like to thank everyone for coming this morning today's hearing is an opportunity for members of congress to be a and other interested stakeholders and parties to provide their views and discuss recently introduced legislation within the purview of this subcommittee the six bills before us today will cover the wide range of topics that are germane to veterans health care issues access to care and a bill of rights is not necessary do not agree or disagree with all these bills i think it's a very important part of the legislative process here are the legislation  continue to do so and i think the veterans across the nation will be better off because of the work of this subcommittee as you said i'm speaking on h r fifty seven thirty what we call the injured an amputee veterans a bill of rights as we see service members returning from iraq and afghanistan with musculoskeletal injuries many will require pathetic and orthotic care and will be entering the v a health care system for that care in order to mitigate the impact of these potentially debilitating injuries i believe the v a should establish a set of standards outlining the expectations and rights every turning veterans with musculoskeletal injuries have with respect to their posts that i can i thought of this bill which i've introduced h standards of care to ensure that injured veterans across the country have the same access to the highest quality were thought of in the most timely manner and using the most effective technology and treatments available over the years for the most part v amputation or musculoskeletal injury requiring the prosthetic and orthotic care our injured veterans deserve the assurance that they will receive the best care possible and this bill i think will provide a step in that direction mr chairman provide that are necessary so i look forward to working with you to get this bill done thank you mr chairman i look forward to working with you as well as we move forward with this piece of legislation the next one is h r twenty eight eighteen a services to those that are able to receive them and the v a should continue to provide these services however the v a does not provide dental services to disabled veterans who are ninety percent or less make our veterans wil fix this problem by allowing all service connected veterans to receive dental care through the v a this will add another two point four million disabled veterans to the program i believe we have a moral obligation to care for these veterans and i understand th not mandate contractor facilities be used instead of simply gives the v a greater authority to use the cost of the bill is a cost of the war it is an investment in our way of life and our future as every member of the subcommittee to ensure that there is a smooth transition for our military members who are entering the civilian workforce we must also ensure that disabled veterans from past wars are given every tool to keep meaningful jobs and this includes dental care i would also like to point out that numerous studies have shown that there is a clear correlation between dental health and someone's overall health i would like to say that association of the national guard of the united states the navy reserve association the air force association the network which includes most of south georgia florida puerto rico and the u s virgin islands the pilot program would give veterans receiving healthcare in visit the opportunity to health care from a primary care provider outside the v a if they have to wait more than thirty days for an appointment through the v a mr chairman it is more than reasonable for a veteran to expect to be seen by a primary care physician within thirty days if the v a cannot provide basic service to our veterans then our veterans should have the option to look elsewhere my bill i'd like to emphasize this does not force any veteran out of the v health care system it simply provides them another option to go outside the v a if they desire to see a physician outside the system it is imperative that the v a be able to keep track of that veterans medical records to ensure continuity of care therefore the bill directs the secretary to provide a form to veterans that would authorize the v a to obtain the records from the out of network visit this provision is critical as the goal of h r fifty six twenty two is to ensure veterans not only receive access to timely healthcare but to quality health care as well make sure that there is a cont care and information sharing mr sherman as a member of congress from i'd like to make this option available to the veterans in and around and certainly to expand it miller the one thing on twenty eight eighteen i think that i apologize i was looking at another bill and i'm trying to get my things together you know last year in twenty one ninety nine we talked about establishing five t b i centers we did address the epilepsy issue albeit not it to the extent that you have and said that one of those five senators needed to assist in what you're trying to accomplish i think yes i think the goal is to have geographically dispersed centers of excellence to study epilepsy because when you start having seizures it's different  every one of these pieces of legislation is critical to our veterans and the question isn't how can we afford to do this the question is how can we afford not to do this whether it's as you said wait on a trial basis and hopefully to expand this nationwide because at the end of the day what i what i have said all the time since i've been on the new here but if we make a promise to our veterans that we're going to take care of them and their families we have to cost of taking care of our veterans is the cost of going to war and if you're not prepared to take care of our veterans when they come home from serving and sacrifice for their fellow citizens in our nation then you not send them in the first place but i am also agonizing over how we intend to pay for this and you know there's a movement to make the president's tax cuts permanent i think as a nation and as a congress we're to comment that i'm a veteran myself and if we don't live up to the promises that we make to our veterans no one is going to enlist volunteer force and if we ignore the problems that are created by the service young men and women provide to our country we will not be able to have an all volunteer force anymore we will have to institute a draft in our sons and our daughters will feel that and we don't want that mr carney we are spending four thousand dollars second let me be precise three thousand nine hundred nineteen dollars a second in iraq and if we're going to spend that take this opportunity to give a special