits and services to family caregivers of all
veterans who were severely injured in the line of duty while serving in
the Armed Forces. Currently, only family caregivers of veterans
severely injured on or after September 11, 2001, are eligible for these
benefits and services such as: caregiver training; support groups,
counseling and other support services; a monthly stipend; health
coverage through CHAMPVA; respite care; mental health services and
counseling related to the caregiver role and burden. Our
catastrophically disabled service-connected veterans from previous wars
caregivers have sacrificed for decades trying to keep their family
member at home. They should have the same Caregiver support as in the
current law for Post-9/11 veterans.
conclusion
Chairman Sanders and Ranking member Burr, BVA again expresses its
support for these proposed changes to VHA programs listed above and
will limit our submission to those because we have no resolutions on
some of the other bills being considered here today. BVA requests
support for these bills which will ensure that VHA can improve care and
access for disabled veterans. BVA appreciates the opportunity to
provide this statement for the record today.
______
Prepared Statement of Consortium of Academic Health Centers for
Integrative Medicine
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Joy J. Ilem,
Deputy National Legislative Director, Disabled American Veterans
Chairman Sanders, Ranking Member Burr and Members of the Committee:
On behalf of the DAV (Disabled American Veterans) and our 1.2 million
members, all of whom are wounded and injured veterans, I am pleased to
present our views on several of the legislative measures that are of
particular interest to the Committee or to DAV and our members.
s. 49, veterans health equity act of 2011
This measure would require availability of at least one full-
service Department of Veterans Affairs (VA) hospital or comparable
services be provided through contract, in each of the 48 contiguous
states.
Arguments have been made that New Hampshire is the only lower 48
state without a VA full-service medical center and that most ill
veterans in that state routinely must drive or be transported to Boston
for more comprehensive health care services. Members of Congress have
stated they are particularly concerned that the sickest and generally
very elderly veterans with complex and chronic health problems were
subjected to having to first report to the VA's Manchester facility--
which could be up to a three-hour drive--and then continue on for
another hour to the Boston VA Medical Center (VAMC) or other VA
provider sites, in order to receive their care. It was also noted
(during her first term) by Representative Shea-Porter of New Hampshire,
that it may not be fiscally responsible, given the veteran population
of New Hampshire, to force VA to directly provide a full continuum of
hospital services, and that contracting for such services may be a
better option.
Convenient access to comprehensive VA health care services remains
a problem for many of our Nation's sick and disabled veterans. While VA
must contract or use fee-basis arrangements to provide care to some
veterans, it maintains high quality care and cost effectiveness by
providing health services directly within the system. According to VA,
the Manchester VAMC in New Hampshire provides urgent care, mental
health and primary care services, ambulatory surgery, a variety of
specialized clinical services, hospital based home care and inpatient
long-term care. In addition, community-based outpatient clinics (CBOCs)
are located in Somersworth, Tilton, Portsmouth, Littleton and Conway.
In light of the escalating costs of health care in the private
sector, and to its credit, VA has done a remarkable job of providing
high quality care and holding down costs by effectively managing in-
house health programs and services for veterans. However, outside care
coordination is poorly managed by VA. When it must send veterans
outside the system for care, those veterans lose the many safeguards
built into the VA system through its patient safety program, evidence-
based medicine, electronic health records, and bar code medication
administration program (BCMA). The proposal in S. 49 to use broad-based
contracting for necessary hospital services in the New Hampshire area
concerns us because these unique internal VA features noted above
culminate in the highest quality care available, public or private.
Loss of these safeguards, which are generally not available in private
sector health systems, equate to diminished oversight and coordination
of care, and, ultimately, may result in lower quality of care for those
who deserve it most. However, we agree that VA must ensure that the
distance veterans travel, as well as other hardships they face in
gaining access, be considered in VA's policies in determining the
appropriate locations and settings for providing VA health care
services.
In general, current law places limits on VA's ability to contract
for private health care services in instances in which VA facilities
are incapable of providing necessary care to a veteran; when VA
facilities are geographically inaccessible to a veteran for necessary
care; when medical emergency prevents a veteran from receiving care in
a VA facility; to complete an episode of VA care; and for certain
specialty examinations to assist VA in adjudicating disability claims.
VA also has authority to contract for scarce medical specialists in VA
facilities, and to share health resources with community providers.
Beyond these limits and outside certain ongoing rural health
initiatives by VHA, there is no general authority in the law to support
broad-based contracting for the care of populations of veterans,
whether rural or urban.
DAV believes that VA contract care for eligible veterans should be
used judiciously and only in these authorized circumstances so as not
to endanger VA facilities' ability to maintain a full range of
specialized inpatient and outpatient services for all enrolled
veterans. VA must maintain a ``critical mass'' of capital, human, and
technical resources to promote effective, high-quality care for
veterans, especially those with complex health problems such as
blindness, amputations, spinal cord injury, Traumatic Brain Injury or
chronic mental health problems. Putting additional budget pressures on
this specialized system of services without making specific
appropriations available for new VA health care programs would only
exacerbate the problems currently encountered.
Nevertheless, after considerable deliberation, and in good faith to
be responsive to those who have come forward with legislative proposals
such as S. 49, to offer alternatives to VA health care and VA's flawed
fee-basis program, VA has developed and is implementing a new,
nationwide program entitled ``Patient Centered Community Care (PCCC).''
As we understand the concept, VA will be awarding contracts to
intermediary managed-care firms that will, in turn, establish networks
of providers and facilities for referred veterans when VA's internal
resources are not available or are insufficient to meet known needs,
when academic affiliates cannot meet them, and when no preexisting VA-
contracted provider can provide for that need. We are optimistic that
the principles of our recommendations from the ``Contract Care
Coordination'' section of the FY 2014 Independent Budget will be used
to guide VA's approaches in this new effort. We support the requirement
that firms that are awarded these PCCC contracts must agree to meet a
number of VA's standards for quality, safety, data security, records
management, etc.
VA must work to improve access for veterans that are challenged by
long commutes and other obstacles in getting reasonable access to a
full continuum of health care services at VA facilities and explore
practical solutions when developing policies in determining the
appropriate location and setting for providing VA health care services.
We believe that the PCCC initiative may offer a practical resolution to
this longstanding dilemma.
s. 62, check the box for homeless veterans act of 2013
S. 62 would amend the Internal Revenue Code of 1986 to allow
taxpayers at the time of filing the tax return to designate any
overpayment of taxes not less than $1.00, as well as make additional
contributions to the Homeless Veterans Assistance Fund. It also notes
that the Secretary could designate another time other than at the
filing of a tax return to make a contribution to the fund. This
addition to the Internal Revenue Code would also be coupled with the
creation of a trust fund to become known as the Homeless Veterans
Assistance fund which would use contributions to develop and implement
new and innovative strategies to prevent and end veteran homelessness
as well as toward implementation of current homeless programs in the
Department of Veterans Affairs, the Department of Labor Veterans'
Employment and Training Service, and the Department of Housing and
Urban Development. These Departments will also include a description of
the use of the funds from the previous fiscal year, beginning with FY
2014, in the President's annual budget submission.
DAV Resolution 234 urges Congress to sustain sufficient funding to
support VA's initiative to eliminate homelessness among veterans and
strengthen the capacity of the VA Homeless Veterans Program, to
include: increasing its mental health and substance-use disorder
programs capacity, provide vision and dental care services to homeless
veterans as required by law, and improve its outreach efforts to help
ensure homeless veterans gain access to VA's specialized health and
benefits programs. Additionally, we urge Congress to continue to
authorize and appropriate funds for competitive grants to community-
based and public organizations including the Department of Housing and
Urban Development to provide health and supportive services to homeless
veterans placed in permanent housing.
Although this bill would provide additional funding to support VA's
Homeless Program and initiatives to prevent and end veterans'
homelessness DAV has no specific resolution from our membership related
to this funding being provided on a voluntary basis from the American
public. Therefore, we take no position on this bill.
s. 131, women veterans and other health care improvements act of 2013
Sections 2 through 8 of the bill would require VA to provide
fertility counseling and treatment for spouses or surrogates of
severely wounded, ill, or injured veterans (enrolled in the VA health
care system) who have infertility conditions incurred or intensified in
the line of duty. In addition to fertility counseling and treatment,
adoption assistance may be provided for covered veterans. The Secretary
of Veterans Affairs would be required to prescribe regulations on the
furnishing of fertility treatment to veterans and annually report to
the Committee on Veterans' Affairs of the Senate and House of
Representatives on such treatment provided to veterans.
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
conceive. The Secretary would ensure that any information produced by
the research deemed useful for other activities of the VHA be
disseminated throughout the VHA and report to Congress on the research
activities conducted within three years after the date of 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 injury or condition that
affects the veteran's ability to conceive. For these reasons, DAV has
no objection to the passage of these sections of the bill.
Section 9 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. Since introduction of this measure, VA has launched a new hotline,
1-855-VA-WOMEN, to receive and respond to questions from veterans,
their families and caregivers about VA resources available to women
veterans. We are pleased that VA has added this service, similar to the
provisions proposed in this section of the bill, and is making progress
to better communicate and inform women veterans of their benefits,
specialized services and health care options. We recommend VA provide
periodic updates to the Committee and veterans service organizations
related to the number of women veterans calling the hotline and the
types of requests for information received to assess its effectiveness.
Sections 10 and 11 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. The bill also directs the Secretary to carry out a pilot program
of providing child care assistance to veterans receiving or in need of
VA readjustment counseling and related mental health services or other
intensive health care services in at least three Veterans Integrated
Service Networks and in no fewer than three Readjustment Counseling
Service Regions.
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.
Section 12 of the bill directs the Secretary to impose a contractor
user fee for each contract entered into by the VA for goods or services
as a term of the contract. The fee amount is to equal 7 percent of the
total value of the contract and authorizes the Secretary to waive the
fee if the contractor is an individual or a small business. This bill
would also establish a VA Fertility Counseling and Treatment Fund in
the Department of the Treasury and all funds received as a result of
the contractor user fee imposed by this section would be deposited into
the Fund.
We support the Committee's continued efforts on improving VA's
women veterans health programs and services and are pleased to support
this bill in keeping with DAV Resolution 213. DAV has heard positive
feedback related to the pilot program of counseling women veterans
newly separated from active duty in retreat settings and the child care
pilots established by Public Law 111-163 and look forward to a full and
comprehensive report from VA on these initiatives. We supported the
original provisions for these pilot programs and are pleased to support
the proposal to expand them.
s. 229, corporal michael j. crescenz act of 2013
S. 229 would designate the Department of Veterans Affairs medical
center located at 3900 Woodland Avenue in Philadelphia, Pennsylvania,
as the ``Corporal Michael J. Crescenz Department of Veterans Affairs
Medical Center.'' DAV has no national resolution on this issue and has
no national position on this bill; however, we leave the decision up to
the local DAV leadership in Pennsylvania.
s. 287, 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
This bill seeks to amend Section 2002(1) of title 38, United States
Code, by striking `in section 103(a) of the McKinney-Vento Homeless
Assistance Act (42 U.S.C. 11302(a))' and inserting `in subsection (a)
or (b) of section 103 of the McKinney-Vento Homeless Assistance Act (42
U.S.C. 11302)'. This change would expand the definition of a homeless
veteran by including veterans who are fleeing, or 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.
Currently, in order to qualify for assistance under the homeless
veteran programs governed by title 38 of the U.S. Code, veterans must
meet the definition of ``homeless veteran.'' This term may appear
straightforward but it has two layers, the first of which is the
definition of ``veteran'' which for purposes of title 38 benefits is a
person who ``served in the active military, naval or air service who
was not dishonorably discharged.'' The second layer is that veterans
are considered homeless if they meet the definition of a ``homeless
individual'' codified as part of the McKinney-Vento Homeless Act (P.L.
100-77) which was signed into law in 1987. Until recently a ``homeless
individual'' was: 1) a person who lacks a fixed, regular and adequate
nighttime residence; 2) who has a nighttime residence that is a
supervised publicly or privately operated shelter designed to provide
temporary housing; an institution that provides a temporary residents
for individuals intended to be institutionalized; and 3) who utilizes a
public or private place not designed for regular sleeping accommodation
for human beings.
In December 2011, as a result of the HEARTH Act passed in the 111th
Congress that expanded the definition of ``homeless individual,'' HUD
issued regulations regarding the new definition that took effect on
January 4, 2012. This definition moves away from the requirement for
literal homelessness and added three new categories: 1) imminent loss
of housing; 2) the addition of unaccompanied youth and homeless
families with children who have experienced a long-term period without
living independently in permanent housing, and 3) a person who has had
frequent moves and can be expected to continue in unstable housing due
to a number of chronic health factors. Another Federal change to the
definition of a homeless individual is, ``a person fleeing a situation
of domestic violence or other life-threatening condition,'' but until
title 38 is changed to include the subsection of the McKinney-Vento
Act, this definition is not part of the definition of a homeless
veteran, and while DAV does not have a national resolution specific to
defining a homeless veteran, defining a homeless veteran to match the
national standard is fair and we do not oppose passage of this bill.
s. 325, a bill to amend title 38, united states code, to increase the
maximum age for children eligible for medical care under the champva
program
This measure would address a needed adjustment to current
eligibility requirements for adult children who receive health care
through age 18 (or age 23 if in school) under the Civilian Health and
Medical Program of the Department of Veterans Affairs (CHAMPVA).
Established in 1973, CHAMPVA provides cost reimbursement for
private health care services provided to dependents, survivors, and
some primary caregivers, of certain disabled veterans. CHAMPVA
enrollment has grown steadily over the years and, and as of fiscal year
2011, CHAMPVA covers approximately 355,000 beneficiaries.
Under current law, a dependent child loses eligibility for CHAMPVA
upon turning 18 years of age, unless the person is enrolled in school
on a continuing and full time basis. Under current law, a dependent
child loses eligibility for CHAMPVA upon turning 18 years of age,
unless that individual is enrolled in school on a continuing and full
time basis, up to age 23. If full-time school attendance is
discontinued, or upon attaining the age of 23 years, the individual
loses eligibility.
With the passage of the Patient Protection and Affordable Care Act
(PPACA), Public Law 111-148 (as amended by the Health Care and
Education Reconciliation Act of 2010, Public Law 111-152), DAV on
behalf of numerous service-connected veterans and their families has
expressed concern regarding these individuals' health care coverage. We
rest our position on the precedent that PPACA extends health insurance
coverage to dependent children until age 26, except for those in the
CHAMPVA program, and we believe the omission of these CHAMPVA
beneficiaries was inadvertent but inequitable.
In accordance with DAV Resolution No. 222, we fully support
enactment of this bill that would ensure CHAMPVA recipients, without
regard to their student status, remain eligible for health care
coverage under their parents' plans in the same manner as for adult
children of the vast majority covered under PPACA.
s. 412, a bill to authorize major medical facility leases for
the department of veterans affairs
If enacted, this bill would authorize (and in three cases,
reauthorize) VA to carry out leases for community-based outpatient
clinics in 15 locations in 12 states, and one in Puerto Rico.
DAV has not received a national resolution from our membership on
the specific topic of VA facility leases, but we would not object to
passage of this bill.
