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37-463 PDF 2007

S. HRG. 110–171

HEARING ON PENDING HEALTH CARE

LEGISLATION

HEARING

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

MAY 23, 2007

Printed for the use of the Committee on Veterans’ Affairs

(

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate 

(II)

COMMITTEE ON VETERANS’ AFFAIRS 

DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

BARACK OBAMA, Illinois 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

LARRY E. CRAIG, Idaho, Ranking Member 

ARLEN SPECTER, Pennsylvania 

RICHARD M. BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

LINDSEY O. GRAHAM, South Carolina 

KAY BAILEY HUTCHISON, Texas 

JOHN ENSIGN, Nevada 

WILLIAM E. BREW, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III)

C O N T E N T S 

MAY 23, 2007

SENATORS 

Page 

Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii ........................... 1

Prepared statement .......................................................................................... 2

Obama, Hon. Barack, U.S. Senator from Illinois .................................................. 3

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 4

Burr, Hon. Richard, U.S. Senator from North Carolina ....................................... 6

Tester, Hon. John, U.S. Senator from Montana .................................................... 6

Craig, Hon. Larry E., Ranking Member, U.S. Senator from Idaho ..................... 56

Prepared statement .......................................................................................... 56

Isakson, Hon. Johnny, U.S. Senator from Georgia ............................................... 65

Sanders, Hon. Bernard, U.S. Senator from Vermont ........................................... 66

WITNESSES 

Cross, Gerald M., M.D., FAAFP, Acting Principal Deputy Under Secretary 

for Health, Department of Veterans Affairs; accompanied by Walter Hall, 

Assistant General Counsel, Department of Veterans Affairs ........................... 6

Prepared statement .......................................................................................... 8

VSO letter opposing S. 815 .......................................................................... 17

Response to additional information requested by Committee Members 

during the hearing ........................................................................................ 19

Blake, Carl, National Legislative Director, Paralyzed Veterans of America ...... 69

Prepared statement .......................................................................................... 71

Cullinan, Dennis M., Director, National Legislative Service, Veterans of Foreign Wars of the United States ........................................................................... 75

Prepared statement .......................................................................................... 77

Ilem, Joy J., Assistant National Legislative Director, Disabled American

Veterans ................................................................................................................ 80

Prepared statement .......................................................................................... 82

Middleton, Shannon, Deputy Director for Health, Veterans Affairs and Rehabilitation Commission, The American Legion .................................................... 89

Prepared statement .......................................................................................... 90

Edelman, Bernard, Deputy Director, Policy and Government Affairs, Vietnam 

Veterans of America ............................................................................................. 93

Prepared statement .......................................................................................... 95

Vietnam Veterans of America’s views on rural veterans health care .......... 98

Beck, Meredith, National Policy Director, Wounded Warrior Project ................. 102

Prepared statement .......................................................................................... 104

Booss, John, M.D., Professor Emeritus of Neurology and Laboratory Medicine, 

Yale University School of Medicine; on behalf of the American Academy 

of Neurology .......................................................................................................... 106

Prepared statement .......................................................................................... 108

Reed, Jerry, Executive Director, Suicide Prevention Action Network USA ....... 109

Prepared statement .......................................................................................... 111

APPENDIX 

Allard, Hon. Wayne, U.S. Senator from Colorado, prepared statement ............. 115

Huston, Ann, Executive Director and CEO, American Therapeutic Recreation 

Association, prepared statement ......................................................................... 116

American Academy of Physical Medicine and Rehabilitation, prepared

statement .............................................................................................................. 119

Page

IV

American Congress of Rehabilitation Medicine, prepared statement ................. 121

Brain Injury Association of America, prepared statement ................................... 123

Commission on Accreditation of Rehabilitation Facilities, prepared statement 124

Vermont resident e-mail to Senator Sanders received May 17, 2007 ................. 126

Coelho, Tony, Epilepsy Foundation, letter of support for S. 1233 ....................... 126

(1)

HEARING ON PENDING HEALTH CARE 

LEGISLATION 

WEDNESDAY, MAY 23, 2007

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 9:30 a.m., in Room 

562, Dirksen Senate Office Building, Hon. Daniel K. Akaka, Chairman of the Committee, presiding. 

Present: Senators Akaka, Murray, Obama, Brown, Tester, Sanders, Craig, Burr, and Isakson. 

OPENING STATEMENT OF DANIEL K. AKAKA, CHAIRMAN,

U.S. SENATOR FROM HAWAII 

Chairman AKAKA. The U.S. Senate Committee on Veterans’ Affairs will come to order. Aloha and good morning, everyone. Welcome to the Committee’s hearing on pending health legislation. 

The Committee has quite a docket of legislation to review, so I 

will make my opening remarks quite brief so that we can get started. As I said at our last legislative hearing, I am thankful for Members’ interest in the needs of veterans and their families and the 

range of attempts to tackle some of the most pronounced issues. I 

know that our witnesses had quite an undertaking to do in order 

to give us views on the various bills we have before us. The Committee has done extensive oversight work and held numerous hearings on these matters. The legislation before us is a culmination of 

those activities. 

Ranking Member Craig and I heard the testimony of witnesses 

at our March 27 hearing on seamless transition and care for veterans with traumatic brain injuries. We used that testimony to develop bipartisan legislation on TBI, which takes a comprehensive 

approach to providing the best possible care for veterans with this 

devastating injury. 

I want to mention my legislation to extend the period of eligibility for VA health care for combat service from two to five years. 

It is my view that doing so will help ensure that returning 

servicemembers receive the care they need from VA in the five 

years immediately following separation or deactivation without 

having to meet strict eligibility rules. The changes my bill would 

make will contribute to the seamless transition of military personnel from active duty to veteran status. 

While the Administration has opposed this legislation in the 

past, I am delighted that the obvious growth in the diagnosis for 

mental health conditions has prompted a reconsideration of their 

2

previous position. Two years is often insufficient time for symptoms 

related to PTSD and other mental illnesses to manifest. In many 

cases, it takes years for such symptoms to present themselves and 

many servicemembers do not immediately seek care. Five years 

would provide a bigger window to address these risks. We face a 

growing group of recently discharged veterans and this legislation 

will help smooth their transition to civilian life. 

I thank the witnesses from VA and other organizations for coming today to share their views. Because the number of measures before us this morning is unusually large and a number of them have 

been added to the agenda only recently, witnesses may not have 

had an opportunity to review them and formulate positions. Therefore, the Committee will hold the record of this hearing open for 

two weeks so that witnesses can submit supplemental views on any 

legislative item. 

It is important that we have your input well in advance of our 

markup, which is scheduled for late next month. I look forward 

with all of you in the days ahead to move the Committee’s agenda 

forward. 

[The prepared statement of Senator Akaka follows:]

PREPARED STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,

U.S. SENATOR FROM HAWAII

Aloha and good morning. I welcome everyone to the Committee’s hearing on pending health legislation. The Committee has quite a docket of legislation to review, 

so I will make my opening remarks quite brief so that we can get started. 

As I said at our last legislative hearing, I am thankful for Members’ interest in 

the needs of veterans and their families and the range of attempts to tackle some 

of the most pronounced issues. That said, I know that our witnesses had quite a 

load to carry in order to give us views on the various bills. 

The Committee has done much oversight work and held various hearings, and the 

legislation before us is a culmination of those activities. Ranking Member Craig and 

I heard the testimony of witnesses at our March 27th hearing on seamless transition and care for veterans with traumatic brain injuries. We used that testimony 

to develop bipartisan legislation on TBI, which takes a comprehensive approach to 

providing the best possible care for veterans with this devastating injury. 

I want to speak very briefly about some of the items on the agenda. 

First, I introduced legislation again this Congress to extend the period of eligibility for VA health care for combat service from two to five years. It is my view 

that doing so will help ensure that returning servicemembers receive the care they 

need from VA in the five years immediately following separation or deactivation, 

without having to meet strict eligibility rules. The changes S. 383 would make will 

contribute to the ‘‘seamless’’ transition of military personnel from active duty to veteran status. 

While the Administration has opposed this legislation in the past, I am delighted 

that the obvious growth in the diagnoses for mental health conditions has prompted 

a reconsideration of the previous position. Two years is often insufficient time for 

symptoms related to PTSD and other mental illnesses to manifest. In many cases, 

it takes years for such symptoms to present themselves, and many servicemembers 

do not immediately seek care. Five years would provide a bigger window to address 

these risks. We face a growing group of recently discharged veterans, and this legislation will help smooth their transition to civilian life. 

Second, S. 117, The Lane Evans Veterans Health and Benefits Improvement Act 

of 2007, introduced by Senator Obama, is a fitting tribute to the former Ranking 

Member of the House Committee on Veterans’ Affairs. The legislation, among other 

things, would make combat-theater veterans eligible for a VA mental health evaluation within 30 days of the veteran’s request. Such a request could be made up to 

five years after the date of the veteran’s discharge or release from active military 

service. 

S. 479, The Joshua Omvig Veterans Suicide Prevention Act, would require the 

Secretary to develop and implement comprehensive programs to reduce suicide 

among veterans. The bill is named after Joshua Omvig, a young veteran who comVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
3

mitted suicide after returning from Iraq. On April 25, 2007, the Committee heard 

testimony from Joshua Omvig’s parents about his struggle. It became clear that VA 

must place greater emphasis on reaching out to returning servicemembers, so as to 

prevent these types of tragedies from occurring in the future. 

S. 1147, the Honor our Commitment to Veterans Act, would repeal the ban on 

enrollment of middle-income veterans, known as Priority 8 veterans, in the VA 

health care system. In the Majority’s Views and Estimates letter to the Budget 

Committee, we recommended including funding in VA’s Fiscal Year 2008 budget to 

enable VA to fully open its doors to all veterans who desire VA health care. In doing 

so, I do not believe that we need to undo what was done in eligibility reform, that 

is, to allow the VA Secretary to manage a priority system for care within the confines of a limited budget. I do believe that this year, the Congress will appropriate 

sufficient resources to allow for open access to VA health care while not severely 

altering the construct of eligibility reform or overburdening the system. 