welcome to my friend and colleague from colorado mr perlmutter has been a champion of veterans you know that people in this committee and people who work on veterans issues don't do it because it's a glamorous job they do it because they care start getting prepared for the budget request you know in the future the bill was never heard before the for even a subcommittee before to take it doesn't give the veteran the opportunity it doesn't mandate that he has to go to a health care provider outside of the v a system it is that i think we should be giving to our veterans but the to six hours in order to get primary health care physician within the v a center mountainous area very dangerous and veterans who are it was very difficult for them to get there and still and very remote and rural areas and most of you know it's very difficult to get a primary health care position i had a friend in colorado who was suffering from chest pains and he was a better and he actually served the same time i did and we couldn't get him an appointment at the v a health center in colorado for almost six months and we were able to to get him an appointment to go to the v a hospital in albuquerque two days after they saw him in albuquerque  gave him five bypass bypass on his heart that shows how critical this is and you know there's just a long waiting list of people waiting to get health care so i applaud each and every one of you and thank you very much for being here today two thousand and eight alone and almost eleven point three billion over the next ten years which is pretty costly is your interest primarily making sure that they get dental health care  and if so would you be amenable working with the armed services committee in opening up dental care when you look at a good example is the army national guard dangerous within the v a system and make them versus contracting that out of course anything that would help the the dental health of our veterans i would support and of course we're very sensitive  costs of these things the eleven billion dollars number was much higher than than the one that we had but whatever we can do to assure that we are taking care of our veterans and covering this ninety percent of the population of service disabled that don't have the dental coverage i think we should explore it's about us not about any particular bills by doing the right thing by our veterans and of course i'll be able to thank you once again i'd like to think four panelists for your testimony this morning i look forward to working with you as we look at each one of these individual pieces of legislation and thank you very much for coming here this all understand we need to be prudent with our expenditures if we have fifty billion dollars of this congress can pass for aids in africa certainly we have the ability to spend the necessary dollars and we all agree on the veterans the money is there it's how this congress decides to allocate that money mr showed you recognize thank you very much present h r five five five for nearly three hundred thousand veterans of operation enduring freedom and iraqi freedom have been seen by the v a health care system and over forty percent of these individuals were diagnosed with mental health conditions separating from military service can be very difficult transition mental and physical wounds make it even more difficult for veterans to adjust according to the v a office of public health and environmental hazards of forty eight thousand six hundred sixty one in dreads have met criteria for substance use disorder this number only reflects it only reflects the veterans who have been seen by the v a which means that the total number of veterans with substance use disorder is likely higher than that number also when you look at the lower income veterans are also have a higher prevalence of substance use disorder to address this issue ranking member miller and i introduced the veterans substance use disorder prevention and treatment act of two thousand and eight  that i was kind of skeptical at first by having talked to the health care provider carrier that is actually one area that has been very beneficial and that's why i'm recommending that they do a pilot project dealing with  t the tools and they have personnel trained and enough personnel trained to take to address these issues when some kid like justin bailey checked himself into a v a facility there should be an expectation by his family that someone there is going to know what they're doing and not you know like maybe read his medical records before they give him yet another medication and i'm not sure that exists right now to make sure that the medical opportunity and a treatment available to you we better make sure it's available with the expertise and knowledge because i feel that we would be contributing to the death and  second panel will include joseph wilson who's the deputy director of veterans affairs and rehabilitation commission with the american legion joy disabled american  it's bernie alun from the vietnam veterans of america so i want to thank god this panel for coming today look forward to your testimony and i would recognize mr wilson according to a v a research approximately fifty fifty three percent of veterans who suffered a penetrating traumatic brain injury or t b i in vietnam develop epilepsy within fifteen years in his effort to treat this condition became the leader in epilepsy research however due to lack of funding research resources eventually the managed according to the american academy of neurology and returning veterans with t b i injuries will access to a full continual care for substance use disorders and veterans in need of such care the american legion has no official position on the issue however when substance use disorders a second service connected conditions it is opposition that veterans should therefore we believe this legislation addresses the real need and dave you would have no objection to passage age are fifty five fifty four the substance use disorders prevention and treatment act of two thousand and eight would mandate that v a provide system wide access to a full continuum of health care for substance use disorders with a special emphasis on outreach to veterans who served in operation enduring and iraqi freedom this measure would require an annual report on the availability of the substance use disorder treatment throughout the system the number of veterans receiving such care the barriers to access the need services and the quality of care provided finally the bill would require a pilot program civically designated to offer web based designed to offer web based options for self assessment education and specified treatment