It is important to note for the record that the authorizing statute
requires VA to obtain Congressional approval for a commercial lease of
a future VA medical facility if the estimated first-year lease cost
exceeds $1 million. This policy has been in place for decades. Hundreds
of leases for VA-operated community-based outpatient clinics have been
approved by Congress and executed by VA under this procedure. Using a
leasing authority rather than constructing VA-owned facilities allows
VA to quickly establish convenient primary care facilities for veterans
in communities where they live. Veterans who use these community
clinics report high satisfaction with their care and the convenience
they offer. Employing leased facilities is a cost-effective method of
providing high quality VA primary care.
In 2012, in evaluating a similar bill for these 15 proposed VA
leases that each exceed the $1 million threshold, the Congressional
Budget Office (CBO) concluded that Congressional rules require that
funds to offset the entire 20-year prospective lease cost would need to
be included either in the VA budget, or would be taken from funding of
ongoing veterans programs--all in the first year of each lease. CBO
indicated this policy also would apply in the future to renewals of
existing VA leases that exceed the threshold cost. This CBO decision
multiplied VA's costs for these proposed 15 leases 20-fold, for a total
need of $1.2-$1.5 billion in fiscal year (FY) 2013 funds. Since funds
of this magnitude could not be diverted from other VA accounts for this
surprising new requirement and were not covered in the budget request
that had been submitted to Congress, these 15 leases were dropped from
further Congressional consideration last year only to return once
again.
In VA's current planning, including these 15 clinics for
California, Connecticut, Florida, Georgia, Hawaii, Kansas, Louisiana (2
sites), Massachusetts, New Jersey, New Mexico, Puerto Rico, Texas (2
sites), and South Carolina, VA projects a need to lease or renew
existing leases for 38 community-based health care facilities through
FY 2017 to provide care for more than 340,000 veterans across 22 states
and US territories.
Unless CBO changes its policy or Congress acts to overturn this CBO
decision with legislation or makes a change in House Rules in current
funding policy, most if not all these leases remain in jeopardy.
Veterans consequently will be denied convenient VA health care.
Absent a change VA may be forced to buy land and construct
government-owned clinics, or more likely will require veterans who need
VA care to travel longer distances to receive it. VA-built clinics
would be more expensive, would take much longer to activate, and would
reduce VA's flexibility to place and move facilities based on the
changing needs of the veteran population. Forcing veterans to travel
for care would increase inconvenience and add additional costs.
We ask the Committee to take action in consideration of this
dilemma to ensure the leases that would be authorized in this bill, and
future leases, can be accommodated in the budget process without VA's
having to reserve or offset billions of dollars from other VA programs
in order for them to be authorized.
s. 422, chiropractic care available to all veterans act of 2013
S. 422 would accelerate the expansion of chiropractic care by
requiring VA to provide chiropractic care and services at no fewer than
75 medical centers by December 31, 2014, and at all VA medical centers
by December 31, 2016.
The National Institute of Health's National Center for
Complementary and Alternative Medicine (NCCAM) cites spinal
manipulation as one of several options--including exercise, massage,
and physical therapy--that can provide mild-to-moderate relief from
low-back pain.
VA was authorized to offer chiropractic care and services under the
provisions of section 204 of Public Law 107-135, the Department of
Veterans Affairs Health Care Programs Enhancement Act of 2001. By
January 2011, 43 VA facilities directly provided chiropractic care and
by January 2012, 45 VA facilities were providing on-site chiropractic
care. The Department of Defense also offers chiropractic care at 60
military treatment facilities including the Walter Reed National
Military Medical Center.
Progress toward providing chiropractic care at each VA medical
center is contingent on discretionary decisions made locally. Many
facilities have decided that eligible veterans can receive chiropractic
care through VA's outpatient fee-basis program (based only on referrals
by primary care providers, with advance authorization). Directly
providing chiropractic care would provide more practical access
compared to the eligibility criteria for fee-basis care, which
generally restricts access to a limited number of veterans. Our
interpretation of the law is that chiropractic care through fee-basis
may only be provided to a smaller subset of enrolled veterans,\1\ and
this result conflicts with Section 204(b) of Public Law 107-135, which
states, ``veterans eligible to receive chiropractic care and services
under the program are veterans who are enrolled in the system of
patient enrollment under Section 1705 of title 38, United States
Code.''
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\1\ 38 U.S.C. 1703, and 38 C.F.R. 17.52-17.56.
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Therefore, in conjunction with DAV Resolution No. 217, adopted by
the delegates to DAV's most recent national convention, calling for
more complementary and alternative medicine (CAM) programs in VA
facilities for the care of veterans, DAV supports enactment of this
bill that will bring additional and non-traditional care options to
veterans enrolled in VA health care.
s. 455, a bill to amend title 38, united states code, to authorize the
secretary of veterans affairs to transport individuals to and from
facilities of the department of veterans affairs in connection with
rehabilitation, counseling, examination, treatment, and care
This bill would provide VA a renewed authority to transport
individuals in connection with their vocational rehabilitation,
counseling, examination, treatment, or care, and would specifically
vitiate a prior act of Congress that eliminated an important
transportation program after only one year of life.
Notably, VA has implemented the provisions of Section 202 of Public
Law 112-260, the Dignified Burial and Other Veterans' Benefits
Improvement Act of 2012, except for eliminating the authority granted
under Section 111A of title 38, United States Code, to create a VA-
operated transportation program one year after enactment. That act had
prompted VA to initiate the Veterans Transportation Service (VTS),
supported by the Veterans Health Administration (VHA) Chief Business
Office (CBO). The VTS was established to provide veterans with
convenient and timely access to transportation services and to overcome
access barriers certain veterans may have experienced, and in
particular to increase transportation options for veterans who need
specialized forms of transportation to VA facilities. The VTS
transportation services to VA medical centers include the use of
technology and mobility management training for medical center staff
that in turn enable VTS services to better interface with other
community transportation resources.
VA medical centers and sites where VTS is operating can be ideal
partners with the DAV National Transportation Network and for the
Veterans Transportation and Community Living Initiative grant projects
establishing One-Call/One-Click Transportation Resource Centers. Based
on our review of this situation, were it not for the expiration of
statutory authority from Public Law 112-260, VTS would have grown from
its current 45 sites to all remaining VA locations by 2015.
The DAV National Transportation Network continues to show
tremendous growth as an indispensable resource for veterans. Across the
Nation, DAV Hospital Service Coordinators operate 200 active programs.
They have recruited 9,249 volunteer drivers who logged over 27 million
miles last year, providing almost 721,000 rides for veterans to and
from VA health care facilities. These veterans rode in vans DAV
purchased and donated to VA health care facilities for use in the DAV
National Transportation Network. DAV Departments and Chapters, together
with our national organization, have now donated 2,586 vans to VA
health care centers nationwide at a cost to DAV of $56.7 million.
DAV believes VTS serves the transportation needs of a special
subset of the veteran patient population that the DAV National
Transportation Network is unable to serve--veterans in need of special
modes of transportation due to certain severe disabilities. We believe
that with a truly collaborative relationship, the DAV National
Transportation Network and VTS will meet the growing transportation
needs of ill and injured veterans in a cost-effective manner.
Currently, DAV supports enactment of this bill; however, our
support is based on the progress gained through our collaborative
working relationship with VHA and CBO to resolve weaknesses we have
observed in the VTS program. As you may be aware, VTS operates with
resources that would otherwise go to direct medical care and services
for veterans. These resources should be used carefully for all
extraneous programs to ensure veterans are not denied care when they
most need it.
We thank VHA and CBO for their commitment and efforts in working
with DAV to ensure VTS will indeed work in concert with all existing
and emerging transportation resources for veterans who need VA care,
and to guard against fraud, waste and abuse of these limited resources.
We look forward to continuing our work with the Committee on this
measure, and to work for its passage.
s. 522, the wounded warrior workforce enhancement act
This bill would establish two VA grant programs, one to be made to
educational institutions to establish or enhance orthotic and
prosthetic masters and doctoral education programs, with an
appropriations limitation of $15 million; and the other to establish a
private ``center of excellence in orthotic and prosthetic education,''
with an appropriations limitation of $5 million.
DAV has no resolution from our membership that would support the
establishment of these specific activities. Nevertheless, prosthetic
and orthotic aids and services are important to injured and wounded
veterans, and constitute a specialized medical program within the VA.
Nevertheless, absent a defined shortage of individuals who possess
related skills and knowledge in these fields, justification for
enactment of this bill seems questionable. Also, assuming the grant
programs take form, graduating students who benefited from them would
not be required to provide obligated employment within VA to repay the
government's investment in their education such as is required in VA's
existing health professional scholarship programs under Chapters 75 and
76 of title 38, United States Code. We believe consideration of that
existing and highly successful mandate be considered in adopting the
concept embedded in this bill, to ensure that VA regains at least some
of the value of the work of these students following their VA-
subsidized education and training. Finally, assuming the establishment
of a center of excellence in this particular field is warranted, DAV
questions whether the center should be outside VA, rather than become a
new VA in-house center of excellence along the lines of those centers
already established in law in Chapter 73 of title 38. We ask that the
sponsor of this bill reconsider the proposal in light of our testimony.
s. 529, to amend title 38, united states code, to modify the
commencement date of the period of service at camp lejeune, north
carolina, for eligibility for hospital care and medical services in
connection with exposure to contaminated water.
This bill would expand the number of eligible persons to the
benefits extended to certain persons by Public Law 112-154, the
Honoring America's Veterans and Caring for Camp Lejeune Families Act of
2012. This proposed expansion will add tens of thousands of new
individuals to the estimated 750,000 currently eligible.
DAV has no resolution specific to this issue, but we remain
concerned that the burden of care for this population rests with VA
through its CHAMPVA program rather than with the military TRICARE
program. Adding more eligible persons as proposed will only make VA's
burden of care more challenging.
s. 543, the visn reorganization act of 2013
This bill would consolidate VA's current 21 Veterans Integrated
Service Networks (VISNs) into 12 prescribed new units with similar
responsibilities but significantly smaller staffs than at present.
Excess staffs would be integrated into subordinate VA medical
facilities or be provided other reemployment assistance. Also, in
making this consolidated restructuring, the bill would require VA to
collaborate with other Federal offices, state and local offices, with
VA affiliates and certain private and voluntary organizations within
each of the 12 new geographical areas. The bill would establish no more
than four regional support centers that would provide certain
administrative and analytic functions dealing with effectiveness and
efficiency of the VISNs. Finally, the bill would require several
reports associated with the proposed consolidations.
DAV has not received a national resolution from our membership on
this specific issue, but we wish to bring a number of concerns to the
attention of the sponsor, and of the Committee as it considers this
bill.
VA's adoption of VISNs as a regional health care organization was
derived from the geographic service area concept of the 1991 VA
Commission on the Future Structure of Veterans Health Care, a Federal
advisory commission chartered by then-VA Secretary Edward J. Derwinski
to make recommendations for organizational, structural, quality, safety
and cultural improvement in VA health care, among other aims. VA
considered the Commission's recommendations for three years before
implementing this one as a part of VHA's 1995 administrative
reorganization. Initially, 22 VISNs were established but two of them--
the smallest in terms of patient workload, staff and funding--were not
independently viable and were soon consolidated, so that today 21
networks remain, covering the continental US, Hawaii, Puerto Rico and
US possessions.
DAV supported the VA's decision to restructure the VA health care
system, the principle benefit of it being a regionalization of health
care delivery, coordination of leadership and decentralization of
decisionmaking with a corresponding reduction of VA Central Office's
involvement in local health care management matters. Like Congress at
the time, we believed that health care decisions were best left to
local VA facility managers and clinicians, while VA Central Office
should focus on national strategy and policies, program development,
practices and standards-setting. The idea was simple: policy is set at
the top; implementation occurs at the local level.
Testimony before this Committee in the last year suggested VA
facility managers are ``gaming the system'' to meet goal numbers
established by the VISNs, rather than providing needed care to veterans
as provided for by law. Potential gaming is also one of our concerns.
We receive much anecdotal information from our members and VA employees
that is consistent with such allegations--although these troubling
reports are difficult to prove in any systematic way. The House
Veterans' Affairs Committee's 2012 oversight hearing on chronic
problems at the Miami VA Medical Center was illustrative of how such
challenges can fester undetected because of lack of adequate public
reporting and the general unavailability of documentary data.
A second concern is the number of staff assigned to the VISNs. When
the networks were formed, VA asserted that they would be staffed by
network directors with small cadres of staff. Management functions that
exceeded this staff's ability to perform them were to be accomplished
by working groups composed of VAMC staffs on temporary assignments.
Over the past 15 years, however, the network offices grew dramatically,
and morphed into 21 permanent mini-central offices, staffed with full-
time professional staffs focused on operations, clinical care, human
resources, quality, safety, internal and external review, media, press,
public affairs, budget, academic affairs, and numerous other functions.
Perhaps the most worrisome concern with the VISN organization has
been the enormous administrative overhead that is being incurred by
these seemingly bloated numbers of staff. We believe thousands of VA
permanent, full-time staff may now be assigned to VISN offices (but
until recently exact numbers were elusive due to lack of publicly
available information). Within VA these network positions are popular
because they represent opportunity for career mobility, professional
advancement, and promotion of local VA employees. We believe a large
number are clinicians who in their network assignments no longer
provide clinical care to veterans. While we believe that clinical
leadership is a strength of VA health care, we believe that the size
and complexity of the current VISNs depart from the recommendations of
the Commission's report, and from the original vision of those who
implemented the geographic service area recommendation. Not only are
clinical staff members being taken away from frontline positions but
also valuable technical and administrative staff have been drained from
medical centers to VISN offices.
Many of the additional positions were VACO-mandated to respond to
the ``crisis of the day'' phenomena. Instead of developing thoughtful
solutions for recognized problems, previous Administrations simply
added new mandatory positions, functions or new offices.
Our third concern with the networks deals with the geographical
boundaries of VISNs. With the exception of the one major consolidation
change mentioned above, no adjustment of VISN boundaries has occurred
in the 15-plus years of the life of this organizational model. The
original VISN geographic boundaries were drawn based on VA patient-
referral patterns and delivery systems from well over twenty years ago;
these may well have changed. Also, some historical anomalies of the
VISN map seem to cry out for review, for example, the small state of
West Virginia remains subdivided into parts of four VISNs; the western
Panhandle of Florida is part of the eight-state VISN 16, while the
remainder of the large state of Florida is in VISN 8. We see other
examples in the current VISN map that raise questions as well.
Another concern is the allocation of appropriated medical care
funds below the level of the network offices. VA's Veterans Equitable
Resource Allocation system is a risk-adjusted capitation model that
allocates Congressional appropriations to the networks rather than the
facilities. Theoretically, this model enables regional coordination and
funding of highly specialized, scarce medical resources, while the
facilities remain the major delivery systems and serve as VHA's basic
building blocks to formulate VHA's annual budget request. VHA's
appropriations have grown dramatically over the past several years--yet
VA facilities often indicate to us that they are significantly
underfunded and must ration spending for numerous categorical needs
across the operating year. We believe the resource allocation model or
the systems being employed by the VISN offices to allocate resources to
the VAMCs might need scrutiny and possibly re-balancing for their
effects on local operations.