As I mentioned a moment ago, I am quite proud of S. 1233, the Veterans Traumatic Brain Injury Act of 2007. Senator Craig and I worked to develop a bill to address VA shortcomings in rehabilitation treatment, research and clinical care programs for veterans. The Brain Injury Association of America, the American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation all support the legislation. 

Finally, I also introduced S. 1384, which would make a number of changes to the 

funding for homeless programs; expand programs to aid in the transition to civilian 

life for both incarcerated veterans and servicemembers being discharged from the 

military; and improve domiciliary care for women veterans. All of these changes are 

yet another step in combating the prevalence of homelessness among those who 

have served our Nation. 

I thank the witnesses from VA and other organizations for coming today to share 

their views. Because the number of measures before us this morning is unusually 

large and a number of them have been added to the agenda only recently, witnesses 

may not have had an opportunity to review them and formulate positions. Therefore, the Committee will hold the record of this hearing open for two weeks so that 

witnesses can submit supplemental views on any legislative item. It is important 

that we have your input well in advance of our markup which is scheduled for late 

next month. 

I look forward to working with all of you in the days ahead to move the Committee’s agenda forward. Thank you.

I would like to ask for any other remarks. Senator Obama, and 

then Senator Murray. 

STATEMENT OF HON. BARACK OBAMA,

U.S. SENATOR FROM ILLINOIS 

Senator OBAMA. Thank you, Mr. Chairman, and thank you for 

holding this hearing. I also want to thank the panelists and especially our friends in the VSO community and expert witnesses for 

their feedback on legislation under discussion today. 

I would like to briefly discuss two important measures that I 

have introduced in this Committee. The Lane Evans Veterans 

Health and Benefits Improvement Act, which you mentioned, Mr. 

Chairman, very graciously, and I appreciate, would enhance mental 

health care and access for our veterans by enabling them to receive 

a mental health screening within 30 days of a request and full access to care required as a result of that screening, including hospital care, nursing home care, or family and marital counseling. 

Veterans would be eligible to request the screening 5 years after 

discharge and would be eligible for any resulting treatment for 2 

years. The bill would also establish one-on-one face-to-face mental 

health screening for all returning servicemembers and would require that they receive individual electronic records upon

discharge. 

Now, unfortunately, the VA has expressed opposition to one provision in the bill, a proposed veterans’ information tracking system 

4

that would help anticipate the needs of our veterans and lead to 

more robust policy planning by the VA and Congress. Although VA 

has regularly struggled—and both you, Mr. Chairman, as well as 

Senator Murray have been working on this for a long, long time—

to adequately anticipate its own budgetary needs and provide information requested by Congress, it argues that current reporting is 

sufficient and believes this provision is too costly and onerous. 

I would argue that whatever costs would be incurred in setting 

up this tracking system would be more than offset by the better 

care that we could provide our Nation’s veterans. It just strikes me 

that our planning process continues to break down. In the time 

that I have been on this Committee, we constantly have to come 

back with supplementals because we have not anticipated needs. I 

don’t understand why the VA is resistant to instituting the sort of 

mechanisms that I think every large business and institution 

around the country puts into place to make sure that their budget 

is adequate to their needs. So I am going to be interested in finding 

once again why the VA is not willing to do that. 

I am also pleased to have introduced the VA Hospital Quality Report Card Act. Our VA hospital system is considered by many to 

be the best health care system in the Nation and I think it is a 

wonderful success story, the progress that the VA has made over 

the last several decades. This bill does not question the assessment 

that VA has a high-quality health care system in place. Rather, it 

is intended to encourage the examination of hospital-specific performance to ensure uniformity and quality across hospitals. The 

bill would also require hospitals to measure and report quality information for sub-populations that have historically received lower 

quality care. 

The VA’s own research studies have identified a number of racial 

and ethnic differences in health outcomes and patient experiences, 

some positive and some negative, which support continued data collection and analysis for minority populations. This likely holds true 

for other patient populations, as well, and I believe that all hospitals should be tasked to conduct this work. 

I worked in the Illinois State Senate to pass similar legislation. 

It succeeded in making my State’s hospitals more responsive to the 

needs of their patients. 

Mr. Chairman, I want to thank you again for holding this hearing. I look forward to working with you on passing these measures 

and thank the panelists for their invaluable feedback. I probably 

will not be able to stay for all the testimony, but I am hoping to 

get some of the testimony before I have to go. 

Chairman AKAKA. Thank you very much, Senator Obama. 

And now, Senator Murray. 

STATEMENT OF HON. PATTY MURRAY,

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Thank you very much, Mr. Chairman. I really 

appreciate your holding this important hearing on ways that we 

can help improve the health care for our veterans and I think it 

is really appropriate that we are holding this hearing so close to 

Memorial Day. It is the day that we honor all of those who have 

paid the ultimate price for our freedom, and as we remember their 

5

sacrifice, it is an appropriate time to make sure we are keeping our 

commitment to all of those who served us. 

Mr. Chairman, as the needs of our veterans change, we have to 

update our policies to meet those needs. For example, we just recently learned that there is a significant association between exposure to nerve agents in the First Gulf War and long-term brain 

damage. That is a great example of how recent research should 

guide us to improve our care for veterans and I am working with 

Senator Rockefeller and Senator Bond to do that. 

Our veterans do deserve the best care and we are taking steps 

to provide it. Last week, we passed a budget that provides $3.5 billion more than the President asked for for our veterans’ programs, 

and in fact, Mr. Chairman, working with you, we provided 98 percent of what the Independent Budget requested, and importantly, 

that budget did away with the Administration’s proposed fees and 

copays for our veterans. 

But we do have to do more and it is why we are looking at a variety of bills here today. I am really pleased that there are a number of really great proposals. One of them is legislation that I have 

introduced that will open the door to VA health care for veterans 

who were unfairly shut out by this Administration more than 4 

years ago. The Bush Administration cut off enrollment of Priority 

8 veterans into the VA health care system. Priority 8s are those 

veterans without service-connected disabilities whose incomes are 

above a means-tested level that varies throughout the country. But 

many of those so-called high-income veterans have incomes as low 

as $26,902. 

My legislation is the Honor Our Commitment to Veterans Act of 

2007. It would rescind the Administration’s January 2003 decision 

to prevent new enrollment of Priority 8 veterans into the VA health 

care system and I am very pleased that this legislation is supported by the American Legion, Veterans of Foreign Wars, Vietnam 

Veterans of America, and the Paralyzed Veterans of America. 

Mr. Chairman, according to a recent Congressional Research 

Service report, the VA estimates that if an enrollment freeze was 

lifted, approximately 273,000 Priority 8 veterans would have been 

eligible to receive medical care from the VA in fiscal year 2006, and 

242,000 Priority 8 veterans would have been eligible in 2007. 

Mr. Chairman, we are nearly 5 years into this war and our veterans are facing lengthy waits just to get to see a primary care 

physician. They are having trouble accessing critical mental health 

services and some are waiting up to 2 years for the benefits that 

they were promised to be processed. These are real problems facing 

real people and they deserve solutions. 

Instead of cutting off enrollment to veterans of modest means 4 

years ago, the Bush Administration should have asked Congress 

for the resources necessary to address its shortcomings and increase access to the VA. It is absolutely unacceptable that veterans 

in need of care are being prohibited from enrolling in the system 

that is supposed to serve them. Veterans who have fought hard to 

secure our freedoms shouldn’t have to fight for access to health 

care at home. They deserve better. 

6

So, Mr. Chairman, I appreciate this opportunity for my bill and 

the others on the calendar today and I look forward to hearing 

from our witnesses. 

Chairman AKAKA. Thank you very much, Senator Murray. 

Senator Burr for your remarks. 

STATEMENT OF HON. RICHARD BURR,

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Mr. Chairman, I thank you. I would only say 

thank you for holding this hearing. I look forward to the panels of 

witnesses that we have today and believe that what we are going 

to learn will help this Committee to move forward with some very 

important legislation. I thank the Chair. 

Chairman AKAKA. Thank you. Thank you very much. 

Now Senator Tester for any remarks he may have. 

STATEMENT OF HON. JON TESTER,

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Mr. Chairman. I, too, want to thank 

you for holding the hearing. I think there are some very good bills 

here. I look forward to hearing the Department’s opinion on them 

and the discussion that will revolve around them. I think there are 

some important issues out there and I think some of these bills 

deal with those issues, so thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much for your remarks. 

Now again, I want to welcome our witnesses from VA, Dr. Gerald 

M. Cross, the Acting Principal Deputy Under Secretary for Health, 

who is accompanied by Walter Hall, Assistant General Counsel. 

I thank both of you for being here this morning and look forward 

to your testimony. VA’s full statement will appear in the record of 

this hearing. Dr. Cross, will you please proceed with your testimony. 

STATEMENT OF GERALD M. CROSS, M.D., ACTING PRINCIPAL 

DEPUTY UNDER SECRETARY FOR HEALTH, DEPARTMENT

OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER HALL, 

ASSISTANT GENERAL COUNSEL, DEPARTMENT OF VETERANS AFFAIRS 

Dr. CROSS. Thank you, sir, and good morning, Mr. Chairman and 

Members of the Committee. Thank you for inviting me here today 

to present the Administration’s views on several bills that would 

affect programs administered by the Department of Veterans Affairs in the provision of health care to veterans. With me today is 

Walter Hall, Assistant General Counsel. 

Sir, with your permission, I would also like to introduce a guest 

who happens to be accompanying me this morning, a fighting 

SeeBee, Michael Christianson—can you stand up, Michael—who is 

accompanying the VA team this morning. He is on a commission 

working with us and others looking at their needs. I wanted to 

thank Michael for his service since he is here with us today, and 

he actually comes from Washington State. 