of substance use disorders d v has a growing concern about the reported effects of combat deployments in iraq and afghanistan and our newest generation of war veterans and the converging evidence that substance abuse is a significant problem for many of these veterans for these reasons stated fully supports just comprehensive measure aimed at substance use or to prevention early intervention and outreach education and training for veterans and their families to close the current gaps health is enter gold to the general health and well being of a patient and is part of comprehensive health care consequently davey supports the passage of this bill h r fifty six twenty two the veterans timely access to health care act would establish a five year pilot program and is an aid to insure a thirty day standard of access to primary care for enrolled veterans in a case where v a is unable to meet the thirty day access standard the bill would require v a to contract for private health care davies supports country options when needed services are unavailable in v a facilities in other circumstances authorized by law however i believe contract care should be used judiciously and that the need to better coordinate the contract a character currently authorizes to ensure high quality safety and cost effectiveness while we appreciate conscious intentions to improve access to care and acknowledge that ackman of this bill would be helpful for some veterans and potentially could damage to be assisted by eroding funding needed to sustain by ability to continue providing specialized services to service able to better and for these reasons we are unable to support this measure fifty seven twenty nine find a bit of a health care program expansion act would amend the existing authority to provide more comprehensive range of qualified practitioners and continuity of the services throughout to be a health care system we believe this measure is consistent with providing a comprehensive high quality patient centered comprehensive high quality health care services for our nation's second disabled veterans chairman ranking miller ranking member miller members of the subcommittee on behalf of the two point three million members of the veterans of foreign wars of the u s and i like to thank you for the opportunity to testify at today's important legislative hearing was a wide range of health care bills under consideration today so i'll limit my remarks are full comments and all may be found in my written statement if you have to use please to support h r twenty eight eighteen which would create centers of excellence for the treatment of epilepsy within v the experience of today's service men and women leads us to believe that epilepsy will be a growing problem in the coming years one of the main contributing factors for some forms of epilepsy is brain injury and ailment that most consider the signature wound of this war well not much study has been done on these issues with respect to today's veterans if the past is our guide we could see a wave of epilepsy and other seizure disorders soon the v a d o d research into vietnam veterans with certain types of head injuries showed a rate of epilepsy that was twenty five times higher than that of their non veteran cohorts further a large number of these disorders did not occur until at least five years after the initial injury meaning this this means that we will not see the impact on today's veterans for a few years these centers would allow v a to better research diagnose treat and educate about these conditions and we urge the subcommittee to take swift action to forestall what will be a growing problem the v f w is also happy to support h r fifty five fifty four the veterans substance use disorders prevention and treatment act we are especially supportive of section two of the bill which would expand the range of services v a provides to veterans suffering from these disorders it lists ten services that v a must provide including peer to peer counseling but also family and marital counseling these expanded services are critical substance abuse often goes hand in hand with other mental health issues such as depression and p t s d v a services for substance abuse have decreased over the last smile act we have long believed that dental care should be part of the standard health care bed package that benefits receive standard health care benefits package that veterans receive poor dental health care can create bigger health problems down the road and the image of poor dental care can be a barrier to employment for some veterans on h r fifty six twenty two we have some concern while we support the ultimate goal of this legislation which is providing timely access to v a s high quality health care but we do have some concerns in the way in which is this bill would achieve it this bill would mandate v a to provide contract care when they cannot see a veteran within thirty days of his or her scheduled appointment contracted care comes at a rate typically much higher than that of v a care further draining resources from the  system if the cost of this contracted care were instead applied to v a we believe v a would be better able to take care of more veterans reducing the waiting times we're seeing v a needs a sufficient timely and predictable health care budget with that in place we believe that the problems that this bill aims to solve would likely go away i would note that we do strongly support the report porting requirements from the bill accurate information about the waiting times will better allow us to understand and fix some of these problems we also support h fifty six twenty two which would require v a to display a prosthetics bill of rights and we support the draft bill which would expand health care to those children of vietnam veterans who are suffering from spinal bifida given that these children are suffering from the debilitating and lifelong effects of this condition because of their parents exposure during military service it is only fair that we give them proper care and the full range of health care services we would note though that these benefits should also be extended to the children of korean war veterans who are also twenty eight eighteen dva generally support legislation but we would like to offer this caveat to you we believe that the location of such centers of excellence must be in close proximity and closely associated and par the traumatic brain injury centers of excellence that are already in operation really the reasons for this are clear within our veteran cohort is most often the result of traumatic brain injury which many consider to be the  can impact survivors cognitive motor auditory olfactory