Less than one month ago, the VA announced its intention to
dramatically reduce VISN offices' core staffing, limiting it to between
55-65 persons on average for each of the 21 offices, depending on size
and complexity. VA has not provided DAV information about disposition
of the staff affected by the new organizational model. We reserve
judgment on whether the new staffing pattern changes any of our
expressed concerns.
With these thoughts in mind, rather than advancing this bill now,
we would recommend the Committee commission an independent, outside
review of the VA network concept, subsequent implementation and current
status of VA's new plan, with recommended changes that may be warranted
by review findings. We believe the time has come for a critical review
of the organization, functions, operations, and budgeting process at
the VISN and VAMC levels. We recommend the review be conducted by the
Institute of Medicine (IOM) rather than by VA or a private contractor.
Involving the IOM would ensure a thoroughgoing, apolitical and unbiased
review. In addition to examining the current referral patterns, the
analysis should account for future demand, changes in veteran and
family expectations, and the changing trends in health care delivery.
Also, we would recommend that the IOM's review and analysis be
comprehensive to include a review of the VHA Central Office
organization. This evaluation should address a value-based analysis of
those programs that are optimally managed and funded at a national,
VISN or VAMC service level.
While the IOM's report should be made to the Committee, VA should
be permitted to comment on the report. We would also recommend the
Committee hold hearings on the results of this review to include
testimony from IOM, VA, this community and other interested parties.
The IOM reviewers should be carefully instructed as to the goals of the
study, which we believe should focus on ways to improve health care
quality, safety, satisfaction, consistency and access. The study should
focus on delivery of comprehensive, patient-centered care to today's
veterans that builds on the obvious progress VA has made over the past
17 years. The IOM's work on this project should be closely monitored by
the Committee as the process occurs to ensure your goals, and those of
this bill's sponsor, are met.
s. 633, to amend title 38, united states code, to provide for coverage
under the beneficiary travel program of the department of veterans
affairs of certain disabled veterans for travel in connection with
certain special disabilities rehabilitation
This bill would amend the VA beneficiary travel statute to ensure
beneficiary travel eligibility for travel expenses in connection with
medical examination, treatment, or care on an inpatient basis, and
while a veteran is being provided temporary lodging at VA medical
centers. Veterans eligible for this benefit would be restricted to
those with vision impairments, spinal cord injury or disorder, and
those with double or multiple amputations whose travel is in connection
with care provided through a VA special disabilities rehabilitation
program.
Currently, VA is authorized to pay the actual necessary expenses of
travel (including lodging and subsistence), or in lieu thereof to pay
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 service-connected ratings of 30 percent or
more; those receiving treatment for service-connected conditions;
veterans in receipt of VA pensions; those whose incomes do not exceed
the maximum annual VA pension rate, or; veterans traveling for
scheduled compensation or pension examinations.
DAV has no resolution on this specific issue and thus takes no
position on this bill. However, we would note that while the intended
recipients of this expanded eligibility criteria would certainly
benefit from it, we would urge the Committee to consider a more
equitable approach rather than one based on the specific impairments of
disabled veterans. Further, we ask that if the Committee does favorably
consider this measure, it also take appropriate action to ensure that
sufficient additional funding be provided to VA to cover the cost of
the expanded program.
s. 800, the treto garza far south texas veterans inpatient care act of
2013
This bill would require VA to establish an inpatient bed service
for veterans at its Harlingen, Texas facility. DAV has no national
resolution on this issue and has no national position on this bill;
however, we leave the decision up to the local DAV leadership in Texas.
s. 825, the homeless veterans prevention act of 2013
S. 825, the Homeless Veterans Prevention Act of 2013, is a
comprehensive bill that focuses on improving services for homeless
veterans.
Section 2 of the bill requires that recipients of VA grants for
comprehensive service programs for homeless veterans meet physical
privacy, safety, and security needs of such veterans.
Sections 3 and 4 authorize increased per diem payments for
transitional housing assistance that becomes permanent housing for
homeless veterans. Also, the section would authorize per diem payments
for furnishing care for a dependent of a homeless veteran while the
veteran receives services from a grant recipient.
Section 5 requires the VA to assess and measure the capacity of
service programs for homeless veterans for which entities receive
grants under section 2011 of title 38, United States Code, or per diem
payments under sections 2012 or 2061 of the same title. The Secretary
would be required to develop and use tools to examine whether
sufficient capacity exists to meet the needs of the population of
homeless veterans in each geographic area, and to determine the
capacity of services that grant and per diem recipients provide. The
information that the Secretary collects would be used to set goals to
ensure that the grant and per diem homeless programs are effectively
serving the needs of homeless veterans, to improve the homeless veteran
referral process, to assess if the programs are meeting goals, and to
inform future funding allocations. The Secretary would be required to
submit a report to the Committee on Veterans' Affairs of the Senate and
House of Representatives no later than 180 days after the completion of
the assessment.
Section 6 would repeal the requirement for annual reports on
assistance to homeless veterans. Section 7 would make permanent the
authority in section 2033, title 38, United States Code, for VA to
carry out a program of referral and counseling services for veterans at
risk for homelessness who are tramsuitionMing from certain
institutions.
Section 8 authorizes the Secretary to partner with public and
private entities to provide legal services in an equitably distributed
geographic area to include rural areas and tribal lands, to homeless
veterans and veterans at risk of homelessness subject to availability
of funding. The legal services provided would be related to housing,
including eviction defense and landlord-tenant cases; family law,
including assistance with court proceedings for child support, divorce
and estate planning; income support, including assistance in obtaining
public benefits; criminal defense, including outstanding warrants,
fines and driver's license revocation, and to reduce the recidivism
rate while overcoming reentry obstacles in employment or housing. The
Secretary may require entities that have partnered with VA and provided
legal services to homeless veterans to submit periodic reports.
Section 9 expands the authority of VA to provide dental care to
eligible homeless veterans who are enrolled for care, and who are
receiving assistance under section 8(o) of the United States Housing
Act of 1937 (42 U.S.C. 17 1437f(o)) for a period of 60 consecutive
days; or receiving care (directly or by contract) in 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 10 of this measure extends the sunset dates affecting
homeless veterans for the following programs in title 38, United States
Code:
Comprehensive Service programs
Homeless veterans reintegration programs
Treatment and rehabilitation for seriously mentally ill
and homeless veterans
Centers for the provision of comprehensive services 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
Technical assistance grants for non-profit community-based
groups; and
The Advisory Committee on Homeless Veterans
DAV is pleased to support S. 825, the Homeless Veterans Prevention
Act of 2013, in conjunction with DAV Resolution No. 234, which calls
for us to support sustained and sufficient funding for the VA's
initiative to eliminate homelessness among veterans and improve its
existing supportive programs. This resolution also urges Congress to
strengthen the capacity of VA's programs to end homelessness among
veterans by increasing capacity for health care, specialized services
for mental health, substance-use disorders as well as vision and dental
care.
s. 832, improving the lives of children with spina bifida act of 2013
This bill would require VA to carry out pilot programs to furnish
case management and assisted living services to children of Vietnam
veterans and certain Korea service veterans who were born with spina
bifida, and children of women Vietnam veterans who have certain birth
defects, and for other purposes.
There are approximately 1,200 enrollees in VA's Spina Bifida Health
Care Program (SBHCP). The SBHCP is administered for those biological
children diagnosed with spina bifida of veterans who served in Vietnam,
and of veterans who served in Korea during the period September 1,
1967, through August 31, 1971.\2\ The program provides reimbursement
for comprehensive medical care for those beneficiaries diagnosed with
spina bifida, except for conditions associated with spina bifida
occulta.
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\2\ 38 U.S.C. 1803; 1821.
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Approximately 15 individuals are enrolled in the Children of Women
Vietnam Veterans Health Care Program (CWVV). Under this program, VA
reimburses for care related to conditions associated with certain birth
defects except spina bifida, which is covered under the VA's Spina
Bifida Program identified by the VA as resulting in permanent physical
or mental disability of the biological child of a woman veteran who
served in Vietnam between February 28, 1961, and May 7, 1975.\3\
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\3\ 38 U.S.C. 1811; 1812; 1813.
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We note that children suffering from associated with certain birth
defects are now dependent adults. Furthermore, Vietnam veterans who
care for dependent adult children are also aging and in all likelihood
are contending with their own health care needs.
Although DAV has no specific resolution regarding this proposal,
DAV would not oppose passage of this legislation since SBHCP and CWVV
are currently provided to children of veterans exposed to Agent Orange
during service in the Republic of Vietnam and would greatly assist
Vietnam veterans.
s. 845, to amend title 38, united states code, to improve the
department of veterans affairs health professionals educational
assistance program, and for other purposes.
This bill would extend for five years VA's existing health
professionals scholarship program, and would place a limitation on the
annual amount of VA-paid educational debt reduction not to exceed
actual amounts paid by eligible employees.
DAV has no resolution from our membership on these specific issues,
but we would not object to enactment of this bill.
s. 851, caregivers expansion and improvement act of 2013
S. 851 would to extend eligibility to all veterans with a serious
service-connected injury for the comprehensive caregiver support and
services program under Section 1720G of title 38, United States Code.
For generations, wives, husbands, parents and other family members
have taken the role of caregivers of veterans who were seriously ill or
injured while serving. Family caregiving is a complex role that bridges
both quality of care and quality of life of disabled veterans.
Caregivers play a critical role in facilitating recovery and
maintaining veterans' independence and quality of life while residing
in the community, and are an important component in the delivery of
health care by the VA. The critical care they provide amounts to
significant personal sacrifice resulting in lost professional
opportunities and reduction in income. Caregiving exacts a tremendous
toll on that caregiver's health and well-being.
Implementation of caregiver benefits and services authorized by the
Caregivers and Veterans Omnibus Health Services Act of 2010, has
improved the lives of caregivers by giving them the support they need.
These services and benefits include a tax-free monthly stipend, travel
expenses, health coverage through CHAMPVA, mental health services and
counseling, caregiver training and respite care for caregivers of
veterans seriously injured on or after September 11, 2001. However,
these services were not made available to caregivers in need of support
caring for veterans with equally serious injuries incurred in military
service before September 11, 2001.
Many caregivers of veterans have been caring for injured veterans
for years with little or no support and DAV believes it is appropriate
to provide equal benefits to veterans and their family caregivers from
all eras.
DAV believes caregivers of severely disabled veterans should be
seen as a resource and supported in their role. Accordingly, the
delegates to our most recent National Convention, held in Las Vegas,
Nevada, August 4-7, 2012, approved resolution number 221 calling for
legislation that would expand eligibility for comprehensive caregiver
support services, including but not limited to financial support,
health and homemaker services, respite, education and training and
other necessary relief, to caregivers of veterans from all eras of
military service. Accordingly, DAV supports this legislation and urges
its enactment.
DAV urges Congress to provide sufficient program funding to expand
and sustain this program's success. We also urge the Committee to
consider other needed changes to Section 1720G of title 38, United
States Code.
These changes include adding the term ``seriously ill'' as we
believe was intended by Congress under title 38 United States Code,
section 1720G(a)(2)(B). Clarification is also needed of the term
``independent activity of daily living'' contained in 1720G(d)(4)(A) to
define ``personal care services.'' VA indicated the statutory term
``independent activity of daily living,'' [d]oes not have a commonly
understood usage or meaning,'' and interprets the phrase to mean,
``[p]ersonal functions required in everyday living to sustain health
and well-being and keep oneself safe from hazards or dangers incident
to one's daily environment.\4\ DAV agrees that ``independent activity
of daily living'' is not a commonly used phrase; however, based on the
context of the statute, the goal of this program, and VA health care
programs and services that allow disabled veterans to remain in the
community, we believe it is reasonable for VA to include in its
proposed definition, services that provide the veteran assistance with
Activities of Daily Living and Instrumental Activities of Daily Living.
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\4\ 76 Fed. Reg. at 26149.
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The Committee's strong oversight is critical to ensure the
effectiveness and viability of this key program. Notably, the two
reports on caregiving required by law have yet to be submitted to the
House and Senate Veterans' Affairs Committees not later than two years
after the effective date (January 30, 2013) on a comprehensive annual
evaluation on implementation and on the feasibility and advisability of
expanding caregiver assistance under Section 1720G of title 38, United
States Code, to caregivers of veterans seriously injured in the line of
duty prior to September 11, 2001.
DAV and others have submitted comments on VA's Interim Final Rule
(IFR) to implement title I of the Caregivers and Veterans Omnibus
Health Services Act of 2010, Public Law 111-163. The natural tendency
for Federal agencies in rulemaking is to be intolerant and at times
defensive once it makes a formal rule determination. However, VA has
testified before this Committee that it considers the IFR to be a good
start and that VA is open to suggestions. We urge this Committee to
ensure that VA carries out the required good faith and serious
consideration of post-promulgation comments from the public on the
proposed IFR. Congressional oversight is critical in this instance to
ensure the IFR is not perceived as, and is not allowed to become, a
monocratic decision.
s. 852, veterans health promotion act of 2013
This bill would establish a new complementary and alternative
medicine (CAM) program in the Department of Veterans Affairs, including
basic legislative authority; 21 new centers of innovation for CAM in
research, education and clinical activities, to include conducting
research, education and outreach on CAM. The bill would authorize a
series of pilot programs in CAM and wellness, including the award of
grants to non-profit entities focused on CAM for veterans with mental
health conditions, and for their families who are eligible for
counseling from VA's Vet Centers; in health promotion for overweight
and obese veterans through direct support of fitness center
memberships, and through establishment of fitness facilities within VA
medical centers and community-based outpatient clinics. The bill would
also authorize a study by an outside entity of barriers to veterans'
receiving CAM within VA facilities. The bill would require a series of
reports to Congress specific to these authorities, if enacted.
In accordance with DAV Resolution No. 217, adopted by our
membership, DAV supports the purposes of the bill to advance CAM
initiatives within the VA health care system, in addition to those
already in place. Whether the various pilot programs the bill would
authorize help cement CAM within VA is difficult to assess, but if VHA
establishes the innovation centers as envisioned in the bill, they
could serve to spark VHA's existing CAM programs into new areas that
could be very helpful to veterans seeking alternatives to traditional
health care.
DAV is concerned with one aspect of the bill. It would not only
enable CAM practitioners to compete for VA's Medical and Prosthetic
Research funding, but in cases of rural CAM practitioners it would
promote a ``priority'' for funding of their research proposals. DAV
strongly supports the scientific merit review practices endemic to VA
research management of awards; DAV does not recommend specific research
be funded by VA; and, we see no justification for granting one type of
research proposal a special priority in law, especially if it had the
potential to introduce bias in the research award process. Therefore,
we ask that this provision be dropped from the bill.
draft bill, the veterans affairs research transparency act of 2013
This bill would require VA to make available in a publicly
accessible form research data from VA-funded projects, and post-
publication manuscripts of research funded by VA. The bill would
require VA to observe copyright law and to provide reports of
activities occurring under this authority subsequent to enactment.
DAV has no resolution from our membership on these specific issues,
but we would not object to enactment of 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.