Senator MURRAY. Very good. Welcome. 

Chairman AKAKA. Welcome to the Committee. 

Dr. CROSS. He is recently back from Iraq. 

7

Knowing my time is limited, I will highlight bills addressing 

some of our common interest. I would like to submit, as you said, 

Mr. Chairman, my written testimony for the record. 

First of all, VA supports S. 383, which extends the 2 years to 5 

years, the period of eligibility for priority access to VA health care 

services for combat veterans. This bill would give additional time 

for separated servicemembers to seek treatment of symptoms that 

may develop later than 2 years in cases such as PTSD or TBI. We 

feel that the passage of this bill would eliminate the need for

S. 117, Section 101 that provides for mental health services for 

combat theater veterans after the 2-year eligibility period. 

VA understands the intent of S. 479 and acknowledges the need 

to address suicide prevention comprehensively. Mr. Chairman, a 

veteran’s suicide is a devastating event for family, for friends, and 

for those who are entrusted with his or her care. VA recognizes the 

pain that families like that of Joshua Omvig are experiencing and 

we are fully in sympathy with the aims of the bill that bears Mr. 

Omvig’s name. We feel, however, that the bill is unnecessary because it duplicates many of the efforts that are already underway 

in the Department. 

VA is currently implementing its Mental Health Strategic Plan 

based on the goals of the President’s New Freedom Commission on 

Mental Health and we are proud of the steps we have already 

taken and would be happy to brief the Committee on our initiatives 

as well as to explore additional measures with you that could supplement our efforts, efforts that would honor the memory of Mr. 

Omvig and pay proper tribute to his family that have done so much 

to keep this issue in the public’s eye. 

S. 692 requires the VA to establish a hospital quality report card 

initiative. VA is already complying with the intent of this bill as 

it comes into compliance with Executive Order 134–10, requiring 

Federal agencies to report provider-level data to their beneficiaries. 

In addition, the Joint Commission on Accreditation for Hospitals 

makes public information on hospital performance in key areas of 

care available on their web site where veterans may compare VA 

hospitals to other accredited hospitals in their communities. Moreover, VA uses over 100 performance measures related to patient 

care in VA facilities as ongoing components of quality improvement. This information is routinely reported to senior leadership 

and is a basis for evaluation for facility and network leadership. 

For these reasons, we do not support S. 692, but we would be 

pleased to work with the Committee staff to explain how we use 

performance measures. 

On S. 1233, while VA is continuing to review this bill and will 

submit formal views following this hearing, I would like to emphasize VA shares the passion this Committee has for the impact of 

TBI on our combat veterans. Mr. Chairman, as you know, VA and 

DOD are working collaboratively on this diagnosis and on many 

issues surrounding it, from diagnostic screening tools to rehabilitative transitional care. There is a range for TBI injuries from mild 

to severe. VA is refining continuously the parts of the program that 

address all aspects of TBI. VA now has an effective screening tool 

in place that also has been presented and taught to our clinicians 

and is also being shared with DOD. 

8

Moreover, VA’s comprehensive polytrauma network has individual case managers for veterans with these complex injuries and 

we are now hiring transitional patient advocates who help families 

work through the more complex aspects of care. VA continues to be 

a leader in new approaches for caring for these patients with using 

their emerging consciousness program. In just 3 years, VA has 

taken tremendous steps in the TBI polytrauma arena and we plan 

to continue these advancements within VA and within our partnership with DOD. 

I am very proud of the steps we already have taken and will be 

happy to brief the Committee on any of our programs, and I would 

be pleased to answer any questions you or any Members of the 

Committee have, sir. Thank you. 

[The prepared statement of Dr. Cross follows:]

PREPARED STATEMENT OF GERALD M. CROSS, M.D., FAAFP, ACTING PRINCIPAL

DEPUTY UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

Good Morning Mr. Chairman and Members of the Committee: 

Thank you for inviting me here today to present the Administration’s views on 

several bills that would affect Department of Veterans Affairs (VA) programs that 

provide veterans benefits and services. With me today is Walter A. Hall, Assistant 

General Counsel. I am pleased to provide the Department’s views on 15 of the 20 

bills under consideration by the Committee. I will briefly describe each bill, provide 

VA’s comments on each measure and estimates of costs (to the extent cost information is available), and answer any questions you and the Committee members may 

have. 

Unfortunately, we are unable to comment on the five other bills (i.e., S. 1233, S. 

1326, S. 1384, S. 1396, and S. 1441) because we only recently received them and 

learned they would be on today’s agenda. However, we will evaluate those bills and 

provide our views and estimates for the record. 

Mr. Chairman, I will begin by discussing four bills on today’s agenda that would 

address the delivery and types of VA health care services available to veterans of 

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) and future 

combat operations. 

S. 117—LANE EVANS VETERANS HEALTH AND BENEFITS

IMPROVEMENT ACT OF 2007

The first of these is S. 117. We testified regarding certain benefits-related provisions on May 9, 2007. Today I will discuss three sections of that bill that relate to 

health care benefits: sections 101, 202, and 203. 

Section 101 of the bill would make combat-theater veterans eligible for a VA mental health evaluation within 30 days of the veteran’s request. The veteran would be 

able to request and receive such an examination up to 5 years after the date of the 

veteran’s discharge or release from active military service. In addition, such veterans would be eligible for hospital care, medical services, nursing home care, and 

family and marital counseling for any mental health condition identified during that 

examination, notwithstanding that the medical evidence is insufficient to conclude 

that the mental health condition is attributable to the veteran’s combat service. Eligibility for medical services needed to treat the veteran’s identified mental health 

condition would continue for 2 years, beginning on the date VA begins to provide 

such services. The bill would not, however, cover any mental health disability found 

by the Under Secretary for Health to have resulted from a cause other than the veteran’s combat service. 

VA supports section 101. However, we note that this bill would be wholly unnecessary should the Congress pass S. 383, which is discussed below. 

Section 102 would amend the statutory requirements applicable to the mandated 

post-deployment examinations conducted by the Department of Defense (DoD). As 

to this provision, we defer to the views of DoD. 

Section 202 would require VA to establish an information system designed to provide an elaborate and comprehensive record of the veterans of the Global War on 

Terrorism (GWOT) who seek VA benefits and the benefits they receive. Section 203 

would mandate that VA submit a quarterly report to Congress on the effects of participation in GWOT on both veterans and the Department. The first of these reports 

9

would be due not later than 90 days after this Act’s enactment. Each quarterly report would include aggregated information on VA health, counseling, and related 

benefits to GWOT veterans, including information on the enrollment status of 

GWOT veterans; the number of inpatient stays they experienced and the related 

cost of that care (by both enrollment status and condition); the number of outpatient 

visits they experienced and the related cost of such services (again by enrollment 

status and by condition); and the number of visits to Vet Centers and the related 

cost of providing them readjustment counseling and services. 

As we testified on May 9, 2007, this bill’s requirements to compile and frequently 

report to Congress massive amounts of data, much of which are not currently available, in the detail and manner specified, would force VA to divert considerable resources from our primary responsibilities. Health care data on these veterans are 

currently collected and tracked through the Veterans Tracking Application, which 

is specific to injured servicemembers who transition to VA care. However, that information is considered only in the aggregate. Therefore, collection and tracking the 

individual-specific data mandated by the bill would require considerably expanded 

administrative personnel and resources. But again first and foremost, complying 

with these sections would require resources that would otherwise be devoted to the 

medical mission of VA. For this reason, we cannot support sections 202 and 203 of 

the bill. We remain very mindful of this Committee’s oversight responsibilities and 

would welcome the opportunity to work with staff to identify information that is 

currently lacking that would be most helpful to the Committee in meeting its responsibilities. 

We are, as yet, unable to reliably estimate the costs of compliance [in terms of 

both manpower and potential for detracting from the primary mission of the Veterans Health Administration], but we believe that they would be substantial. 

S. 383—EXTENSION OF TREATMENT AUTHORITY

FOR COMBAT-THEATER VETERANS

S. 383 would amend existing law to increase to five the number of years a combattheater veteran is eligible for free VA health care for illnesses or conditions that 

might be associated with combat service. The five-year window of eligibility would 

begin on the date of discharge or separation from active military, naval, or air service. Currently, the law provides these veterans with two years of such eligibility. 

VA supports S. 383. When these veterans seek care from VA they are placed in 

priority Category 6 and make no copayments for covered conditions. When the special treatment authority for combat-theater veterans was originally enacted, it was 

generally assumed that 2 years was sufficient. However, experience has shown that 

this is not always the case. In caring for OEF/OIF veterans we have discovered that 

the onset of symptoms, or adverse health effects, related to Post-Traumatic Stress 

Disorder (PTSD), and even Traumatic Brain Injury (TBI), are often delayed, or do 

not manifest clinically, for more than two years after a veteran has left active service. As a result, many OEF and OIF veterans do not seek VA health care benefits 

until after their two-year window of eligibility has closed. Without eligibility for enrollment in priority Category 6, many, i.e., those with higher incomes and non-service connected conditions, would not be eligible to enroll because they would be in 

priority Category 8. 

In addition, many OEF/OIF veterans are non-career military members who are 

unfamiliar with veterans benefits and the procedures for obtaining them. For that 

reason many fail to enroll in a timely fashion. Providing combat-theater veterans 

with an additional 3 years within which to access VA’s health care system would 

help to ensure that none of them is penalized because of reasons beyond their control or because they have been unable to navigate through VA’s claims system in 

time. 

VA estimates the costs associated with enactment of S. 383 to be $14.1 million 

in fiscal year 2008 and $289 million over a 10-year period. These estimates include 

both expenditures and lost copayment revenue. 