and visual skills it can also collapse a family there's also one issue that needs to be considered although there are licensed clinical case managers number in the hundreds of thousand licensed brain injury case managers number only in the tens of dozens according to the case management society of america of all the medically challenging injuries brain injuries require the most involvement and cost over time the v a believes h r twenty eight eighteen is a good bill beginning from vitally needed legislation here are five five five four we believe is laudable we believe  is doable to many far too many veterans self medicate to assuage the demons inside demons that often derive from the experiences while in uniform in order for them to lead complete and productive lives they need to get the monkey off  of course going to have to gear up to comply with the provisions of h r five five five four becomes law they're going to need to find and hire enough experienced substance counselors and clerical staff something we believe we believe that this bill will likely cause more bureaucratic and clerical headaches than make the delivery of health care more efficient congress has sought to improve the very services this bill seeks to remedy by appropriating several billion congress i believe must demand accountability if there are waiting lines in florida or in seattle has got to be a reason for that incompetent management do they need more funding offering care program expansion of our fifty seven twenty nine we certainly support we would advocate over the congress consider either as part of this bill or a new bill mandating that the a conduct research into other potential intergenerational effects of exposure to dioxin and other toxins while in military services we're hearing far too many stories from far too many children most of them women  how can it be that there is such a disconnect between the stakeholders and new users of the system and the v a s that this bill is is not necessary i'll start with mr wilson example they're driving seventy eighty miles still to to receive care and when i informed them that they're a mobile clinic or seebach within that area they they basically know nothing about it so there's there's continued to be a disconnect i think i spoke on pollock programs in erected in certain parts of the country  geographic you have certain areas where there are large catchment areas and it does not reach certain veterans and i think that's the disconnect i think they are looking at their respective isn't as excellence we think and do a lot in this form of research and then actually helping patients who come down with epilepsy so we support you my next question is if you had t you know it's really hard to try to pick two out of a dozen or two out of ten whatever it is a lot of the health issues are interwoven traumatic brain injury with p t s d with stigma with i gather a bunch of the experts who are servicemen and service women who are affected and listen to what they have to say and also i would suggest the issue that i brought up with agent defects that are also believed associated with and there's been very little research does not have any research projects going on now when we asked if they had any going on we were told there may have been one awhile ago allows people to go outside of the system yet you have full support for chairman filner bill fifty seven thirty which gives the right to the person to select their own practitioner outside of the system in another sense you're saying that it's ok writes the right to select a practitioner that best out of her prosthetic needs whether or not that practitioners an employer department of veterans affairs a private practitioner who has entered into a contract with the secretary of department  provide prosthetic orthotic services for a private practitioner with specialized expertise there are a lot of areas in the country where you know we think that the program of the coming off a long way and downs over the past couple of physical therapy two and a half hours away from the v a medical center it can be done effectively locally that's fine does have to get a better handle on this and also get electronic health information which that waiting time should be one of the first things that needs to be eliminated and really no reason why folks can't be seen within a thirty day time period and we believe if you open system for certain types of care for certain types of care or for the amount i think if i recall was that allowing them to go after they could get an appointment in thirty days i could go outside it would degrade the quality of the care degrade the v a system and i'm just trying to figure out you know i think i think you might need to at least go back and revisit your testimony i understand your your explanation but i think they're  conflicting and you know we have heard just this morning an enormous amount of projects that are going to require require additional funding and resources and this committee will do everything that it can authorize that and it may be that some people would sit here and say that the first thing that you need to focus on with additional resources that congress provided is not shortening the wait time but if that's the case then we should try the veterans in the system for whatever reason it may happen to be i mean you did thank goodness say that it could be for inappropriate management or it could be for lack of dollars but i don't think anybody would want to say that the veteran would have to be band i'm not travelling that far i'm not going to sit there and wait for hours and hours and hours for something that i'm five minutes away from isn't there a way or maybe there is but isn't there a way out of this bill where  can get that and have that information transmitted to where it needs to be without having to put them through that type of wait and that you know it would just seem to be i understand major things but the t procedures that we could do literally in a matter of minutes could save hours and tons of frustration and as i said i don't want to see a veteran say i'm gone i'm not going to go through this process again because to me this was just  and there was a veteran who's who said that he had to travel eighty miles to see the care he waited for two hours and it only took outreach from the v a to the veteran for us today thank you written services would be comprehensive here as i understand it but they would not necessarily probably not be coming from so they would as a rule they would not be using the capabilities further questions i will close the hearing on that on these piece of legislation thank you very much and thank the committee members