______
Prepared Statement of Iraq and Afghanistan Veterans of America
------------------------------------------------------------------------
Bill # Bill Name Sponsor Position
------------------------------------------------------------------------
S. 49 Veterans Health Equity Act Shaheen Support
of 2013
------------------------------------------------------------------------
S. 62 Check the Box for Homeless Boxer Support
Veterans Act of 2013
------------------------------------------------------------------------
S. 131 Women Veterans & Other Murray Support
Health Care Improvements
Act of 2013
------------------------------------------------------------------------
S. 229 Corporal Michael J. Toomey Support
Crescenz Act of 2013
------------------------------------------------------------------------
S. 287 Bill to amend title 38 to Begich Support
expand the definition of
homeless veteran for
purposes of benefits under
the law
------------------------------------------------------------------------
S. 325 Bill to amend title 38 to Tester Support
increase the maximum age
for children eligible for
medical care under CHAMPVA
------------------------------------------------------------------------
S. 412 Keep Our Commitment to Landrieu Support
Veterans Act
------------------------------------------------------------------------
S. 422 Chiropractic Care Available Blumenthal Support
to All Veterans Act of
2013
------------------------------------------------------------------------
S. 455 Bill to amend title 38 to Tester Support
authorize the Secretary of
Veterans Affairs to
transport individuals to
and from VA facilities
------------------------------------------------------------------------
S. 522 Wounded Warrior Workforce Durbin Support
Enhancement Act
------------------------------------------------------------------------
S. 529 Bill to amend title 38 to Burr Support
modify the commencement
date of the period of
service at Camp Lejeune
------------------------------------------------------------------------
S. 543 VISN Reorganization Act of Burr Support
2013
------------------------------------------------------------------------
S. 633 Bill to amend title 38 to Tester Support
provide for coverage under
the beneficiary travel
program
------------------------------------------------------------------------
S. 800 Tetro Garza Far South Texas Cornyn Support
Veterans Inpatient Act of
2013
------------------------------------------------------------------------
S. 825 Homeless Veteran Prevention Sanders Support
Act of 2013
------------------------------------------------------------------------
S. 832 Bill to require the Donelly Support
Secretary of Veterans
Affairs to carry out
certain pilot programs
------------------------------------------------------------------------
S. 845 Bill to amend title 38 to Tester Support
improve the Department of
Veterans Affairs Health
Professionals Educational
Assistance Program
------------------------------------------------------------------------
S. 851 Caregiver Expansion and Sanders Support
Improvement Act of 2013
------------------------------------------------------------------------
S. 852 Veterans Health Promotion Sanders Support
Act of 2013
------------------------------------------------------------------------
S. 877 The Veterans Affairs Begich Support
Research Transparency Act
of 2013
------------------------------------------------------------------------
Chairman Sanders, Ranking Member Burr, and Distinguished Members of
the Committee: On behalf of Iraq and Afghanistan Veterans of America
(IAVA), I would like to extend our gratitude for this opportunity to
share with you our views and recommendations regarding these important
pieces of legislation.
IAVA is the Nation's first and largest nonprofit, nonpartisan
organization for veterans of the wars in Iraq and Afghanistan and their
supporters. Founded in 2004, our mission is important but simple--to
improve the lives of Iraq and Afghanistan veterans and their families.
With a steadily growing base of over 200,000 members and supporters, we
strive to help create a society that honors and supports veterans of
all generations.
IAVA believes that all veterans must have access to quality health
care and related services. The men and women who volunteer to serve in
our Nation's military do so with the understanding that they and their
families will be cared for during their period of service, and also
after their period of service should they sustain injuries or
disabilities while serving.
s. 49
IAVA supports S. 49, the Veterans Health Equity Act of 2013.
Ensuring equal access to quality care and services is critical to
helping veterans maintain their quality of life. This bill ensures that
eligible veterans in the 48 contiguous states can receive services in
at least one in-state, full-service Department of Veterans Affairs
medical center, or receive comparable services provided by contract
care.
s. 62
IAVA supports S. 62, the Check the Box for Homeless Veterans Act of
2013, which will allow taxpayers to check a box on their tax forms to
indicate that a portion of their tax refund can be donated to the
Homeless Veterans Assistance Fund. Homelessness within the veteran
community is an alarming trend that deserves national attention and
resources, and IAVA stands behind any effort to support ending veterans
homelessness and to engage the public in this effort.
s. 131
IAVA supports S. 131, the Woman Veterans and Other Health Care
Improvements Act of 2013. IAVA believes that all servicemembers and
veterans should be able to pursue one of the most fundamental of
American dreams--starting a family. Unfortunately, many of our Nation's
severely wounded veterans are not able to pursue this goal as a direct
result of their service-connected injuries. This bill will help give
these injured veterans an alternative pathway to starting a family if
they so choose.
IAVA also believes this bill is a step in the right direction
toward eliminating yet another hurdle to mental health care that many
veterans with children may experience. By establishing a pilot program
to provide child care assistance to veterans receiving or in need of VA
readjustment counseling or other mental health services, this
legislation helps veterans who need counseling and treatment to also be
able to pursue that care.
s. 229
IAVA supports S. 229, the Corporal Michael J. Crescenz Act of 2013.
This bill will designate the Department of Veterans Affairs medical
center at 3900 Woodland Avenue in Philadelphia, Pennsylvania, as the
``Corporal Michael J. Crescenz Department of Veterans Affairs Medical
Center.''
s. 287
IAVA supports S. 287. This bill would expand the definition of
``homeless veteran'' to include veterans fleeing domestic violence,
sexual assault, or stalking so that they are able to qualify for
assistance from the VA under the McKinney-Vento Homeless Assistance
Act. The definition of homelessness was updated in the 2009 Homeless
Emergency Assistance and Rapid Transition to Housing (HEARTH) Act to
cover individuals escaping domestic violence. We strongly believe that
title 38 must be updated as well to reflect this definition of
homelessness and to provide services to those veterans who are fleeing
domestic violence.
s. 325
IAVA supports S. 325. With the enactment of the Affordable Care
Act, children up to age 26 can now be covered by their parents' health
insurance plans. However, these provisions did not extend to recipients
of TRICARE and the Civilian Health and Medical Program of the
Department of Veterans Affairs (CHAMPVA). While legislation was
subsequently enacted to extend this coverage option to eligible
children of TRICARE recipients, no action has been taken on behalf of
the same population under CHAMPVA. IAVA believes that we must enact
this bill so that CHAMPVA benefits continue to be provided to the
children of our Nation's wounded warriors and those who paid the
ultimate price in service to our country.
s. 412
IAVA supports S. 412, the Keep Our Commitment to Veterans Act. This
bill will authorize the VA to carry out specified major medical
facility leases in FY 2013-FY 2014 in New Mexico, New Jersey, South
Carolina, Georgia, Hawaii, Louisiana, Florida, Puerto Rico, Texas,
Connecticut, and Massachusetts. This bill also reduces lease amounts
authorized in previous fiscal years for VA outpatient clinics in
Johnson County, Kansas, San Diego, California, and Tyler, Texas.
s. 422
IAVA supports S. 422, the Chiropractic Care Available to All
Veterans Act of 2013. This bill will require VA to provide chiropractic
care and services to veterans at all Department of Veterans Affairs
medical centers. It will also expand access to chiropractic care to
veterans as an option for physical rehabilitation and preventative
wellness care. IAVA believes this bill will benefit all veterans who
are seeking new options as a part of their overall health care plan.
Furthermore, IAVA has always advocated that all veterans should have
equal access to VA care and services regardless of where they reside in
the Nation. This bill is a step in the right direction toward achieving
that goal.
s. 455
IAVA supports S. 455. This bill offers a long-term solution to the
VA's Veterans Transportation Service (VTS) program. In 2010 the VA
launched its VTS initiative to enhance transportation services for
disabled veterans accessing VA health care and resources. However, in
the summer of 2012 the VA Office of the Inspector General decided that
the VA never had the authority to run such an initiative and thus
halted the program. This quickly became a problem in communities
throughout the Nation because VTS, which had been in operation for
approximately seven months, had been tremendously successful in
connecting tens of thousands of veterans to the care they needed. It
became clear that while volunteers were providing an amazing service,
they, in many instances, were unable to transport veterans who were not
ambulatory, required portable oxygen, or had other medical needs
associated with their disability. While Congress did answer this need
with a one-year extension of the VTS program, IAVA believes that it is
time to address the transportation needs of disabled veterans with a
more long-term approach. IAVA believes S. 455 will start this process.
s. 522
IAVA is pleased to offer our support for S. 522, the Wounded
Warrior Workforce Enhancement Act of 2013. This bill will authorize
funding to help schools train more professionals in the fields of
orthotics and prosthetics (O&P), and it establishes a second VA
Training Center of Excellence for O&P. Today's wounded warriors are
returning from combat with injuries that are more complex than those we
have seen during past conflicts. These complex wounds require highly
trained professionals in specialized fields like O&P. However, while
the need for these highly trained professionals is at an all time high,
the number of schools designed to train individuals in this complicated
field remains incredibly low. The Wounded Warrior Workforce Enhancement
Act of 2013 addresses this critical shortage of providers and helps
further advancements in the field of O&P so that our wounded warriors
can receive the highest quality of care and services available.
s. 529
IAVA supports S. 529, which would modify the date set out in
Section 1710(e)(1)(F) of title 38 from January 1, 1957 to August 1,
1953. Public Law 112-84, or the Honoring America's Veterans and Caring
for Camp Lejeune Families Act of 2012, provides hospital and related
medical services to veterans and their families who were exposed to a
contaminated water supply while they were stationed at Camp Lejeune,
North Carolina. Since the enactment of this law, further research has
shown that the water contamination at Camp Lejeune started in 1953, as
opposed to the originally designated year of 1957. IAVA believes it is
necessary to care for any servicemember, veteran, or military family
member who has suffered an illness or disability as a result of
exposure to toxins while serving this Nation.
s. 543
IAVA supports S. 543, the VISN Reorganization Act of 2013.
According to numerous reports released by the VA Office of the
Inspector General in 2011 and 2012, the Veterans Health Administration
has failed to manage and monitor the growth of Veterans Integrated
Service Network (VISN) offices. These reports also noted that the VA
lacked adequate management controls and needed to improve the quality
of VISN office data to oversee and evaluate the effectiveness of VISN
staff and organizational structures. IAVA believes that given our
Nation's current economic situation and the projected increase of
veterans seeking VA care over the next few years, the VA must
demonstrate more fiscal responsibility and purpose driven resource
allocation. IAVA believes that the VISN structure has grown far beyond
its original intent and no longer necessarily functions in the best
interest of the veteran or the VA's overall budget. IAVA believes
S. 543 will help eliminate duplication of efforts, bring VISN staffing
levels back to where they should be, and ultimately offer veterans more
options in health care.
s. 633
IAVA supports S. 633, which will authorize the VA to reimburse the
travel costs associated with seeking approved in-patient care at a VA
Special Disabilities Rehabilitation Program for additional categories
of catastrophically disabled veterans. Under current law, the VA
reimburses certain veterans for costs associated with travel to and
from approved VA medical facilities. However, there are certain
categories of catastrophically disabled veterans who are not entitled
to this reimbursement. We believe this legislation would provide
critical assistance for more disabled veterans to allow them to receive
the specialized in-patient treatment they need.
s. 800
IAVA supports S. 800, the Tetro Garza Far South Texas Veterans
Inpatient Act of 2013. This bill will require the South Texas VA Health
Care Center at Harlingen, Texas to include a full-service inpatient
health care facility, an urgent care center, and to provide gender-
specific care to women veterans. IAVA supports these requirements given
the large veterans population currently residing in this area.
s. 825
IAVA strongly supports S. 825, the Homeless Veterans Prevention Act
of 2013. This comprehensive piece of legislation provides a
multifaceted approach to assisting the VA in its goal of eradicating
veteran homelessness by 2015 and ensuring the safety of veterans while
working toward that goal. This piece of legislation also addresses
other often-overlooked needs that homeless veterans may have, including
free legal services and dental care.
s. 832
IAVA supports S. 832, the Improving the Lives of Children with
Spina Bifida Act of 2013. This bill requires the VA to conduct pilot
programs for certain services for the children of Vietnam and Korea-era
veterans with Spina Bifida and other birth defects. IAVA believes these
pilot programs will be helpful in measuring the potential impact of
such services on the children of these veterans. They can also provide
useful data and metrics for the VA to use should future presumptive
conditions arise from the wars in Iraq and Afghanistan. We must ensure
that our newest generation of veterans and their families do not have
to endure the unnecessary hardships that many Vietnam and Korean War
veterans had to endure.
s. 845
IAVA supports S. 845. This bill improves the VA's Health
Professional Education Assistance Program by extending the Health
Professional Scholarship Program through 2019 and increasing the
maximum amount of funding that program participants can receive. These
adjustments will be critical in recruiting and retaining high quality
health professionals within the VA's health care system. IAVA, also
believes this bill will assist the VA in filling certain health care
provider vacancies that it has struggled to fill.
s. 851
IAVA supports S. 851, the Caregiver Expansion and Improvement Act
of 2013. IAVA believes that every veteran who has sustained severe
injuries and illnesses as a result of their service must be cared for,
regardless of which war or conflict they served in and when those
injuries or illnesses present. Part of caring for our wounded warriors
entails caring for the family members who devote their time and their
lives to rendering necessary care for those veterans. All of our
Nation's veteran caregivers deserve support, and this bill would help
provide that support to more veteran caregivers.
s. 852
IAVA supports the understood intent of S. 852, the Veterans Health
Promotion Act of 2013. IAVA has been a proponent of various types of
alternative medicine programs and practices, which many veterans of all
generations have found to be very helpful and therapeutic. However, we
are still unclear as to the specific complementary and alternative
medicine programs referred to in this bill and look forward to finding
out more about what these specific programs referred to here would
entail.
s. 877
IAVA supports S. 877, the Veterans Affairs Research Transparency
Act of 2013. This bill requires the VA to allow public access to
research executed by its Department of Research and Development. IAVA
believes that transparency as well as the sharing of important findings
with the public is an important goal and practice, and this bill will
allow and encourage those types of practices with respect to VA
research.
We again appreciate the opportunity to offer our views on these
important pieces of legislation, and we look forward to continuing to
work with each of you, your staff, and the Committee to improve the
lives of veterans and their families. Thank you for your time and
attention.
______
Prepared Statement of Integrative Healthcare Policy Consortium
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement submitted by Janet R. Kahn, Ph.D., LMT,
President and CEO, Peace Village Projects, Inc.
I thank Senator Sanders and Members of the Committee for the
opportunity to offer a statement for the record regarding pending
legislation to increase access to complementary and alternative
medicine and other preventive and wellness oriented care, for those
receiving health care through the Department of Veterans' Affairs. This
is important legislation with real promise to address the physical,
mental and spiritual injuries incurred in war, and I am honored to
address to it.
My name is Janet Kahn. I am a medical sociologist, a massage
therapist, and a social scientist actively engaged in research with
veterans of Iraq and Afghanistan. I am Research Assistant Professor in
the Department of Psychiatry at the University of Vermont, where we
have a MindBody Medicine Clinic. I currently serve the Federal
Government as a member of the Advisory Group on Prevention, Health
Promotion and Integrative and Public Health, for which I chair the
Working Group on Integrative Healthcare. Previous service includes
terms as a member the National Advisory Council for NIH's National
Center for Complementary and Alternative Medicine, and reviewer for the
Institute of Medicine on their Report of the Committee on the Use of
Complementary and Alternative Medicine by the American.