S. 479—JOSHUA OMVIG VETERANS SUICIDE PREVENTION ACT

S. 479 would require the Secretary to develop and implement a comprehensive 

program (comprised of 10 specific elements) for reducing the incidence of suicide 

among veterans. First, the program would include a national mental health campaign to increase awareness in the veteran community that mental health is essential to overall health and that effective modern treatment can promote recovery 

from mental illness. Second, it would call for mandatory training on suicide prevention for appropriate employees and contract personnel (including all medical personnel) who interact with veterans. This training would require the provision of inVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
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formation on the recognition of risk factors for suicide, protocols for responding to 

crisis situations involving veterans who may be at high risk for suicide, and best 

practices for suicide prevention. Third, the comprehensive program would include 

outreach programs and educational programs for veterans and their families, in particular OEF/OIF veterans and their families. The educational programs would serve 

to help: eliminate or overcome stigmas associated with mental illness; further understanding of veterans’ readjustment issues; identify signs and symptoms of mental 

health problems; and encourage veterans to seek assistance for these types of problems. 

Fourth, the program would include a peer counseling program in which veterans 

are trained as peer-counselors to assist other veterans suffering from mental health 

issues. (Training of these veterans would have to include specific education on suicide prevention.) The peer-counselors would also be responsible for conducting outreach on mental health matters to veterans and their families. The legislation would 

require the Secretary to make this peer-program available in addition to other mental health services already offered by VA (including those that would be established 

by this Act). 

Fifth, the Secretary would be directed, as part of the comprehensive program, to 

encourage all veterans applying for VA benefits to undergo a mental health assessment at a VA medical facility or Vet Center. 

Sixth, the program would include the provision of referrals, as appropriate, to veterans who show signs or symptoms of mental health problems. 

Seventh, the Secretary would need to designate a suicide prevention counselor at 

each VA medical facility (other than a Vet Center). These counselors would work 

with a variety of local non-VA entities to engage in outreach to veterans about available VA mental health services. They would also be responsible for improving the 

coordination of mental health care furnished to veterans at the local level. 

Eighth, VA’s program would have to include research on best practices for suicide 

prevention among veterans. Moreover, the Secretary would need to establish a 

steering committee to advise on such research. Such committee would be comprised 

of representatives from the National Institute of Mental Health (NIMH), Substance 

Abuse and Mental Health Services Administration (SAMHSA), and the Centers for 

Disease Control and Prevention (CDC). 

Ninth, the Secretary would have to ensure the availability of VA mental health 

services on a 24-hour basis. 

Finally, the Secretary would be authorized to establish a continuously operational, 

toll-free telephone number that veterans could call for information on, and referrals 

to, appropriate mental health services. 

This legislation would permit the Secretary to include any other activities in the 

comprehensive program that the Secretary deems appropriate. It would also require 

the Secretary to submit, not later than 90 days after the date of enactment, a detailed report to Congress on all of the Department’s suicide prevention programs 

and activities. (Any suicide prevention programs VA establishes afterwards would 

have to be developed in consultation with NIMH, SAMHSA, and CDC.) 

We appreciate the purpose of this legislation; however, we do not support this bill. 

It is unnecessary because it duplicates many efforts already underway by the Department. Indeed, many of the bill’s requirements are already being addressed and 

implemented through VA’s current Mental Health Strategic Plan. (As you will recall, this Strategic Plan was designed to both ensure that our Department continues 

as a leader in the area of mental health and to implement the goals of the President’s New Freedom Commission on Mental Health.) We therefore ask that the 

Committee forbear in its consideration of S. 479. In the meantime, we will be happy 

to brief the Committee on the myriad initiatives we have right now and explore with 

you additional measures that could supplement these efforts. 

Should the Committee proceed to act on this measure, we note our objection to 

the bill’s requirement to train and use veterans as peer counselors for other veterans with mental health issues. The use of adult veterans as peer-counselors in 

caring for other veterans who suffer from mental health issues is simply not advisable. Data on the efficacy of these types of programs do not reflect favorable results. 

Although well-intended, we believe such an approach to clinical care lacks scientific 

support. We strongly believe that VA mental health care services, including counseling, should continue to be provided by our capable, experienced, and appropriately trained cadre of mental health care professionals. 

In addition, we do not think the bill’s requirement that we encourage every veteran seeking any type of VA benefit to obtain a mental health assessment is justified, and it may cause veterans to believe they have been stigmatized. 

11

S. 882—VETERAN NAVIGATORS TRANSITION ASSISTANCE PROGRAM

Mr. Chairman, the fourth bill on today’s agenda that would have particular significance for those returning from deployment in OEF/OIF is S. 882, although it 

would, in fact, apply to all servicemembers of the Armed Forces who are 

transitioning from DoD’s health care system to VA’s. 

S. 882 would require the Secretary, in consultation with the Secretary of Defense, 

to establish and carry out a 5-year pilot grant program to assess the feasibility and 

advisability of using eligible entities to assist members of the Armed Forces in applying for, and receiving, VA health care benefits and services after completion of 

military service. 

The mandated pilot grant program would focus on eligible entities that provide 

assistance to members with serious wounds or injuries; members with mental disorders; female members; and members of the National Guard and the Reserves. Eligible entities would include non-VA, non-DoD entities or organizations that possess, 

or which can acquire, the capacity to provide the described transitional assistance. 

The entities would provide the assistance through ‘‘Veteran Navigators,’’ qualified 

individuals who would provide assistance to members on an individual basis. The 

legislation would establish very specific qualifications for, and responsibilities of, 

Veteran Navigators. 

S. 882 would require the Secretary to establish at least one pilot site in the vicinity of a military treatment facility that treats members of the Armed Forces who 

are seriously wounded or injured in Afghanistan or Iraq, another in the vicinity of 

a rural VA medical center, and one in the vicinity of an urban VA medical center. 

To add additional sites, the Secretary would need to consult with the grant application evaluation panel, which would be established by this legislation. 

Grants awarded under this pilot program could not exceed 3 years, although a 

grant could be renewed for 1 year. Eligible entities seeking grants would be required 

to submit a detailed application to the Secretary, which addresses all of the specified information set forth in the bill. A grant could not be awarded, however, to an 

eligible entity that is receiving Federal funds for the same activities on the date on 

which the eligible entity submits an application to VA, unless the Secretary determines that the entity will use the grant authorized under this bill to expand services or provide new services. The bill would permit these grants to be used to recruit, assign, train, and employ Veteran Navigators. 

The grant application panel would be comprised of VA employees, DoD employees, 

and representatives from both Veterans Service Organizations and organizations 

that provide services to members of the Armed Forces. It would evaluate all grant 

applications and make recommendations to the Secretary. Finally, S. 882 would create reporting requirements for both the grant recipients and the Department. The measure would authorize $2 million to be appropriated to carry out the pro- gram for fiscal year 2008; $5 million for fiscal year 2009; $8 million for fiscal year 

2010, $6.5 million for fiscal year 2011; and $3.5 million for fiscal year 2012. Any 

amount authorized to be appropriated would remain available for obligation through 

the end of fiscal year 2012. 

Mr. Chairman, VA does not support S. 882 because it is unnecessary and duplicative of ongoing outreach services and seamless transition efforts currently underway 

by VA and DoD. It would also duplicate responsibilities of Veterans Service Organizations and State veterans’ offices and agencies. 

S. 815—VETERANS HEALTH CARE EMPOWERMENT ACT OF 2007

Mr. Chairman, we next address S. 815, a bill that would significantly change the 

nature of the VA health care system. S. 815 would authorize veterans with a service-connected disability to obtain their health care at VA-expense from any provider 

eligible to receive payment under Medicare or TRICARE. This authority would cease 

after September 30, 2009. 

VA strongly opposes enactment of S. 815. We fully concur in the views of several 

of the major VSOs, who recently wrote to the Chairman of the Senate Committee 

on Veterans Affairs in opposition to S. 815. (We will provide this letter to the Committee for the record.) At bottom, S. 815 could lead to the undoing of the VA healthcare system—a world-class health care system—as we know it today. For this fundamental reason, we must oppose this bill. 

We also have other concerns. The proposal would fragment the care of our veterans. VA would no longer have a complete record of all the care a covered veteran 

has received. This could lead to VA duplicating care already provided in the private 

sector or providing care that conflicts with what the veteran is receiving in the private sector. As you are aware, some in the private sector rely on paper records while 

the VA uses a comprehensive electronic health record. Electronic records promote 

12

patient safety. We are concerned that the bill, if enacted, could jeopardize continuity 

of care for our patients. Last, unlike the private sector, VA screens all returning 

combat-theater veterans for TBI, PTSD, depression, and substance abuse. 

S. 1146—RURAL VETERANS HEALTH CARE IMPROVEMENT ACT OF 2007

We now turn to S. 1146, which is intended to improve VA’s ability to meet the 

health care needs of rural veterans. Section 2 of this bill would amend VA’s beneficiary travel program by making VA pay or reimburse eligible veterans at the same 

per diem rates and mileage rates that apply to Federal employees using privately 

owned vehicles for official travel. This section would also repeal existing deductible 

requirements that apply to the receipt of VA beneficiary travel benefits. 

Section 3 would require the Secretary, through the Director of the Office of Rural 

Health, to establish up to five Rural Health Research, Education, and Clinical Centers of Excellence (‘‘Centers’’). The bill sets forth detailed requirements that would 

govern the Secretary’s designation and placement of such Centers. It also would 

limit designation of Centers to those facilities found by a peer review panel to meet 

the highest competitive standards of scientific and clinical merit and also found by 

the Secretary to have met the requirements specified in the legislation. 

Section 4 would require the Secretary to establish a grant program for State Veterans’ Service Agencies and Veterans Service Organizations for purposes of providing veterans living in remote rural areas with innovative means of travel to VA 

medical centers (and to assist them with their other medical care needs). A grant 

awarded under this section could not exceed $50,000. Grant recipients would not be 

required to provide matching funds as a condition for receiving a grant. This section 

would require the Secretary to prescribe regulations to implement this program and 

also authorize to be appropriated $3 million for each of FYs 2008 through 2012 to 

carry out this program. 