I am also President of Peace Village Projects (PVP), a 501(c)(3)
non-profit organization of Burlington, Vermont and Acton. PVP engages
in both educational and research efforts, and is currently involved in
a Phase II SBIR grant from NIMH entitled ``Mission Reconnect: Promoting
Resilience and Reintegration of Post-Deployment Veterans and their
Families,'' for which I am I am Co-Principal Investigator with William
Collinge, Ph.D. As a Vermonter I am particularly interested in
provision of care to veterans in rural areas and those too far from
care to access it easily. I am also aware that many veterans perceive,
somewhat accurately, that there may be a career price paid for
accessing mental health services. For that reason, Mission Reconnect is
designed as a self-education program in which veterans and their
partners are provided with media materials through which they teach
themselves mind-body techniques known to beneficially alter
neurochemistry (e.g. increase of serotonin production, decrease of
cortisol), which in turn may render a veteran more able to benefit from
contemplative techniques to quiet the mind, control anger, etc.
While Phase I data (see below) indicate positive results from
Mission Reconnect, and demonstrate veterans' openness to these
therapies, I have no doubt that the best care for the mental health
spectrum we address--which is worried well through high PTSD--would be
a combination of in-person treatment by professionals supplemented by a
Mission Reconnect-like program that the veteran can use at home, on
their own schedule, as often as they like. The pending ``Veterans
Health Promotion Act of 2013'' will make this possible, at the same
time that it makes possible complementary and alternative medicine care
for veterans with acute and chronic pain conditions.
In addition to mind-body and contemplative techniques, Mission
Reconnect provides veterans and their partners instruction in
relaxation massage techniques which Phase I participants found very
helpful in reducing pain and anxiety and in promoting better sleep.
Sleeplessness is a serious issue for veterans and exacerbates other
problems including irritability, pain levels and more. A growing body
of literature indicates that therapeutic massage enhances sleep and we
were delighted to find that this was true even of non-professional
partner-provided massage. Given the findings of Mission Reconnect, I
encourage you to be sure that the legislation is written such that
educational programs may be included along with complementary and
alternative health care clinical treatments.
While I am aware that the VA generally treats only the veteran, not
family members, I have become acutely aware of the extent of secondary
trauma suffered by spouses of veterans with PTSD. In addition, the
design of Mission Reconnect draws on lessons learned in 1995 when PVP
was unexpectedly drawn into teaching Israeli and Palestinian parents
touch-based and mind-body techniques to ease children who were
suffering from war trauma. In fact, we were asked to treat children who
had gone mute from war trauma. Despite having been a massage therapist
since 1969, I was stunned to see the power of touch with these
children, a number of whom cried and then spoke for the first time in a
few years.
While the children of U.S. veterans have not experienced the
immediate danger and trauma faced by Palestinian and Israeli children
in the 1990's, our children are suffering and it is possible that
complementary and alternative medicine care and education would be
helpful to the entire family. Perhaps there can be at least one Center
of Innovation allowed to conduct research on this.
The VA and the Department of Defense have each served at times as
leaders for this country in advancing health care, as well as other
areas of science and technology. A solid body of literature indicates
the potential of individual complementary and alternative medicine
therapies and of integrated healthcare for servicemembers and civilians
alike. The potential of integrated care can only be explored when lack
of reimbursement and other obstacles to complementary and alternative
care are removed. I believe that S. 852 will give us the opportunity to
pilot these methods responsibly within the VA in ways that target the
mental health and pain issues with which so many of our soldiers are
returning home. I expect this will be another instance in which the
country learns from the VA.
The attention given in the bill to staff training, and the decision
to coordinate this through Dr. Gaudet's Office of Patient Centered Care
and Cultural Transformation are important. My experience at the
Community Health Center of Burlington included critical lessons about
the challenges of integration in a clinic whose staff had not chosen
specifically to work in an integrated environment. Many integrated
clinics in the US are private clinics attracting a workforce seeking an
integrated care environment. That will not be true of the whole VA. The
training, beginning with listening to the staff of the VA Centers for
Innovation, will be a critical element in the success of this program.
I applaud the intention and design of this bill and commend you for
taking the initiative in this vital area.
______
Prepared Statement of Paralyzed Veterans of America
Chairman Sanders, 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 pending
legislation impacting the Department of Veterans Affairs (VA) that is
before the Committee. These important bills will help ensure that
veterans receive the best health care services available to them.
s. 49, the ``veterans health equity act of 2013''
PVA does not support S. 49, the ``Veterans Health Equity Act of
2011,'' which proposes to amend title 38, U.S.C. to require veterans to
have access to at least one full-service Department of Veterans Affairs
(VA) medical center in each of the 48 contiguous states, or have access
to hospital care and medical services comparable to the services
typically provided by full-service VA medical centers through contract
with health care providers in the state. Under this legislation, if a
VA medical center is not a full-service facility, ``does not provide
hospital care, emergency medical services, and surgical care that is
rated by the Secretary as having a surgical complexity level of
`standard,''' veterans may utilize contracted services from private
health care providers in their state. While this legislation is an
attempt to address issues involving access to health care, PVA believes
that if enacted, S. 49 will lead to diminution of VA health care
services, and increased health care costs in the Federal budget. This
legislation would turn VA's current fee-basis policy, which allows VA
to purchase care from a private provider when VA medical care is not
``feasibly available to veterans,'' into a permanent treatment plan.
While access is indeed a critical concern for PVA, we believe 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. Unfortunately, funding for VA
health care in the past has had difficulty keeping pace with the
growing demand. Even with the passage of Advance Appropriations and
record budgets in recent years, funding is not guaranteed to be
sustained at those levels and PVA is concerned that contracting health
care services to private facilities is not an appropriate enforcement
mechanism for ensuring access to care. In fact, it may actually serve
as a disincentive to achieve timely access for veterans seeking care.
PVA is also concerned about the continuity of care. The VA's unique
system of care is one of the Nation's only health care systems that
provides developed expertise in a broad continuum of care. The VA
provides specialized health care services that include program specific
centers for care in the areas of spinal cord injury/disease, blind
rehabilitation, Traumatic Brain Injury, prosthetic services, mental
health, and war-related polytraumatic injuries. Coordination of such
care is critical to providing veterans quality care, and contracting
out to private providers will leave the VA with the difficult task of
not only ensuring that veterans seeking treatment at non-VA facilities
are receiving quality health care, but also coordinating the various
types of care that may be provided by a contractor. The quality of VA's
health care and ``veteran-specific'' expertise cannot be adequately
duplicated in the private sector.
For these reasons, PVA does not support S. 49, and strongly
believes that VA remains the best option available for veterans seeking
health care services.
s. 62, the ``check the box for homeless veterans act of 2013''
PVA does not have a position on the, ``Check the Box for Homeless
Veterans Act of 2013,'' a bill to amend the Internal Revenue Code of
1986 to allow tax payers to designate overpayments of tax as
contributions and to make additional contributions to the Homeless
Veterans Assistance Fund. PVA, however, fully supports the VA and the
Secretary's goal to eradicate homelessness among veterans.
s. 131, the ``women veterans and other health care improvements act of
2013''
PVA strongly supports S. 131, the ``Women Veterans and Other Health
Care Improvements Act of 2013.'' 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 the VA's Women Veterans Contact
Center by making information involving health care services and
benefits, provided in the community or by the VA, readily available to
women veterans when it is requested. PVA believes that the VA must
continue working toward developing a comprehensive model of care that
provides woman veterans with a variety of quality services. As the
number of woman veterans seeking health care services and benefits
through the VA continues to increase, we must not only work to improve
the variety of services available to meet women's health care needs,
but also work to ensure that there is adequate care coordination and
referral services with the non-VA providers as well. Care coordination
is the only way to monitor the quality of care provided to women
veterans outside the VA health care system. 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.
PVA also supports the proposed modifications of the pilot program
for counseling in retreat settings for women veterans newly separated
from service, and the assistance programs 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.
s. 229
PVA's National office has no position on naming the VA medical
center in Philadelphia, Pennsylvania as the ``Corporal Michael J.
Crescenz 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 Keystone Chapter or to our
Colonial Chapter.
s. 287
PVA supports S. 287, 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. 287 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. 325
PVA supports S. 325, legislation to amend title 38, United States
Code, to increase the maximum age for children eligible for medical
care under the Civilian Health and Medical Program of the Department of
Veterans Affairs (CHAMPVA) program. CHAMPVA is a comprehensive health
care program in which the VA shares the cost of covered health care
services for eligible beneficiaries, including children up to age 21.
As a part of health reform, all commercial health insurance coverage,
as well as health care coverage provided to servicemembers and their
families through TRICARE, the age for covered dependents to receive
health insurance on their parents plan was increased from 21 years of
age to 26 years, in accordance with the provisions of Public Law 111-
148, the ``Patient Protection and Affordable Care Act.''
At this time the only qualified dependents that are not covered
under a parent's health insurance policy up to age 26 are those of 100
percent service-connected disabled veterans covered under CHAMPVA. This
unfortunate oversight has placed a financial burden on these disabled
veterans whose children are still dependent upon the parents for
medical coverage, particularly if the child has a preexisting medical
condition. This legislation makes the necessary adjustment in this VA
benefit.
s. 412, the ``keep our commitment to veterans act''
PVA supports S. 412, a bill which would authorize major medical
leases by the Veterans Health Administration (VHA). However, we remain
concerned with the ongoing problem VHA has to complete a number of
capital leases as a result of new rules that the Congressional Budget
Office (CBO) is now using to score the costs of those leases. Last
year, CBO changed its methodology for estimating costs of capital
leases. While previously, CBO recognized that capital lease costs were
spread out over a 15 or 20-year period, now the CBO scores all of the
cost of a major capital lease up front. This leads to lease
authorization legislation having very large cost estimates. As a
result, without having a method to pay this high cost, legislation is
essentially blocked from consideration. This has left a number of major
medical facility leases in limbo with many more still pending. We
encourage the Committee and Congress to take whatever action is
necessary to correct this action by CBO. Otherwise, veterans face the
real possibility of not receiving critical care as a result of
political nonsense.
s. 422
PVA supports the provisions of S. 422, the ``Chiropractic Care
Available to All Veterans Act.'' Chiropractic care has become a widely
accepted and used medical treatment. It is a treatment covered by
TRICARE and it is only appropriate that it should be provided at VA
facilities. But it is also important for the Subcommittee to recognize
that by providing this treatment benefit to veterans, it will entail a
new type of care which is currently not considered in funding. When new
treatments are authorized at VA facilities, they must be considered
when determining VA appropriations to prevent those becoming unfunded
mandates.
s. 455
PVA supports S. 455, a bill to amend title 38 U.S.C. to authorize
the Secretary of Veterans Affairs to transport individuals to and from
facilities of the VA in connection with rehabilitation, and counseling
required by the Secretary; or for the purpose of examination,
treatment, or care. Often disabled veterans do not have adequate access
to health care services because they do not have transportation that is
cost efficient or accessible. While PVA believes that S. 455 is a step
toward the elimination of transportation as a barrier to health care
access, we strongly suggest that language be included in the bill that
requires the VA to provide accessible transportation for disabled
veterans, specifically veterans who have incurred a spinal cord injury
or disorder, or veterans who use a wheelchair. For disabled veterans
who do not have personal means of transportation, arranging for
accessible transportation can be very arduous and time consuming.
Unfortunately, it is not uncommon for disabled veterans who are not
able to drive themselves to delay medical visits until transportation
can be arranged or forgo medical attention completely. PVA believes
that authorizing the VA to provide veterans with accessible
transportation to and from VA facilities will increase veterans' access
to care.
s. 522
PVA does not have a position on S. 522, the ``Wounded Warrior
Workforce Enhancement Act,'' legislation that would provide funds for
the VA to award grants to eligible institutions to assist in
establishing post- graduate degree programs in orthotics and
prosthetics, or to expand on existing masters or doctoral programs. PVA
members utilize VA prosthetic services on a regular basis and rely on
prosthetics devices daily, and therefore, we fully support and
understand the importance of enhancing the quality of VA prosthetic
services, and developing a professional staff that is able to meet the
complex prosthetic needs of veterans. While PVA supports increased
promotion and development of professionals in the field of prosthetics,
we believe that any partnership that VA enters into with an educational
institution must include specific agreements that help VA recruit and
retain quality professionals in the field of prosthetics.
S. 522 would also provide funds to an institution with experience
in these areas to establish a Center of Excellence in orthotic and
prosthetic education. While PVA agrees that such a center is much
needed to conduct research, and coordinate and disseminate information
involving veterans and prosthetics, it must first be determined if it
is best for both veterans and the VA to have such a center established
within the VA or with an outside entity. PVA believes that the primary
focus of a Center of Excellence in Orthotic and Prosthetic Education
should be the prosthetic needs of veterans.
s. 529
PVA has no objection to the provisions of S. 529. However, we
believe that the emphasis should be placed on providing the VA
Secretary all the discretion necessary to make a determination as to
the commencement date for the period of military service to establish
the eligibility for hospital care and medical services provided to
servicemembers and their families who experienced toxic exposure at
Camp Lejeune, North Carolina. In fact, we believe that a specific
delimiting date should be removed all together.
s. 543, the ``visn reorganization act of 2013''
PVA opposes S. 543, 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 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. With this thought in mind, we believe it would be prudent to
withhold this proposed legislation until all of the details of the VA's
plan can be assessed.
s. 633
PVA strongly supports S. 633, a bill to amend title 38, United
States Code, to provide for coverage under the beneficiary travel
program of the VA of certain disabled veterans for travel in connection
with certain special disabilities rehabilitation. If enacted, this
legislation would provide reimbursement for travel that is in
connection with care provided through a VA special disabilities
rehabilitation program to veterans with a spinal cord injury or
disorder, double or multiple amputations, or vision impairment. Such
care must also be provided on an inpatient basis or during temporary
lodging at a VA facility. 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. 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.
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.
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.
s. 800, the ``treto garza far south texas veterans inpatient care act
of 2013''
PVA generally supports the provisions of S. 800, the ``Treto Garza
Far South Texas Veterans Inpatient Care Act.'' This bill would ensure
that the Department of Veterans Affairs (VA) has the resources and
capacity to meet the health care needs of veterans living in the Far
South Texas area. Specifically, this bill will require the VA medical
center in Harlingen, Texas, to provide ``full-service'' inpatient
health care for veterans in Far South Texas. This legislation improves
access to VA health care for approximately 108,000 veterans.
We do have questions about the provisions of the legislation that
specifically require adding inpatient beds, an urgent care center, and
women veterans' services. It is our understanding that this facility
and its network have established a women veterans' health care program.
Additionally, we are uncertain as to what analysis has been done to
justify the increased number of inpatient beds. We certainly see no
problem with providing urgent care services, if those services do not
already exist at this facility.
However, PVA's National office has no position on naming the VA
medical center in Harlingen, Texas as the ``Treto Garza South Texas
Department of Veterans Affairs Health Care 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 Lonestar Chapter or Texas Chapter.
s. 825, the ``homeless veterans prevention act of 2013''
PVA supports S. 825, the ``Homeless Veterans Prevention Act of
2013,'' a bill that will help insure the safety of facilities that
offer services to homeless veterans and extend VA's authority to
provide and fund support programs and services for veterans. Many of
the grant programs outlined in the legislation will help veterans who
are homeless, or facing the prospect of homelessness, overcome the
hurdles that prevent them from becoming socially and financially
established. PVA believes that S. 825 is in direct alignment with
Secretary Shinseki's goal of eradicating homelessness among America's
veterans. 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.
s. 832
PVA supports, S. 832, the ``Improving the Lives of Children with
Spinal Bifida Act of 2013.'' This legislation would require the VA to
carry out two pilot programs that furnish case management services and
assisted living to children of Vietnam veterans, and certain Korea
service veterans born with Spina Bifida and children of women Vietnam
veterans born with certain birth defects. When living with physical
disabilities and disorders such as Spina Bifida, the impact of
associated illnesses and complications requires frequent medical visits
and various types of routine medical treatments and therapies. Managing
such care can be extremely difficult and overwhelming. Providing case
management services will help ensure that proper care is received by
the children of veterans who are living with Spina Bifida. PVA believes
that both pilot programs promote independence and allow people with
disabilities a degree of personal freedom, and give them the
opportunity to become a part of and engaged in their local communities.
s. 845
PVA strongly supports, S. 845, a bill to amend title 38 U.S.C., to
improve the VA Health Professionals Educational Assistance Program.
Maintaining a skilled and competent professional staff is critical to
the successful delivery of high-quality VA medical services. Extending
the Health Professionals Educational Assistance Program will not only
serve as a recruitment incentive for potential VA employees, but also
prove to be an effective retention tool within VHA. This legislation
also proposes to repeal the cap on the amount of the Education Debt
Reduction Program (EDRP). PVA supports this change and believes that as
educational costs continue to rise and new professional graduates enter
the workforce with educational debt, this is a benefit that the VA must
improve in order to attract the highest caliber of new graduates and
students from degree programs to provide quality care to veterans, and
remain competitive with private sector employers in the health care
industry.
s. 851, the ``caregiver expansion and improvement act of 2013''
PVA fully supports S. 851, the ``Caregiver Expansion and
Improvement Act of 2013.'' This legislation addresses the greatest
concern that we had with the original legislation when this program was
established. PVA was extremely disappointed that veterans who became
injured or ill prior to September 11, 2001, were excluded from the
comprehensive caregiver support programs. The fact is, PVA's members--
veterans with spinal cord injury or disorder--would benefit from this
program more than any other population of veterans. And yet, the
majority of those veterans were excluded by the arbitrary date of
September 11, 2001, from the comprehensive caregiver program. No
reasonable justification (other than cost considerations) can be
provided for why pre-9/11 veterans with a service-connected injury or
illness should be excluded from the comprehensive caregiver program.
Catastrophically disabled veterans needs are not different simply
because they may have been injured prior to the selected date.
PVA also encourages the Committee to consider amending the
legislation to ensure that veterans who have incurred a catastrophic
illness or disease will benefit from the caregiver program. Currently,
veterans who have incurred a severe illness or disease as a result of
their service are excluded from consideration as eligible for this
program. This proposed legislation excludes these veterans as well.
Aside from the fact that nearly all PVA members are unfairly excluded
from this program, the second biggest complaint that we have received
from our members who are eligible under the Post-9/11 criteria for this
program is the exclusion for serious illnesses or diseases. A spinal
cord disease is no less catastrophic than a spinal cord injury. It is a
fact that veterans who have been diagnosed with Amyotrophic Lateral
Sclerosis (ALS) and Multiple Sclerosis (MS) will eventually experience
a catastrophic impact on their activities of daily living. And yet,
these individuals who may be in greater need of caregiver services than
any other population of injured veterans have no avenue for support
through the new caregiver program. We strongly urge the Committee to
consider these issues when marking up this legislation.
Additionally, we urge the Committee to follow through on oversight
regarding the reporting requirements that the VA has as a result of
Public Law 111-163, the ``Caregivers and Veterans Omnibus Health
Services Act.'' In accordance with the provisions of the law, the VA is
required to report on the feasibility of expanding the caregiver
program. Specifically, the law states:
``Not later than 2 years after the date described in subsection
(a)(3)(A), the Secretary shall submit to the Committee on
Veterans' Affairs of the Senate and the Committee on Veterans'
Affairs of the House of Representatives a report on the
feasibility and advisability of expanding the provision of
assistance under section 1720G(a) of title 38, United States
Code, as added by subsection (a)(1), to family caregivers of
veterans who have a serious injury incurred or aggravated in
the line of duty in the active military, naval, or air service
before September 11, 2001.''
As of this time, the VA has already missed its deadline for
submitting this important report. We understand that VA is currently in
the process of developing this report. However, the Committee must not
allow the VA to simply choose to ignore this requirement so as not to
draw attention to an obvious deficiency in the caregiver program that
it cannot or will not be able to implement. The VA must ensure that it
fulfills this reporting requirement as it is an integral part of the
implementation of the caregiver program. This critical report will pave
the way to access to much-needed caregiver assistance for many more
catastrophically disabled veterans who are currently being denied
eligibility simply because of the arbitrary date assigned to this
benefit by Congress.
s. 852, the ``veterans health promotion act of 2013
PVA does not have a position on S. 852, the ``Veterans' Health
Promotion Act of 2013,'' a bill to improve health care furnished by the
VA by increasing access to complementary and alternative medicine and
other approaches to wellness and preventive care. Nonetheless, PVA
fully supports the use of complementary and alternative medicine and
believes such care options will give veterans with catastrophic
injuries and disabilities additional options for pain management and
rehabilitative therapies. However, PVA cautions VA to make certain that
clinicians utilize evidence-based therapies when selecting
complementary and alternative forms of medicine. Veterans' safety and
overall health and well-being must not be compromised. PVA also
believes that the implementation of preventive health programs within
VA will potentially lead to positive health outcomes for veterans, as
well as create long-term cost savings for the VA if veterans are
informed of the prevention health services and incentivized to use
them.
the ``veterans affairs research transparency act of 2013''
PVA supports the ``Veterans Affairs Research Transparency Act.''
PVA is intimately involved in research activities, funding a great deal
of research in the areas of spinal cord injury and disorder with the
long-term goal of finding a cure for spinal cord injury. We certainly
recognize the benefits of having information about research activities
being conducted through VA available to the larger public. Much of the
American public is not even aware of the great advancements and
discoveries that have been made through the efforts of VA research.
This legislation should help disseminate that work.
However, we would offer a couple of cautions as this legislation is
considered. First, we must emphasize the importance of confidentiality
of any human subjects involved in the research that is made available.
Additionally, we believe some clarification is necessary to address
copyright and intellectual property issues that may arise from outside
entities accessing research that VA essentially owns.
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 services available to veterans, servicemembers,
and their families. We would be happy to answer any questions that you
may have for the record.
______
Prepared Statement of Service Women's Action Network
Chairman Sanders, Ranking Member Burr and distinguished Members of
the Committee: Thank you for the opportunity to submit written
testimony for the record and thank you for your continued leadership on
veteran's issues and for convening this hearing today.
The Service Women's Action Network (SWAN) is a non-profit, non-
partisan veterans led civil rights organization. SWAN's mission is to
transform military culture by securing equal opportunity and freedom to
serve without discrimination, harassment or assault; and to reform
veterans' services to ensure high quality health care and benefits for
women veterans and their families.
We challenge institutions and cultural norms that deny equal
opportunities, equal protections, and equal benefits to servicemembers
and veterans. SWAN is not a membership organization, instead we utilize
direct services to provide outreach and assistance to servicemembers
and veterans and our policy agenda is directly informed by those
relationships and that interaction.
SWAN extends opportunities to and promotes the voices and agency of
service women and women veterans without regard to sex, gender, sexual
orientation or gender identity or the context, era, or type of their
service.
SWAN welcomes the opportunity to share our views on three of the
bills before the Committee today, S. 131, the Woman Veterans and Other
Healthcare Improvement Act of 2013, S. 287, a bill to amend title 38,
United States Code, to expand the definition of homeless veteran for
purposes under the laws administered by the Secretary of Veterans
Affairs and S. 325, the proposed bill to amend title 38, United States
Code and increase the maximum age for children eligible for medical
care under CHAMPVA.
s. 131
SWAN supports S. 131. This bill will provide access to much needed
fertility treatments for seriously injured veterans and their spouses,
research into infertility treatments adoption assistance, permanent
authority for VA to provide child care, and in addition improve the
responsiveness of the VA to women's health issues and significantly
expand a critical pilot program for women's VA heath retreat centers.
After a decade at war, many women servicemembers are still at risk
for reproductive and urinary tract issues due to deployment conditions
and a lack of predeployment women's health information, compounded by
privacy and safety concerns. Moreover, the nature of the current
conflict and increasing use of improvised explosive devices leaves both
men and women servicemembers far more susceptible to blast injuries
including spinal cord injury and trauma to the reproductive and urinary
tracts. Pentagon data shows that between 2003 and 2008 nearly 2,000
women and men suffered these life-altering battle injuries while
serving in Iraq or Afghanistan.\1\
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\1\ http://blogs.seattletimes.com/today/2012/12/senate-lifts-ban-
on-va-funding-for-in-vitro-fertilization/
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Infertility is a devastating diagnosis to receive and it is further
complicated by a lack of access to readily available infertility
treatments. S. 131 would provide research, treatment and adoption
assistance to veterans grievously wounded in the line of duty and allow
them to have the family that many of them right now can only dream of
having.
Additionally, S. 131 would assist VA in making greater strides in
improving the area of women's health services. The bill would enhance
the Department of Veterans Affairs women veterans contact center to
respond to requests for assistance with accessing health care and
providing referrals. It would also improve the VA's women's health
retreat pilot program by more than quadrupling the number of facilities
(from 3 to 14) and doubling the length of the program.
It is important for the Committee to note that more than 250,000
women have served in Iraq and Afghanistan, and as the population of
women veterans continues to grow, VA must continue to adapt to meet the
unique health care needs of women veterans and their families. VA has
taken steps in this direction, yet studies have indicated that women
veterans who use VA services reported a lower quality of care and
higher dissatisfaction compared to women using outside care.\2\ Clearly
more work remains to make VA a friendly environment for women veterans.
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\2\ Kelly et al. 2008. ``Effects of Military Trauma Exposure on
Women Veterans' Use and Perceptions of Veterans Health Administration
Care.'' Journal of General Internal Medicine 23 (6):741-747.
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s. 287
SWAN supports S. 287. This is an extremely important bill that
ensures veterans fleeing domestic violence or another life threatening
condition are eligible for VA homeless assistance. The 2009 Homeless
Emergency Assistance and Rapid Transition to Housing (HEARTH) Act
updated the definition of homelessness to cover individuals fleeing
domestic violence. However, the definition of ``homeless veteran'' was
not updated to reflect this change. The Department of Veterans Affairs
has developed a number of programs to assist homeless veterans, however
the outdated definition of ``homelessness'' could cause problems for
victims of domestic violence. S. 287 addresses this issue by updating
the legal definition of ``homeless veteran'' to bring it to the same
standard as the rest of the law, and it will allow veterans who are in
a domestic violence situation to access the same benefits available to
other homeless veterans. It corrects a grievous oversight and will
allow those who have served our country and find themselves in
difficult and dangerous domestic violence situations to receive the
support and benefits they have earned.
s. 325
SWAN supports S. 325. This common-sense bill would allow CHAMPVA
beneficiaries to keep coverage until age 26. Currently, beneficiaries
lose coverage at age 18 unless they are enrolled as full-time students.
Then, they become ineligible at age 23. The bill would create program
parity with age requirements of the Affordable Care Act, which now
allows adult children to remain on their parents' health insurance
until age 26. This bill is similar to a law passed in January 2011 that
increased coverage for adult children of TRICARE beneficiaries,
bringing it on par with the Affordable Care Act.
Again, we appreciate the opportunity to offer our views on these
key bills and we look forward to continuing our work together to
improve the lives of veterans and their families. Any questions can be
directed to Greg Jacob, Policy Director at 646-569-5216 or
[email protected]
______
Prepared Statement of Raymond C. Kelley, Director, National Legislative
Service, Veterans of Foreign Wars of the United States
With Respect to S. 49, S. 62, S. 131, S. 229, S. 287, S. 325,
S. 412, S. 422, S. 455, S, 522, S. 529, S. 543, S. 633, S. 800,
S. 825, S. 832, S. 845, S. 851, S. 852, and Draft Legislation
s. 49, veterans health equity act of 2013
VA routinely assesses veterans' health care access needs through
its Strategic Capital Investment Plan (SCIP). SCIP prioritizes all
levels of construction projects based on a scoring system, placing
those with the highest score at the top of the list. This model of
evaluation and resource allocation allows for equitable and consistent
distribution of capital funding. However, for SCIP to fully be
realized, sufficient funding must accompany the plan.
The requirement in S. 49 mandating VA to maintain a full-service
medical center in each of the 48 contiguous states could cause funding
for a higher priority construction project to be redirected. The VFW
does encourage VA to reevaluate New Hampshire, to ensure at any gaps in
service are identified and prioritized by SCIP.
s. 62, check the box for homeless veterans act of 2013
The VFW appreciates the spirit of this legislation, but has some
reservations about the possible negative unintended consequences of
creating non-traditional funding sources for important VA programs.
This bill would give taxpayers the option of donating to a new Homeless
Veterans Assistance Fund, which would be established through the U.S.
Treasury, by checking a box on their annual tax returns. That money
would then be made available to VA, the Department of Labor, and the
Department of Housing and Urban Development, for the purposes of
supporting programs that serve homeless veterans. It also provides for
oversight of the Homeless Veterans Assistance Fund by requiring that
the secretaries of the aforementioned departments submit detailed
expenditure plans prior to using the funds, and that the use of the
funds for the prior and upcoming years must be described in the
President's annual budget submission.
Although the VFW commends the intent of this legislation which is
designed to support the administration's goal of ending homelessness by
2015, we are concerned that the establishment of the Homeless Veterans
Assistance Fund may create the rationale for future reductions in
traditional funding for homeless veterans' programs. VA has made marked
and consistent progress toward that goal over the past several years
through adequate funding for effective initiatives such as Supportive
Services for Veterans Families, the Grant Per Diem Program, the
Homeless Veterans Reintegration Program, and HUD-VASH vouchers. The VFW
feels that now is not the time to experiment with alternative funding
sources for these critical services. We must continue to pay for these
programs with congressionally appropriated dollars in order to ensure
that they receive consistent and reliable funding levels.
s. 131, women veterans and other health care improvements act of 2013
A decade of war has put servicemembers at risk for experiencing
reproductive and urinary tract issues due to the lack of pre-deployment
health information, and the use of improvised explosive devices (IED)
leaving many more susceptible to blast injuries including trauma to the
reproductive areas. DOD has reported that from 2003 to 2011at least
2,000 servicemembers have suffered from reproductive and/or urinary
tract trauma.
Providing reproductive services that meet the complex needs of our
severely wounded veterans is critical in helping many move forward with
their lives and aspirations. Dreams of having a family often are at the
top of the list. Currently, VA offers some fertility services, but they
often do not meet the needs of those severely injured with more complex
reproductive needs (In-vitro fertilization or IVF is excluded from VA
medical benefits package under 38CFR 17.38 (c) (2)).