Section 5 would require the Secretary, through the Director of the Office of Rural 

Health, to carry out demonstration projects to examine alternatives for expanding 

care to veterans in rural areas. In so doing, the Secretary would be required to establish partnerships with the Department of Health and Human Services (HHS) to 

coordinate care for veterans in rural areas at both critical access hospitals and community health centers. VA would also be obliged to coordinate with HHS’ Indian 

Health Service to expand care for Native American veterans. 

The bill would institute annual reporting requirements, the first of which would 

have to include the results of the statutorily mandated assessment of VA’s fee-basis 

program on the delivery of care to veterans residing in rural areas, along with the 

results of VA’s extensive outreach program to OEF/OIF veterans living in rural veterans. 

Mr. Chairman, in accordance with Congress’ mandate in the ‘‘Veterans Benefits, 

Health Care, and Information Technology Act of 2006,’’ VA recently established the 

Office of Rural Health (ORH) within the Veterans Health Administration. Part of 

that office’s charge is to determine how we can best continue to expand access to 

care for rural veterans. 

Indeed, VA has already done much to remove barriers to access to care for enrolled veterans residing in rural areas and is continuing a robust rural health program. Currently, over 92 percent of enrolled veterans reside within one hour of a 

VA facility, and 98.5 percent of all enrollees are within 90 minutes. Still, we continue our efforts to try to ensure that all enrolled veterans living in rural areas have 

adequate and timely access to VA care. We expect the data for this year to be even 

better. 

Community-Based Outpatient Clinics (CBOCs) have been the anchor for VA’s efforts to expand access to veterans in rural areas. CBOCs are complemented by contracts in the community for physician specialty services or referrals to local VA medical centers, depending on the location of the CBOC and the availability of specialists in the area. In addition, there are a number of rural outreach clinics that are 

operated by a parent CBOC to meet the needs of rural veterans, and several additional outpatient clinics are positioned to provide care for veterans in surrounding 

rural communities. VA’s authority to contract for care under 38 U.S.C. § 1703 provides a local VA Medical Center director with another avenue through which to 

meet the needs of many rural veterans. 

These efforts have borne fruit. Rural veterans tell us that they are satisfied with 

the services and high-quality care we are providing to them. This is substantiated 

by their reporting even higher satisfaction with VA services than their urban counterparts. Moreover, performance measure data indicate that as a result of our intensive efforts to expand services for rural veterans, veterans have access to services 

much nearer to home. In 1996, VA users of mental health services lived an average 

13

of 24 miles from the nearest VA clinic; as of 2006, they now live only 13.8 miles 

away. In addition, quality of care in the rural environment matches that of urban 

care on 40 standard measures. 

Mr. Chairman, VA shares the Committee’s concern for ensuring that rural veterans have adequate access to needed health care and services. However, for the 

aforementioned reasons, we do not support S. 1146 and we recommend that no legislative action be taken in this area until VA has had sufficient time to complete and 

review the internal assessments currently underway by ORH and other Department 

components. We will of course share ORH’s findings and recommendations with the 

Committee. On the changes proposed for beneficiary travel, we note that similar 

provisions are found in S. 994. We therefore address these changes in our comments 

on S. 994, below. 

S. 1147—TERMINATION OF THE ADMINISTRATIVE FREEZE ON ENROLLMENT

OF VETERANS IN CATEGORY 8

Mr. Chairman, S. 1147 would require VA to enroll all eligible veterans in Category 8. As you and the Subcommittee are well aware, VA suspended the enrollment 

of new veterans in the lowest statutory enrollment priority (priority category 8—veterans with higher incomes and no compensable service-connected disabilities) in 

January of 2003. This action was taken to protect the quality and improve the timeliness of care provided to veterans in higher enrollment-priority categories. 

VA strongly opposes enactment of S. 1147. In 1996, Congress enacted Eligibility 

Reform legislation that allowed VA to provide comprehensive care to veterans in the 

most appropriate treatment setting. Additionally, in order to protect the traditional 

mission of VA (to cover the health care needs of service-disabled and lower-income 

veterans), that law originally defined seven priority levels (PL) of veterans—PL 7 

veterans (higher income and not service-disabled) were the lowest priority. The law 

mandated that beginning in fiscal year 1999, VA use its enrollment decision to ensure that care to higher-priority veterans was not jeopardized by the infusion of 

lower priority veterans into the system for the first time. In FYs 1999 through 2002, 

the VA Secretary determined in each year that all veterans were able to enroll. 

Prior to 1999, PL 7 veterans’ care was not funded in budgets, but they could use 

the system on a space available basis. Consequently, they were only about 2 percent 

of the annual users. In fiscal year 2001, 25 percent of enrollees and 21 percent of 

users were PL 7 veterans (using 9 percent of the resources). In 2001 PL 7 veterans 

were split into two parts—those making above the geographic-specific HUD threshold for means-tested benefits were moved to a new PL 8 category. More than half 

of the 830,000 new enrollees in fiscal year 2002 were in Priority Group 8 and VA 

was not able to provide service-connected and lower income enrolled veterans with 

timely access to health care services because of the unprecedented growth in the 

numbers of the newly eligible category of users. When the appropriation was finally 

enacted for fiscal year 2003, VA’s Secretary made the decision that the Department 

would not enroll any new PL 8 veterans—but those currently in the system would 

retain their right to care. Every appropriation since 2003 has supported this enrollment decision. 

S. 1147 would essentially render meaningless the prioritized enrollment system, 

leaving VA unable to manage enrollment in a manner that ensures quality and access to veterans in higher priorities. VA would have to add capacity and funding 

to absorb the additional workload that this bill would entail, and so the quality and 

timeliness of VA health care to all veterans, including service disabled and lower 

income veterans, would unavoidably suffer until this capacity is added. 

We note VA has authority to enroll combat-theater veterans returning from OEF/

OIF in VA’s health care system and so they are eligible to receive any needed medical care or services. 

S. 994—DISABLED VETERANS FAIRNESS ACT

Like S. 1146, S. 994 would amend VA’s beneficiary travel benefits program by repealing the statutory deductible-requirements and requiring the Secretary to reimburse all beneficiary travel benefits and allowances at the same rates that apply to 

Federal employees. Beneficiary travel benefits would be paid out of amounts appropriated or otherwise made available to VA specifically for this purpose. S. 994 would 

provide that these changes apply to travel expenses incurred after the 90-day period 

beginning on the date of enactment. 

Although S. 994 would appear to prevent payment of beneficiary travel allowances 

and payments from funds appropriated to VA for direct patient care, we believe the 

cost of S. 994 would be utterly prohibitive. The cost of this bill would be significantly increased without the buffering effect of deductibles. As you know, 

14

deductibles play an important cost-sharing function and help contain costs by discouraging needless travel. Increased funding in the amount this bill would require 

could be put to better use on the provision of direct patient care to our veterans, 

particularly on our aging veterans and new cohorts of OEF/OIF veterans. We are 

unique among health care providers in that we already provide beneficiary travel 

benefits to eligible veterans. 

S. 692—VA HOSPITAL QUALITY REPORT CARD ACT OF 2007

Mr. Chairman, S. 692 would require VA to establish a Hospital Quality Report 

Card Initiative to, among other things, help inform patients and consumers about 

the quality of care in VA hospitals. Not later than 18 months after the date of enactment, the Department would be mandated to establish a hospital Quality Report 

Card Initiative. Under the Initiative, the Secretary would be required to publish, at 

least bi-annually, reports on the quality of VA’s hospitals that include quality-measures data that allow for an assessment of health care effectiveness, safety, timeliness, efficiency, patient-centeredness; and equity. 

In collecting and reporting this data, the Secretary would have to include very extensive and detailed information (i.e., staffing levels of nurses and other health care 

professionals; rates of nosocomial infections; volume of various procedures performed, hospital sanctions and other violations; quality of care for specified patient 

populations; the availability of emergency rooms, intensive care units, maternity 

care, and specialty services; the quality of care in various hospital settings, including inpatient, outpatient, emergency, maternity, and intensive care unit settings; 

ongoing patient safety initiatives; and, other measures determined appropriate by 

the Secretary). However, VA would be allowed to make statistical adjustments to 

the data to account for differences relating to characteristics of the reporting hospital (e.g., size, geography, and teaching status) and patient characteristics (e.g., 

health status, severity of illness, and socioeconomic status). In the event VA makes 

such adjustments, there would be a concomitant obligation to establish procedures 

for making that data available to the public. 

The bill would permit the Secretary to verify reported data to ensure accuracy and 

validity. It would also require the Secretary to disclose the entire methodology (for 

the reporting of the data) to all relevant organizations and VA hospitals that are 

the subject of any information prior to making such information available to the 

public. 

Each report submitted under the Initiative would have to be available in electronic format, presented in an understandable manner to various populations, and 

presented in a manner that allows, as appropriate, for a comparison of VA’s hospital 

quality with local hospitals or regional hospitals. The Department would also need 

to establish procedures to make these reports available to the public, upon request, 

in a non-electronic format (such as through a toll-free telephone number). 

In addition, S. 692 would require the Secretary to identify and acknowledge the 

analytic methodologies and limitations on the data sources used to develop and disseminate the comparative data and to identify the appropriate and inappropriate 

uses of such data. The bill would further mandate that, at least an annual basis, 

the Secretary compare quality measures data submitted by each VA hospital with 

data submitted in the prior year or years by the same hospital to identify and report 

actions that would lead to false or artificial improvements in the hospital’s quality 

measurements. 