The VFW thanks Senator Murray for taking the lead on this issue and
supports Sections 2 and 3 which will provide fertility counseling and
treatment to include assisted reproductive technology, like IVF, to a
spouse or surrogate of a severely wounded, ill or injured veteran who
has an infertility condition which was incurred in the line of duty or
while on active duty. The patient must be enrolled in VHA and, in the
case of a spouse or surrogate of a veteran not enrolled, VA would
coordinate fertility and counseling for them. VA is not required to
find or certify a surrogate, or connect the veteran with a surrogate,
or provide maternity care for the spouse or surrogate, which will
negate any legal issue that may arise during the process.
The legislation also calls on VA to conduct collaborative research
with DOD and Health and Human Services (National Institutes of Health)
to address the long-term reproductive health care needs of veterans
with service-connected reproductive injuries. We believe that this
research is critical in addressing and treating the unique infertility
issues of veterans with combat injuries now and in to the future.
The VFW also supports section 9 which improves access to services
for women veterans through VA's Women Veterans Call Center. With an
increasing number of female veterans entering the health care arena, VA
must take every opportunity to reach out and provide assistance and
guidance, as well as referrals to community resources for services not
offered within VA.
We are also pleased to see provisions in sections 10 and 11 of the
bill that would expand the child care pilot program for veterans
seeking readjustment counseling at Vet Centers, and also increase the
number of counseling retreat locations which help to ease newly
separated female veterans back into civilian life. The VFW supported
the original language established in Public Law 111-163, and is happy
to see these programs continue.
s. 229, corporal michael j. crescenz act of 2013
The National VFW does not take positions on the designation of
Federal property. We do encourage our state and local VFW members to be
involved in these designations to ensure community buy-in.
s. 287, a bill 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, and for other
purposes.
The VFW is pleased to support S. 287, legislation that would
clarify the definition of ``homeless,'' thereby aligning it with the
McKinney-Vento Act to include those displaced by domestic violence.
No veteran should ever be homeless, and expanding the definition to
include those veterans who are fleeing situations of domestic abuse is
the right thing to do. By making this change, we support this
population of veterans and help them to have the courage and means to
leave their abusive and sometimes life-threatening situation. This bill
will also ensure they receive access to the benefits VA already
provides thousands of homeless veterans.
We believe this legislation will significantly improve the lives of
those who become homeless as a result of difficult circumstances
outside of their control, and help them on their way to beginning a new
chapter in their lives. We urge the Committee to pass this bill
quickly.
s. 325, a bill to amend title 38, united states code, to increase the
maximum age for children eligible for medical care under the champva
program, and for other purposes.
The VFW strongly supports this legislation to extend the age limit
for coverage of veterans' dependents through the Civilian Health and
Medical Program of the Department of Veterans Affairs (CHAMPVA) to the
level set by the Patient Protection and Affordable Care Act.
The health care reform legislation, passed in early 2010, allowed
families with private health insurance coverage to keep their children
on their plans until age 26. Left out of that change was TRICARE and
CHAMPVA recipients. Thanks to responsible leaders in Congress, TRICARE
coverage has been guaranteed to this age group. Unfortunately, CHAMPVA
beneficiaries have not been afforded the same privileges. This program,
which was established in 1973 and has more than 330,000 unique
beneficiaries comprised of dependents and survivors of certain
veterans, should in no instance ever receive less than the national
standard. This legislation would provide equity to CHAMPVA
beneficiaries and rectify this outstanding issue.
s. 412, keep our commitment to veterans act
The VFW supports S. 412. Congress must authorize the funding of the
FY 2013-FY 2014 major medical leases. Without this funding, twelve VA
facilities across the United States may not be able to properly serve
their communities. For example, the Errera Community Care Center
(ECCC), a leading center of innovation providing psychological
rehabilitation, homeless reintegration, substance abuse counseling, and
employment services to over 4,700 veterans in the greater West Haven,
Connecticut area must relocate to a larger facility in order to remain
effective. The facility that currently houses the ECCC is so
insufficient to meet the demand for services that veterans' group
therapy sessions are conducted in hallways, and two to three staff
members share a single desk. In order to ensure that the momentum that
has recently been achieved in solving the complex problems many
veterans face is maintained, community centers like the ECCC must be
provided with adequate facilities.
However, the passage of this Act does not solve the long-term
problem of funding VA major medical leases under the Congressional
Budget Office's new lease evaluation. While S. 412 is a good first
step, Congress must take action to ensure that these annually
appropriated leases are not continually delayed.
s. 422, chiropractic care available to all veterans act of 2013
The VFW supports this legislation which would establish
chiropractic care services at all VA medical centers by the end of
2016. In accordance with Public Law 107-35, chiropractic care is
currently offered at 47 of the 152 VA medical centers nationwide, with
at least one facility being in each VISN. This bill would initiate a
gradual expansion of chiropractic care services, requiring that they be
made available at no fewer than 75 medical centers by December 31,
2014, and all medical centers by December 31, 2016.
It is well known that servicemembers who deploy to combat and
participate in military training are subject to extraordinary physical
demands, often resulting in the premature onset of painful spine and
joint conditions. The 2010 VA analysis of health care utilization among
OIF and OEF veterans listed ``diseases of musculoskeletal system/
connective system'' as the number one condition for which Iraq and
Afghanistan veterans sought VA care. Chiropractic care can often be a
successful alternative to drugs or invasive procedures for treating
musculoskeletal disorders, while also offering suggestions for
lifestyle modifications which promote overall wellness. The VFW
believes that chiropractic care is a valuable option and should be made
available to veterans at all VA medical centers.
s. 455, a bill to amend title 38, united states code, to authorize the
secretary of veterans affairs to transport individuals to and from
facilities of the department of veterans affairs in connection with
rehabilitation, counseling, examination, treatment, and care, and for
other purposes.
The VFW supports this legislation to permanently authorize the
Veterans Transportation Service (VTS). This program, commissioned by
the VHA Office of Rural Health in 2010, has greatly improved access to
care for rural and seriously disabled veterans by allowing VA
facilities to establish and coordinate networks of local transportation
providers including VSOs, community and commercial transportation
providers, and government transportation services. The VTS serves an
innovative supplement to the existing beneficiary travel programs of
mileage reimbursement, which does nothing to assist in the coordination
of transportation for those who need it, and special mode travel, for
which few veterans medically qualify.
The VTS program suffered a major setback in 2012 when it was
temporarily suspended following a determination by the VA Office of
General counsel that VA lacked the statutory authority to provide the
new benefits. Congress wisely passed a one-year authorization of the
program in January 2013, but a long-term fix is still needed.
The VFW believes that unnecessary hardships associated with
accessing VA health care should be eliminated at every opportunity.
This legislation would guarantee the continuation and future expansion
of VTS, which plays a critical role in minimizing the challenges many
veterans face in traveling to their appointments due to physical
disabilities or great distances.
s. 522, wounded warrior workforce enhancement act
The VFW does not support this legislation which would require the
VA to award grants to eligible educational institutions that establish
or expand existing master's degree programs in orthotics and
prosthetics. The bill would also create a grant to be awarded to an
institution that establishes a private Center of Excellence in Orthotic
and Prosthetic Education. Although the VFW recognizes the importance of
promoting the development of high quality prosthetic staff and
services, we feel that this bill takes the wrong approach. Since it
mandates no service requirement for the students who would benefit from
the funding provided by the grants, VA does not stand to reap any
direct benefit from their enhanced training. Additionally, the VFW
questions whether veterans would be better served by a Center of
Excellence in this field within the VA, as opposed to one that is
privately operated.
s. 529, a bill to amend title 38, united states code, to modify the
commencement date of the period of service at camp lejeune, north
carolina, for eligibility for hospital care and medical services with
exposure to contaminated water, and for other purposes.
The VFW supports this legislation which would adjust the date for
VA health care eligibility associated with exposure to contaminated
water at Camp Lejeune, North Carolina from January 1, 1957 to August 1,
1953 or an earlier date specified by the Secretary in consultation with
the Agency for Toxic Substances and Disease Registry, due to recent
findings by the ATSDR that the drinking water at that installation was
contaminated as early as 1953.
s. 543, visn reorganization act of 2013
The VFW does not support the enactment of S. 543. The intent of
this bill has merit. VA should assess the VISN structure for improved
efficiency and possible VISN realignment. VA has taken steps to improve
efficiency and is studying the impacts of VISN realignment. Congress
should continue oversight of this process to ensure veterans are
receiving the highest level of care in the most effective and efficient
manner.
s. 633, a bill to amend title 38, united states code, to provide for
coverage under the beneficiary travel program of the department of
veterans affairs of certain disabled veterans for travel in connection
with certain special disabilities rehabilitation, and for other
purposes.
The VFW supports this legislation which would extend beneficiary
travel benefits to veterans with certain severe non-service-connected
disabilities who travel to receive care provided through a VA special
disabilities rehabilitation program. Veterans who are catastrophically
disabled due to spinal cord injuries, visual impairments, and multiple
amputations often require in-patient care in order to achieve full
rehabilitation. Not all VA facilities, however, offer the specialized
programs of care needed to properly treat these severe disabilities,
and many veterans are forced to travel great distances to receive the
care they need. Those not eligible for travel reimbursement must do so
at great personal cost and, as a result, may be forced to forego
essential primary or preventative care for financial reasons. This
legislation would alleviate that hardship for this small but vulnerable
population of veterans.
s. 800, treto garza far south texas veterans inpatient care act of 2013
The VFW does not hold an opinion regarding this legislation. The
bill calls for the expansion of the Harlingen VA Outpatient Clinic to a
full-service, inpatient care facility. The VFW would suggest that VA
assess South Texas' access and utilization gaps to ensure that veterans
in that region are receiving a full continuum of care without the
burden of excessive travel, and if there are gaps, prioritize the need
and have it added to Strategic Capital Investment Plan.
s. 825, homeless veterans prevention act of 2013
The VFW supports most provisions of this legislation which expands
and reauthorizes a number of programs aimed at addressing the
unacceptable problem of homelessness among veterans. It also keeps
families together by allowing VA to house the children of veterans in
transitional housing, while also improving the security of those
facilities. The VFW firmly believes that no veteran who has honorably
served this Nation should have to suffer the indignity of living on the
streets. We praise the great progress that has been made in reducing
veterans' homelessness in recent years as a direct result of
coordinated efforts across multiple government agencies to provide
transitional housing, rapid re-housing, and employment programs for
veterans in need. The extension and adequate funding provided by this
bill for these and other programs are vital to achieving the
Secretary's goal of eradicating homelessness among veterans by 2015.
The VFW generally supports Section 8 of the bill which would allow
the Secretary to ``enter into partnerships with public or private
entities'' to fund a portion of certain legal services for homeless
veterans. While we recognize that legal problems are often a
significant barrier to homeless reintegration and must be addressed, we
are concerned that there may be some for-profit legal entities that
would view this program as an opportunity to exploit the availability
of government resources in exchange for poor or inadequate services.
For this reason, we suggest that the language in this section be
changed to allow VA to only enter into partnerships with public or non-
profit private legal entities that provide services to homeless
veterans.
s. 832, improving the lives of children with spina bifida act of 2013
Current law (Chapter 18, title 38, United States Code) defines the
services provided to children of Vietnam veterans and certain Korea
service veterans born with spina bifida to include comprehensive health
care, but some veterans have reported that they have had difficulty
accessing these benefits for their severely handicapped children.
This bill will help remedy some of these issues by requiring VA to
carry out a pilot program in rural areas, and report to Congress on
services they are providing to children under the law. The legislation
is of little or no cost to VA and will allow Congress an inside view of
specifics within the program to include statistics on what types of
services and how many are being provided.
The VFW believes that this is an appropriate use of Congressional
oversight and the findings will provide insights into the program,
specifically answering questions as to whether VA is doing everything
within the law to provide care and services to this most vulnerable
population. The VFW encourages Congress to enact this legislation so
those in need of care and services can access what is rightfully and
legally theirs--we owe them nothing less.
s. 845, a bill to amend title 38, united states code, to improve the
department of veterans affairs health professionals assistance program,
and for other purposes.
The VFW supports this legislation which removes the $60,000 cap on
the total amount payable under the Education Debt Reduction Program
(EDRP) and extends the expiration date of the Health Professionals
Education Assistance Program from December 31, 2014 to December 31,
2019. VA must be given the tools to recruit and retain high quality
medical professionals in order to guarantee the continued delivery of
the highest level of care. By providing targeted education debt
repayment incentives to physicians in specific fields based on VA need
in exchange for service obligations, these programs play a vital role
in properly meeting VA staffing needs.
s. 851, caregivers expansion and improvement act of 2013
The VFW strongly supports this legislation which would extend
current caregiver benefits to those who care for veterans who were
severely injured prior to September 11, 2001. We believe that severely
wounded veterans of all conflicts have made incredible sacrifices, and
that all family members who care for them are equally deserving of
recognition and support.
The VFW applauded the passage of the Caregivers and Veterans
Omnibus Health Services Act of 2010 which provided a monthly stipend,
respite care, mental and medical health care, and the necessary
training and certifications required for caregivers of severely
disabled Post-9/11 veterans, but have consistently maintained that
eligibility should be expanded to include veterans of all eras. By
striking ``on or after September 11, 2001'' from 38 U.S.C. Section
1720G(a)(2)(B), this bill would accomplish that objective.
s. 852, veterans' health promotion act of 2013
This legislation would create a new complementary and alternative
medicine (CAM) program within VA in order to promote the overall health
and well-being of veterans. Although the VFW feels that CAM and
wellness programs have the potential to play a significant role in VA
health care, we would like to offer several suggestions which we feel
would strengthen this bill.
S. 852 would establish at least one Center of Innovation for CAM in
each of the 21 VISNs for health research, education, and clinical
activities in each VISN, while simultaneously establishing a three year
pilot program to assess the feasibility of CAM centers in VA medical
facilities. The VFW feels that it would be more appropriate to conduct
the pilot program and analyze its results before mandating the
establishment of CAM Centers of Innovation across VA. Additionally, we
are concerned that some VISNs may not currently have a medical center
suitable to be designated a center of excellence.
The bill also establishes two pilot programs intended to address
the issue of obesity. The first would subsidize fitness center
memberships for veterans who are determined to be overweight or obese
by VA physicians. The VFW suggests that veterans who participate in
such programs should be required to report for regular examinations to
ensure that fitness programs are being executed effectively and
benefits are being achieved. The second pilot program would establish
fitness centers at VA facilities which would be made available to any
veteran enrolled in the VA health care system. Recognizing that space
and resources are scarce, the VFW recommends that the use of such
fitness centers be reserved for those veterans deemed overweight or
obese by a VA physician. With these changes, we believe that these
programs would enhance the overall wellness of the veterans' community,
while allowing VA to most effectively experience the associated long-
term cost savings.
draft bill, veterans affairs research transparency act of 2013
The VFW has no position on this legislation which would establish a
new Web site to make VA research data available to the public, and
require the Veterans Affairs-Department of Defense Joint Executive
Committee to submit recommendations on the establishment of a data--
sharing program between VA and DOD in order to better facilitate
research. Although we see the value of the public dissemination of
information and greater cooperation between VA and DOD with regards to
data-sharing, we are unable to comment on whether the mandates of this
bill would achieve those objectives most effectively.