This measure would further require the Secretary to develop and implement effective safeguards to: protect against the unauthorized use or disclosure of VA hospital 

data reported under this measure; protect against the dissemination of inconsistent, 

incomplete, invalid, inaccurate, or subjective VA hospital data; and ensure that 

identifiable patient data is not released to the public. In addition, the Secretary 

would need to evaluate and periodically report to Congress on the effectiveness of 

this Initiative and its effectiveness in meeting the purposes of this Act. And such 

reports would have to be made available to the public. Finally, this legislation would 

direct the Secretary to use the results of the evaluations to increase the usefulness 

of this Initiative. 

S. 692 would authorize to be appropriated to carry out this section such sums as 

may be necessary for each of FYs 2008 through 2016. 

Mr. Chairman, we do not support S. 692 because it is overly prescriptive and 

largely duplicative of existing activities. As such, we believe this legislation is unnecessary. Relevant information on VA hospital quality is already available to the 

public through several mechanisms, including our compliance with Executive Order 

13410 that requires transparency of quality measures in Federal health care programs. (Because of our efforts in meeting the Executive Order, we are way ahead 

15

of the private sector in making our health care system and outcomes data transparent; there exist no bases for comparison with the private sector.) 

Information on the quality of VA hospital care is also available from the Joint 

Commission on Accreditation for Healthcare Organizations (JCAHO). JCAHO provides standardized comparative data in a form that has been tested for consumer 

understandability and usefulness. 

We believe the design of such a program, such as this, is best left to industry experts, including VA. We further believe that highly technical health care matters 

such as this are not well-suited to detailed statutory mandates. For example, the 

proposed measures set forth in the bill are less reliable, robust, and helpful than 

those currently used by VA. Further, they are indicators of process, not of patient 

outcomes. We would be pleased to meet with the Committee to discuss how we comply with Executive Order 13410, identify the sources of information currently available on the quality of VA hospitals, and demonstrate how such information may be 

accessed. 

S. 610—CLARIFICATION OF EFFECTIVE DATE OF SECTION 132 OF THE DEPARTMENT OF

VETERANS AFFAIRS HEALTH CARE PROGRAMS ENHANCEMENT ACT (RELATING TO COM- PUTATION OF RETIREMENT ANNUITY FOR CERTAIN HEALTH-CARE PERSONNEL)

Mr. Chairman, another bill under consideration by the Committee is S. 610, which 

would retroactively change retirement benefits to certain VA health-care personnel. 

VA defers to the Office of Personnel Management on this issue and notes that it 

is contrary to Administration policy to make such changes retroactively. 

S. 874—SERVICES TO PREVENT VETERANS HOMELESSNESS ACT OF 2007

Mr. Chairman, I will next discuss S. 874, which is a measure intended to prevent 

low income veterans transitioning to, or residing in, permanent housing from falling 

back into their former homeless condition. Subject to the availability of appropriations provided for the bill’s purpose, S. 874 would require the Secretary to provide 

financial assistance in the form of per diem payments to eligible entities to provide 

and coordinate the provision of supportive services for very low-income veteran-families occupying permanent housing or transitioning from homelessness to permanent 

housing. 

S. 874 would establish the amount of per diem payment as the amount of the 

daily cost of care estimated by the eligible entity. Yet, in no case could that amount 

exceed the per diem rate that VA pays to State homes for domiciliary care. The bill 

would permit the Secretary to adjust the per diem rate by excluding from the entity’s cost-estimate any costs it incurs in furnishing services to homeless veterans for 

which the entity already receives funding from another source (both public and private). It would further require that such financial assistance be equitably distributed across geographic regions, including rural communities and tribal lands. 

To receive such financial assistance, eligible entities would have to submit an application including all of the detailed information specified in the bill. It would also 

require the Secretary to consult with the Secretaries of Housing and Urban Development and Health and Human Services when selecting the recipients. S. 874 would 

also require the Secretary to provide training and technical assistance to participating entities on the planning, development, and provision of supportive services. 

Such assistance could be provided either directly, or through grants or contracts 

with appropriate public or nonprofit private entities. 

S. 874 would define ‘‘supportive services’’ to include, among other things, outreach 

services, health care services, transportation, educational services, assistance in obtaining income support, legal assistance, fiduciary and representative services, and 

child care services. 

As to funding, the proposed law would make available out of the amounts appropriated for medical care $15 million for fiscal year 2008, $20 million for fiscal year 

2009, and $25 million for fiscal year 2010. Of these amounts, not more than 

$750,000 in any fiscal year could be used to provide technical assistance. 

Finally, this bill would require the Secretary to conduct a study of the effectiveness of this program in meeting the needs of very low-income veteran-families. As 

part of the study, the Secretary would have to compare the results of this program 

with other VA programs dedicated to the delivery of housing and services to veterans. 

VA opposes S. 874 as currently configured. We understand there is a high demand 

for supportive services for these vulnerable low-income veterans and their families 

who are at risk of becoming homeless. However, it is inappropriate to provide such 

assistance in the form of per diem payments. We recommend that the bill be modified so that financial assistance is furnished in the form of grants, similar to all 

16

other Federal programs that provide financial assistance to entities providing supportive services to homeless persons. 

We also note other concerns with this legislation. First, the list of supportive services should not include health care services because this would be duplicative of 

those already furnished to homeless veterans through VA and/or Medicaid. Second, 

the term ‘‘habilitation and rehabilitation services’’ is not defined, and supportive 

services provided under VA and other Federal programs for homeless persons typically include referrals to legal services, not actual legal services. Third, the application requirements are inadequate as they fail to require the applicants to demonstrate the need for the services they propose to provide. Fourth, because of the 

administrative costs involved, it would be more efficient to disburse the very small 

amount of funding available for technical assistance directly and apart from the 

grant program. Fifth, the definition of ‘‘private nonprofit organization’’ should not 

include for-profit partnerships, as it presently does. Finally, the definition of veteran-family differs from that used in the McKinney-Vento Homeless Assistance Act 

(42 U.S.C. § 11302). 

S. 472—MAJOR MEDICAL FACILITY PROJECT FOR DENVER, COLORADO

Mr. Chairman, the last four bills on today’s agenda relate to construction and real 

property matters. The first of these is S. 472, which would authorize the Secretary 

to carry out a major medical facility project for a replacement facility for the Denver 

Veterans Affairs Medical Center in an amount not to exceed $523,000,000. It would 

also authorize the Secretary to obligate and expend any unobligated amount in the 

‘‘Construction, Major Projects’’ account to purchase a site for, and for the construction of, that replacement facility. VA supports S. 472. Authorization in the amount of $98,000,000 was provided for 

this project in P.L.109–461; however, additional authorization in the amount of 

$548,000,000 is required to complete the project, bringing it to the total of 

$646,000,000, which is consistent with the President’s budget submission request. 

S. 1026—RENAMING OF VA MEDICAL CENTER IN AUGUSTA, GEORGIA

The second of these bills is S. 1026, which would designate the Department of 

Veterans Affairs Medical Center in Augusta, Georgia as the ‘‘Charlie Norwood Department of Veterans Affairs Medical Center.’’ Captain Norwood helped develop the 

military’s Dental Corps while serving in Vietnam. After his military service, he continued to provide needed dental care to military personnel and dependents through 

his private practice. Later, as a distinguished Congressman, he was key in advancing the military’s health and dental programs. 

The Department defers to Congress in the naming of Federal property. 

S. 1043—USE OF LANDS AT VA WEST LOS ANGELES MEDICAL CENTER

S. 1043 would require the Secretary to submit a report on the master plan relating to the use of Department lands at West Los Angeles mandated by Public Law 

105–369. Such report would have to include the master plan, if it exists; a current 

assessment of the master plan; any Departmental proposal for a veterans’ park on 

such lands; any VA proposal to use a portion of these lands as dedicated green 

space; and, an assessment of any such proposal. In addition to establishing new reporting requirements for the master plan, S. 1043 would require that the master 

plan be completed before the adoption of the plan under the Capital Asset Realignment for Enhanced Services (CARES) initiative. 

VA shares the Committee’s desire to have a short term and long term strategy 

to address how we are to manage our capital assets and operational needs for the 

care of more than 78,000 enrolled veterans in the Los Angeles area. However, VA 

opposes S. 1043. As you are aware, since the enactment of Public Law 105–368, VA 

has embarked upon the CARES Business Plan Studies generally, and specifically 

the CARES Business Plan Study (Study) of the West Los Angeles campus. In the 

Study, options will be identified for use of any underutilized capital assets, as well 

as modernizing the campus to provide care to veterans now and in the future at 

the safest state-of-the-art facilities possible. VA’s contractor has completed the initial steps in preparing planning options for public input through Local Advisory 

Panel (LAP) public meeting sessions. The third LAP session is presently expected 

to be held this summer and will be well advertised. The LAP sessions allow for 

input from those on the reviewing panel, veterans, as well as the community at 

large. All LAP and community input will be considered when formulating final recommendations for the Secretary, as well as during the Secretary’s decisionmaking 

process. The development of the master plan for the West Los Angeles campus must 

be done in conjunction with this CARES study to ensure that operational needs are 

17

met into the future. Indeed, the CARES study, with some refinement, is designed 

to meet the requirement for a master plan as set forth in the Public Law. We will 

continue to keep the Committees informed as the process continues. 

S. 1392—MAJOR MEDICAL FACILITY PROJECT PITTSBURGH, PENNSYLVANIA

S. 1392 would authorize an increased amount, $248,000,000 instead of 

$189,205,000, for the consolidation of the Department’s medical facilities in Pittsburgh, Pennsylvania (at University Drive and H. John Heinz III divisions). VA supports S. 1392, as the bill’s increased amount is consistent with the President’s budget submission request. 

Mr. Chairman, this concludes my prepared statement. I would be pleased to answer any questions you or any of the Members of the Committee may have. 

[Note: The following is a copy of the letter sent by major VSOs to Senator Larry 

Craig regarding their views on S. 815.] 

MARCH 22, 2007. 

Hon. Larry Craig, 

Ranking Member, Comminee of Veterans’ Affairs, 

U.S. Senate, Hart Senate Office Building, 

Washington, DC. 

DEAR SENATOR CRAIG: While we appreciate your concern about the need for veterans’ improved access to care in the Department of Veterans Affairs (VA), your bill, 

S. 815, to provide health care benefits to veterans with service-connected disabilities 

at virtually any private medical facility, raises a number of concerns among our organizations. We want to bring these concerns to your attention in hope that you 

might reconsider the merits of your proposal. 

As a general principle, we believe service-disabled veterans should have the highest priority access to VA health care services, and that those services should be of 

the highest quality. Service-connected veterans generally have that level of access 

and quality in VA today, but no doubt you will recall that early in the current Administration then-Secretary Principi directed all VA field facilities to ensure that 

service-connected veterans not be placed on waiting lists or refused cure. In fact 

VA’s current policy statement on this issue clearly affirms this priority, as follows:

‘‘VA is committed to providing priority care for non-emergent outpatient 

medical services and inpatient hospital care for any veteran seeking treatment of his or her service connected disability. It is VA’s policy to provide 

priority access to outpatient medical care and elective inpatient hospital 

care for any veteran who requires non-emergent care for a service connected disability... For veterans who are 50 percent service connected or 

higher, VA’s policy is to provide priority access to medical services and inpatient care, regardless if treatment is needed for their service connected 

disability.’’

With this policy in mind, it is difficult to comprehend your rationale for establishing a precedent for the highest priority veterans in the VA health care system 

to leave that system and seek services elsewhere. Over the past year we have read 

as you did all the accolades given to VA health care by independent observers, 

newsweeklies and other publications. While we believe VA represents the best available care, oversight is needed to provide an additional guarantee that VA-provided 

services are of the highest quality for all veterans who use VA, but especially for 

those with service-incurred disabilities. 

While your bill may be well intentioned, it raises a series of potential unintended 

consequences, including a rekindled debate on so-called ‘‘Medicare subvention,’’ a 

policy proposal that Congress and the Administration have been unable to resolve 

in ten years, and diminution of established quality, safety and continuity of VA care. 

It is important to note that VA’s specialized health care programs, authorized by 

Congress and designed expressly to meet the needs of combat wounded and ill veterans, such as the blind rehabilitation centers, prosthetic and sensory aid programs, 

readjustment counseling, poly-trauma and spinal cord injury centers, the centers for 

war-related illnesses, and the national center for post-traumatic stress disorder, as 

well as several others, would be irreparably affected by the loss of service-connected 

veterans from those programs. The VA’s medical and prosthetic research program, 

designed to study and hopefully cure the ills of disease and injury consequent to 

military service, would lose focus and purpose were service-connected veterans no 

longer present in VA health care. Additionally, Title 38, United States Code, section 

1706(b)1 requires VA to maintain the capacity of these specialized medical proVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
18

grams, and not let their capacity fall below that which existed at the time when 

Public Law 104–262 was enacted. 

We are also concerned about the financial implications of S. 815. Previously you 

have expressed your concern over the increasing costs for veterans’ health care. Yet, 

your proposal would seem to move VA in this very direction—toward higher costs. 

The escalating costs of health care in the private sector are well documented. To 

its credit VA has done an excellent job of holding down costs by effectively managing its in-house health programs and services for veterans. While as a consequence of enactment of your bill some service-connected veterans might seek care 

in the private sector as a matter of personal convenience, they would lose the many 

safeguards built into the VA system through its patient safety program, evidencebased medicine, electronic medical records and medication verification program. 

These unique VA features culminate in the highest quality care available, public or 

private. Loss of these safeguards, that are generally not available in the private sector systems, would equate to diminished oversight and coordination of care, and ultimately may result in lower quality of care for those who deserve it most. 

An additional possible consequence of your bill, if enacted, would be to most likely 

shift care for service-connected veterans from discretionary to mandatory spending. 

While we are devoted to proposals that Congress move VA health accounts into the 

mandatory funding arena, we question whether this would be your intent as well. 

The undersigned organizations could not support a bill that would move VA from 

a primary provider of health care to an insurer, even if funding for that function 

were made mandatory. 

We believe that mixing complex chronically-ill service-disabled veterans with 

other veterans in VA care creates a needed critical mass and properly balanced case 

mix. A diverse case mix with the variety of acute and chronic clinical patients that 

motivates excellence in the academic health center environments cements solid relations beteeen those tertiary VA facilities and their health professions schools—another guarantor of quality of care. 

We know, as the former Chairman, you would not want to bear witness to deterioration in quality of care or in availability of services in the VA for service-disabled 

veterans as a result of your bill. Therefore, we question the wisdom of S. 815 and 

ask that you consider withdrawing this ill-advised legislation. 

Sincerely, 

KIMO HOLLINGSWORTH, 

National Legistative Director, 

AMVETS (American Veterans). 

DENNIS CULLINAN, 

Legistative Director, 

Veterans of Foreign Wars 

of the United States. 

JOSEPH A. VIOLANTE, 

National Legistative Director, 

Disabled American Veterans. 

THOMAS ZAMPIERI, 

Director of Governmental Relations, 

Blinded Veterans Association. 

HERB ROSENBLEETH, 

National Executive Director, 

Jewish War Veterans of the USA. 

HERSHEL GOBER, 

National Executive Director, 

Military Order of the Purple Heart 

of the USA, Inc. 

CARL BLAKE, 

Legistative Director, 

Paralyzed Veterans of America. 

RICHARD F. WEIDMAN, 

Director of Government Relations, 

Vietnam Veterans of America, Inc.

cc: Chairman Daniel Akaka, Commitee on Veterans’ Affairs. 

19

RESPONSE TO ADDITIONAL INFORMATION REQUESTED

BY COMMITTEE MEMBERS DURING THE HEARING

Question 1. Regarding the President’s New Freedom Commission on Mental 

Health, please provide a list of recommendations and the status for each one on 

whether or not it has been implemented. 

Response: Please see the attached document providing a list, description, and status of the requirements of the President’s New Freedom Commission on Mental 

Health and VHA’s Mental Health Strategic Plan. 

Here is a glossary for acronyms used. 

AASC = Action Agenda Steering Committee 

ADA = Americans with Disabilities Act 

CARES = Capital Asset Realignment for Enhanced Services 

CBOC = Community Based Outpatient Clinic 

CME = Continuing Medical Education 

CMO = Chief Medical Officer 

CPG = Clinical Practice Guidelines 

CPRS = Computerized Patient Record System 

CWT = Compensated Work Therapy 

CWT/TR = Compensated Work Therapy/Transitional Residence 

DOD = Department of Defense 

DOL = Department of Labor 

DOM = Domiciliary Unit 

ECF = Executive Career Field 

EES = Employee Education System 

ELDA = Enrollment-Level Decision Analysis 

EPRP = External Peer Review Program 

FE = Family Education 

FPE = Family Psycho-Education 

FPE/FE = Family Psycho-Education/Family Education 

G&PD = Grant and Per Diem 

GEC = Geriatrics and Extended Care 

HACU = Hispanic Association of Colleges and Universities 

HBCU = Historically Black Colleges and Universities 

HCS = Health Care System 

HEDIS = Health Plan Employer Data and Information Set 

HHS = Department of Health and Human Services 

HPDM = High Performance Development Model 

HR = Human Resources 

HRSA = Health Resources and Services Administration 

HSR&D = Health Services Research and Development 

HUD = Department of Housing and Urban Development 

IDMC = Informatics and Data Management Committee 

IHS = Indian Health Service 

IOM = Institute of Medicine 

IT = Information Technology 

LT = Long Term 

MAP = Medical Advisory Panel 

MD = Medical Doctor 

MEB = Mental Evaluation Board 

MHICM = Mental Health Intensive Case Management Program 

MHSHG = Mental Health Strategic Healthcare Group 

MHSP = Mental Health Strategic Plan 

MHSPWG = Mental Health Strategic Planning Workgroup 

MICA = Mental Illness and Chemical Abuse 

MIRECC = Mental Illness Research, Education, and Clinical 

Center 

MOU = Memorandum of Understanding 

MST = Military Sexual Trauma 

MTF = Military Treatment Facility 

NAMI = National Alliance on Mental Illness 

NCPTSD = National Center for Post Traumatic Stress Disorder 

NEPEC = Northeast Program Evaluation Center 

NIMH = National Institute of Mental Health 

OAA = Office of Academic Affiliations 

OAT = Opiate Agonist Treatment 

OCC = Office of Care Coordination 

OEF = Operation Enduring Freedom (Afghanistan) 

20

OIF = Operation Iraqi Freedom 

OQP = Office of Quality and Performance 

ORD = Office of Research and Development 

PCS = Patient Care Services 

PDHRA = Post-Deployment Health Reassessment 

PEB = Physical Evaluation Board 

PRRTP = Psycho-social Residential Rehabilitation Treatment 

Program 

PSR = Psycho-social Rehabilitation 

PTSD = Post Traumatic Stress Disorder 

QMO = Quality Management Officer 

QUERI = Quality Enhancement Research Initiative 

RCS = Readjustment Counseling Service (Vet Centers) 

RFP = Request for Proposals 

SA = Substance Abuse 

SAMHSA = Substance Abuse and Mental Health Services 

Administration 

SARRTP = Substance Abuse Residential Rehabilitation 

Treatment Program 

SHG = Strategic Healthcare Group 

SMI = Serious Mental Illness 

SMITREC = Serious Mental Illness Treatment, Research, and 

Evaluation Center 

STRAF = Special Therapeutics Rehabilitation Activities Fund 

TIDES = Translating Initiative for Depression into Effective 

Solutions 

USB = Under Secretary for Benefits 

USH = Under Secretary for Health 

VACO = Veterans Affairs Central Office 

VAMC = VA Medical Center 

VAPAHCS = VA Palo Alto Health Care System 

VARO = VA Regional Office 

VASH = VA Supported Housing 

VBA = Veterans Benefits Administration 

VCT = Veterans Construction Team 

VHA = Veterans Health Administration 

VISN = Veterans Integrated Service Network 

WMHC = Women’s Mental Health Coordinator 

WRAMC = Walter Reed Army Medical Center

[The Comprehensive VHA Mental Health Strategic Plan follows:]

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Question 2. Please provide a listing of Community Based Outpatient Clinics 

(CBOCs) and outreach clinics that will be opening. What is the status of the Secretary’s decision on the proposed list? 