______
Prepared Statement of Wounded Warrior Project
Chairman Sanders, Ranking Member Burr, and Members of the
Committee: Thank you for inviting Wounded Warrior Project (WWP) to
provide views on pending health-related legislation. Several of the
measures under consideration address issues of keen importance to
wounded warriors and their family members.
health promotion
Among these bills, Mr. Chairman, we welcome the focus on health-
promotion in S. 852, and believe VA health care facilities can be
important settings to advance the goal of wellness. As an organization
deeply engaged in developing and operating programs to empower wounded
warriors, we work very actively to promote health and wellness.
Complementing WWP's programmatic work, we see merit in advancing
health-promotion and wellness in the VA, and in expanding through
rigorous scientific study our understanding of the potential benefits
of complementary and alternative medicine (CAM) for certain chronic
health conditions. Given its size and reach, the VA health care system
could certainly serve as a national laboratory to participate in
studying the potential of certain avenues of complementary and
alternative medicine to treat, or complement the conventional treatment
of, particular conditions. Working in concert with NIH's National
Center for Complementary and Alternative Medicine, VA could, for
example, help mount large-scale, rigorous studies to assess the
effectiveness and safety of particular practices in the treatment of
certain chronic conditions.
S. 852 would direct VA to operate in each network at least one
center to conduct CAM research, education and training, and clinical
care. The bill would also direct VA to establish several pilot
programs, including establishing an additional 15 centers to provide
services involving CAM for veterans who have mental health conditions
and suffer with pain; a grant program to assess the use of wellness
programs for combat veterans and their family members; and pilot
programs involving fitness activities. While we are supportive of an
increased emphasis in VA on health promotion and wellness for wounded
warriors, we would encourage further refinement of S. 852.
We see particular value in fostering the study and evaluation of
promising therapies to complement the treatment of certain behavioral
health conditions and the management of chronic pain and to help
improve overall wellness of wounded warriors and their family members.
These are areas where we--and many warriors--see a need for more
therapeutic options than conventional health care offers. But there
exist a wide range of therapies, products and practices under the
umbrella of ``complementary and alternative medicine.'' These include
alternative health care systems (such as homeopathic medicine,
naturopathic medicine, ayurvedic medicine, traditional Chinese
medicine, and Native American medicine); mind-body interventions
(including hypnosis, meditation, and guided imagery); biological-based
therapies (including herbal therapies, special diets, and megavitamin
therapy); therapeutic massage and somatic movement therapies; energy
therapies (quigong, reiki, and therapeutic touch); and
bioelectromagnetics.\1\ Some of these systems of care have evolved over
generations (such as in traditional Chinese medicine), and others from
the clinical experiences of a single practitioner or small groups of
practitioners who have developed a particular intervention.\2\ Some
seem much more promising than others. To illustrate, the National
Center for PTSD recently reported on the current state of research for
complementary and alternative treatments for PTSD. They concluded that
while CAM treatments like acupuncture, relaxation, and meditation hold
some promise as an adjunct to traditional therapies, there is limited
evidence of their effectiveness as alternative or stand-alone
approaches. They report there is better support for using complementary
methods in addition to other treatments or as a gateway to evidence-
based services to engage those veterans who might otherwise not take
part in other approaches.\3\ Not only should distinctions be drawn
among interventions in terms of their likely efficacy, but establishing
the safety of interventions can be no less important with respect to
complementary and alternative medicine than to conventional
medicine.\4\
---------------------------------------------------------------------------
\1\ Final Report, White House Commission on Complementary and
Alternative Medicine Policy (March 2002), accessed at http://
www.whccamp.hhs.gov/pdfs/fr2002_document.pdf
\2\ Id.
\3\ Strauss, J. & Lang, A. Complementary and Alternative Treatments
for PTSD. PTSD Research Quarterly (2012). Accessed at: http://
www.ptsd.va.gov/professional/newsletters/research-quarterly/v23n2.pdf
\4\ Recent study found that ginko biloba, a widely-used herbal
supplement, caused carcinogenic activity in mice. ``New Doubts about
Ginko Biloba,'' New York Times (April 30, 2013) accessed at http://
well.blogs.nytimes.com/2013/04/29/new-doubts-about-ginkgo-biloba/
---------------------------------------------------------------------------
We recommend that S. 852 provide for a specific framework to assure
that any CAM programs carried out under VA's auspices adhere rigorously
to such fundamental imperatives as safety and effectiveness. Equally
important, we urge that any legislation involving CAM be built on the
bedrock of the scientific method, to assure that any VA provision of
CAM interventions, through pilot programs or otherwise, contributes to
scientific and medical understanding, and better care in the future.
Finally, we would suggest consideration of further revisions to the
bill to take account of the following:
that priority for research funding for CAM or any other
health-related research should be determined through a merit-based
peer-review process;
that the designation of any specific number of new centers
or programs involving the study or evaluation of CAM should be based on
a methodology that includes such elements as (1) an independent
assessment of what are the most promising CAM interventions that have
particular relevance to health care issues prevalent among veterans,
and (2) rigorous evaluation of the capabilities (including the
potential size of a study cohort) of one or more VA medical centers to
study each such issue (independently, collaboratively with other VA
medical centers, or in partnership with an affiliated academic
center(s); and
whether a particular proposed pilot program can produce
statistically significant results or is susceptible of meaningful
evaluation.
caregiver-assistance
S. 851 would expand VA's comprehensive caregiver-assistance program
to cover caregivers of veterans who were injured prior to 9/11. The
Caregivers Act of 2010 was historic legislation that directed VA to
provide important services and supports. However VA has yet to meet in
full its obligations under that law. More than two years after initial
implementation, VA still has not answered--let alone remedied--the
problems and concerns that WWP and other advocates raised regarding the
Department's implementing regulations. For example, those regulations
leave ``appeal rights'' unaddressed (including appeals from adverse
determinations of law); set unduly strict criteria for determining a
need for caregiving for veterans with severe behavioral health
conditions; and invite arbitrary, inconsistent decisionmaking. Simply
extending the scope of current law at this point to caregivers of other
veterans would inadvertently signal to VA acquiescence in its flawed
implementation of that law. We recommend that the Committee insist on
VA's resolving these long-outstanding concerns as a pre-condition to
extending the promise of this law to caregivers of pre-9/11 veterans.
prosthetics and orthotics
S. 522, the Wounded Warrior Workforce Enhancement Act, would direct
VA both to establish a program to provide grants to institutions that
provide or intend to provide graduate education in prosthetics and
orthotics, and to award a grant to support the establishment of a
center of excellence in orthotic and prosthetic education, and research
into the skills and optimal training needed by clinical professionals
in such fields.
WWP has had concerns regarding the VA's prosthetics and orthotics
program. With its generally older patient population whose prosthetic
needs are most often linked to diabetes and post-vascular disease, VA
has faced a steep adaptation-curve as it relates to serving young
warriors who have lost limbs in war.\5\ War zone injuries that result
in amputations are often complex and can prove difficult for later
prosthetic fitting because of length, scarring, and additional related
injuries such as burns.\6\ VA has instituted an amputation system of
care and initiated the development of amputee centers of excellence
which can become important components of needed changes, but much more
progress is needed to realize the underlying vision. Indeed the
Department of Defense (DOD) has surpassed VA in providing state-of-the-
art rehabilitation for this generation of combat-injured amputee
servicemembers and veterans. Some have suggested that VA's leadership
role in prosthetics has declined and that prosthetics no longer holds
the priority for VA it did in the past.\7\ VA prosthetics research,
particularly--an area of real strength in the past and so important to
serving wounded warriors tomorrow--has lagged, even as the numbers of
new veteran-amputees climb steadily.
---------------------------------------------------------------------------
\5\ Sigford BJ, ``Paradigm Shift for VA Amputation Care,'' J
Rehabil Res Dev; 47(4): (2010) xv-xx.
\6\ Ibid.
\7\ See Hearing, ``Optimizing Care for Veterans with Prosthetics,''
Subcommittee on Health, Committee on Veterans Affairs, House of
Representatives (May 16, 2012) accessed at http://veterans.house.gov/
hearing/optimizing-care-for-veterans-with-prosthetics
---------------------------------------------------------------------------
We do see a need for Congress to press VA to make these concerns a
higher priority, and have urged such steps as the following:
Ensure through ongoing oversight that the vision of a VA
Amputee System of Care is realized; that VA meets its commitment to
provide timely, needed prosthetics; and that it works to regain
leadership in prosthetics research and service.
Ensure that VA's amputee-registry is deployed and used to
track amputee-care and outcomes, conduct longitudinal studies and other
research, and--working in concert with DOD--expand understanding of
best practices;
Establish a steering committee of experts composed of
academicians, clinicians, and researchers to oversee and provide
guidance to VA on the direction and operation of its prosthetics and
orthotics program; and
Develop guidance to assist clinicians in more
appropriately prescribing durable medical equipment (in particular,
expanding clinical practice recommendations through the use of
guidelines such as are commonly employed in other fields of medical
practice).
With regard to S. 522, we would acknowledge that VA may well face
challenges in filling future vacancies in prosthetics and orthotics.
But it is not clear that S. 522, while authorizing grants to
institutions for a wide range of uses relating to prosthetics and
orthotics education, is sufficiently focused to meet VA's potential
workforce needs.
reproductive assistance
S. 131, the Women Veterans and Other Health Care Improvements Act
of 2013, raises important issues in proposing that VA would provide
reproductive services and adoption assistance to assist in helping
severely wounded, ill or injured veterans who have service-incurred
infertility conditions to have children.
The experience of our operations in Iraq and Afghanistan has
heightened the importance of grappling with the issue of reproductive
services. Blasts from widespread use of improvised explosive devices
(IED's) in Iraq and Afghanistan, particularly in the case of warriors
on foot patrols, have increasingly resulted not only in traumatic
amputations of at least one leg, but also in pelvic, abdominal or
urogenital wounds.\8\ While not widely recognized, the number and
severity of genitourinary injuries has increased over the course of the
war, with more than 12% of all admissions in 2010 involving associated
genitourinary injuries.\9\ With that increase has come not only DOD
acknowledgement of the impact of genitourinary injuries on warriors'
psychological and reproductive health,\10\ but recent adoption of a
policy authorizing and providing implementation guidance on assisted
reproductive services for severely or seriously injured active duty
servicemembers.\11\ DOD's policy, set forth in recent revisions to its
TRICARE Operations Manual, applies to servicemembers of either gender
who have lost the natural ability to procreate as a result of
neurological, anatomical or physiological injury. The policy covers
assistive reproductive technologies (including sperm and egg retrieval,
artificial insemination and in vitro fertilization) to help reduce the
disabling effects of the servicemember's condition to permit
procreation with the servicemember's spouse.\12\
---------------------------------------------------------------------------
\8\ Dismounted Complex Injury Task Force, ``Dismounted Complex
Blast Injury: Report of the Army Dismounted Complex Injury Task
Force,'' I (June 18, 2011) available at: http://
www.armymedicine.army.mil/reports/DCBI%20Task%20Force%20Report%20%
28Redacted%20Final%29.pdf.
\9\ Id. at 16.
\10\ Id.
\11\ Asst. Secretary of Defense (Health Affairs) & Director of
TRICARE Management Activity, Memorandum on Policy for Assisted
Reproductive Services for the Benefit of Seriously or Seriously Ill/
Injured (Category II or III) Active Duty Servicemembers (April 3, 2012)
available at: http://www.veterans.senate.gov/upload/
DOD_reproductive_letter.pdf.
\12\ Dept. of Defense, TRICARE Operations Manual 6010.56-M, Chapter
17, Section 3, para. 2.6 (Sept. 19, 2012).
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For veterans, however, VA coverage is very limited in scope. The
regulation describing the scope of VA's ``medical benefits package''
states explicitly that in vitro fertilization is excluded \13\ and that
``[c]are will be provided only * * * [as] needed to promote, preserve,
or restore the health of the individual * * * .'' \14\ Consistent with
that limiting language, the VA's benefits handbook advises women
veterans with regard to health coverage that `` * * * infertility
evaluations and limited treatments are also available.'' \15\
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\13\ 38 CFR Sec. 17(c)(2).
\14\ 38 CFR Sec. 17(b) (Emphasis added).
\15\ Dept.of Veterans Affairs, ``Federal Benefits for Veterans,
Dependents and Survivors'' available at http://www.va.gov/opa/
publications/benefits--book/benefits--chap01.asp.
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In a departure from longstanding policy, the VA stated last year
that ``[t]he provision of Assisted Reproductive Services (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.'' \16\ In its
statement, the Department also expressed support in principle for
legislation authorizing VA to provide assistive reproductive services
to help a severely wounded veteran with an infertility condition
incurred in service and that veteran's spouse or partner have children.
It conditioned that support, however, on ``assurance of the additional
resources that would be required.'' \17\
---------------------------------------------------------------------------
\16\ Health and Benefits Legislation Hearing Before the S. Comm. on
Veterans Affairs, 112th Cong. (2012).
\17\ Id.
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Certainly the administration of a VA program that would assist
wounded warriors and their spouses to conceive children would require
careful attention to ethical \18\ and regulatory \19\ issues associated
with providing advanced reproductive services. Economic considerations
certainly can arise in that regard.\20\ But while these advanced
interventions can be quite costly, cost should not be a barrier as it
relates to this country's obligation to young warriors who sustained
horrific battlefield injuries that impair their ability to father or
bear children.
---------------------------------------------------------------------------
\18\ See Meena Lal, ``The Role of the Federal Government in
Assisted Reproductive Technologies, 13 Santa Clara Computer and High
Tech. L.J. 517 (1997).
\19\ See Michelle Goodwin ``A Few Thoughts on Assisted Reproductive
Technology,'' 27 L. & Ineq. 465 (2009). Among these regulatory issues,
VA would have to address the need for physicians providing advanced
reproductive technologies to fully inform couples as to their risks,
including greater health risks in children born through these
technologies. See N.Y. State Dept. of Health Task Force on Life and the
Law, Assisted Reproductive Technologies: Analysis and Recommendations
for Public Policy, available at: http://www.health.ny.gov/regulations/
task--force/reports--publications/execsum.htm
\20\ Id.
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WWP urges Congress to enact legislation that would enable couples
who are unable to conceive because of the warrior's severe service-
incurred injury or illness to receive fertility counseling and
treatment, including assisted reproductive services, subject to the
development of reasonable regulations.
beneficiary travel
S. 633 would amend current law governing VA's ``beneficiary
travel'' program to cover certain severely disabled veterans' travel in
connection with care provided on an inpatient (or lodger-basis) through
a special VA disability-rehabilitation program.
WWP works extensively across the country with wounded warriors,
specifically veterans and servicemembers who were injured, wounded or
developed an illness or disorder of any kind in line of duty during
military service on or after September 11, 2001. Our warriors certainly
encounter barriers to receiving needed VA services--barriers that
include sometimes-rigid VA appointment-scheduling, long-distance
travel, and instances of inflexible program requirements. We are not
aware, however, of problems that warriors have encountered regarding
receipt of beneficiary travel generally or with respect to travel to
special disability-rehabilitation programs. As such, we have no
position on S. 633.
Thank you for your consideration of WWP's views on these issues.