Response: The only approved Outreach Clinic not yet activated is in Craig, CO. 

The following locations were approved by the Secretary for a Community Based 

Outpatient Clinic (CBOC) in FY 2007:

Morgantown (Monongalia County), WV Dover, DE 

Norfolk, VA Childersburg, AL 

Stockbridge, GA Bessemer, AL 

Morristown (Hamblen County), TN Hamilton, OH 

Daviess County, KY Conroe, TX 

NW Tucson, AZ Metro East, OR 

Canyon County, ID Central Washington, WA 

American Samoa, HI Fallon, NV 

South Orange County, CA Bellevue, NE 

Carroll, IA Cedar Rapids, IA 

Marshalltown, IA Shenandoah, IA 

Wagner, SD Watertown, SD 

Bemidji, MN Holdrege, NE 

Spirit Lake, IA Western Wisconsin, WI 

The following three locations were opened in FY 2007: Conroe, TX; NE Bexar 

County, TX; and Williston (Outreach Clinic), ND.

The following locations have been approved for a CBOC in FY 2008:

Southern Prince George County (Andrews AFB), MD Charlottesville, VA 

Hickory, NC Lynchburg, VA 

Franklin, NC Hamlet, NC 

Aiken, SC Spartanburg, SC 

Eastern Puerto Rico (Fajardo), PR Putnam County, FL 

Camden County, GA Jackson County, FL 

Hawkins/Sullivan County/Bristol, TN Berea, KY 

Madison County, TN Grayson County, KY 

Morehead City, KY Perry County/Hazard, KY 

Parma, OH Clare County, MI 

Elkhart County, IN Alpena County, MI 

Knox County, IN Hutchinson, KS 

Jefferson City, MO Eglin AFB, FL 

Pine Bluff, AR Branson, MO 

SE Tucson, AZ Globe/Miami, AZ 

Thunderbird (North Central Maricopa County), AZ West Salt Lake Valley City, UT 

Cut Bank, MT Lewiston, MT 

North Idaho, ID Metro West, OR 

Bellingham Area (Whatcom County/

NW Washington (Skagit County), WA 

RESUMPTION OF PRIORITY 8 ENROLLMENT

Message. Reopening Priority 8 enrollment would require a significant increase in 

budgetary requirements. In addition, VA has serious concerns that this additional 

demand will strain VA’s capacity to provide timely, quality care for all enrolled veterans and lead to longer waits for care. 

Key points

• The Veterans’ Health Care Eligibility Reform Act of 1996 opened VA’s health 

care system to all veterans and provided a uniform medical benefits package of 

health care services to all enrollees. 

• The legislation also established a priority-based enrollment system, and each 

year, the VA Secretary is required to assess veteran demand and determine if resources are available to provide timely, quality care to all enrollees. 

53

• Since Eligibility Reform, veteran demand for VA health care has escalated and 

the actuarial model predicts continued growth in demand. In FY 2002, this escalating demand led to waiting lists for care. • As a result, VA suspended enrollment in Priority 8 on January 17, 2003, to 

focus on those veterans who need VA most—those with service-connected disabilities, those with low income, and veterans with special health care needs.

Question 3. How much additional funding would VA need to resume Priority 8 enrollment? 

Response. Reopening Priority 8 enrollment in FY 2008 is estimated to increase 

enrollment in Priority 8 by approximately 1.6 million and require an increase in 

budgetary requirements of $1.7 billion. VA has serious concerns that this additional 

demand will strain VA’s capacity to provide timely, quality care for all enrolled veterans and lead to longer waits for care. VA must also consider the impact of this 

policy in future years. In 2017, this policy would increase Priority 8 enrollment by 

an estimated 2.4 million and would require $4.8 billion in budgetary requirements. 

Over the next 10 years, resumption of Priority 8 enrollment would require $33.3 billion in budgetary requirements.

Question 4. VA estimated that $1.7 billion is needed to resume Priority 8 enrollment. How did VA calculate this estimate? 

Response. The VA Enrollee Health Care Projection Model (Model) is extremely robust. Data used in developing the Model includes VHA’s survey of 42,000 enrolled 

veterans, utilization and cost information from VA data systems, Medicare utilization information for enrolled veterans, a detailed analysis of enrollee reliance on VA 

health care, and information from the Census 2000 long form which enables VA to 

assign veterans into the income-based priorities (Priorities 5, 7 and 8). The Model 

is built from the bottom up which determines the expected veteran demand for 

health care and is used to lay the foundation for developing resource requirements. 

One of the Model’s features is its capability to project future VHA enrollment 

under a variety of policy scenarios, including the resumption of enrollment. The 

rates at which veterans are expected to enroll are calculated at a very detailed level. 

The Model has over 13,000 enrollment rate factors which consider veterans priority 

level, age and geographic location. 

The Model tracks Priority 8 veterans who have applied for enrollment but were 

denied. The Model presumes that those veterans who have been denied eligibility 

to enroll will be very likely to enroll in the future if their eligibility status changes 

and VA resumes enrollment of Priority 8 veterans. 

Reopening Priority 8 enrollment in FY 2008 is estimated to increase enrollment 

in Priority 8 by approximately 1.6 million enrollees and require an increase in budgetary requirements of $1.7 billion. 

Priority 8 Veterans—Talking Points 

• The Veterans’ Health Care Eligibility Reform Act of 1996 opened VA’s health 

care system to all veterans and provided a uniform medical benefits package of 

health care services to all enrollees. 

• The legislation also established a priority-based enrollment system, and each 

year, the VA Secretary is required to assess veteran demand and determine if resources are available to provide timely, quality care to all enrollees. 

• Priority 8 veterans and eligibility—Veterans who agree to pay specified copay 

with income and/or net worth above VA Means Test threshold and the Geographic 

Means Test Threshold. 

• Since Eligibility Reform, veteran demand for VA health care has escalated and 

the actuarial model predicts continued growth in demand. In FY 2002, this escalating demand led to waiting lists for care. 

• As a result, VA suspended enrollment in Priority 8 on January 17, 2003, to 

focus on those veterans who need VA most—those with service-connected disabilities, those with low income, and veterans with special health care needs. 

• Reopening Priority 8 enrollment in FY 2008 is estimated to increase enrollment 

in Priority 8 by approximately 1.6 million and require an increase in budgetary requirements of $1.7 billion. 

• VA has serious concerns that this additional demand will strain VA’s capacity 

to provide timely, quality care for all enrolled veterans and lead to longer waits for 

care. 

• VA must also consider the impact of this policy in future years. 

• In 2017, this policy would increase Priority 8 enrollment by an estimated 2.4 

million and would require $4.8 billion in budgetary requirements. 

• Over the next 10 years, resumption of Priority 8 enrollment would require $33.3 

billion in budgetary requirements.

54

Question 5. Please provide written clarification on eligibility for National Guard 

members and Reservists. 

Response: Reservists and National Guard members activated for Federal service 

who completed the period for which they were called to active duty qualify for VA 

health care, but generally must be enrolled to receive services, just like any other 

veteran. 

Reservists and National Guard members who served on active duty in a theater 

of combat operations during a period of war after the Gulf War or in combat against 

a hostile force after November 11, 1998, are eligible for enrollment in Priority Group 

6 unless otherwise eligible for enrollment in a higher priority group. All Reservists 

and National Guard members are eligible for free health care services for conditions 

potentially connected to combat service for 2 years following separation from active 

duty. 

Veterans who enroll with VA under this authority will retain enrollment eligibility even after their 2-year post discharge period ends under current enrollment 

policies. At the end of that 2-year period, VA reassesses the veteran’s information 

(including all applicable eligibility factors) and makes a new enrollment decision. If 

the veteran was in Priority Group 6 and no other eligibility factors apply, the veteran will continue enrollment in either Priority Group 7 or Priority Group 8, depending on income level, and will be required to make applicable copayments. 

Note: For veterans who do not enroll during the 2-year post-discharge period, eligibility for enrollment and subsequent care is based on other factors, including a 

compensable service-connected disability, VA pension status, catastrophic disability 

determination, or the veteran’s financial circumstances. Combat veterans are 

strongly encouraged to apply for enrollment within 2 years of release from active 

duty to take advantage of the special eligibility conditions for combat veterans, even 

if no medical care is currently needed. 

Additional information for VA health care benefits is available at: http://

www.va.gov/healtheligibility/, http://www1.va.gov/environagents/docs/

SVABENEFITS.pdf, and http://www.seamlesstransition.va.gov/res—guard.asp.

Chairman AKAKA. Thank you very much for your testimony, Dr. 

Cross. 

Before I ask any questions, I call on Senator Brown for any comments. 

Senator Brown. I have no opening remarks. 

Chairman AKAKA. Thank you, Senator Brown. 

Dr. Cross, I am delighted that this Administration is now supporting the idea of extending the window for easy access to care for 

separating servicemembers from two to 5 years. Can you please 

elaborate on how you see the extension of this window enabling VA 

to better serve younger veterans, especially those with mental 

health issues? 

Dr. CROSS. Yes, sir, I can. By extending this time period, sir, we 

will be able to provide with very little enrollment issues access to 

care for all the combat veterans that are returning to us for a period of 5 years. I think your concern and our concern was that 

sometimes the need for care, the symptoms, particularly perhaps 

related to PTSD, may not show up within that time period. The individual may not feel the need to come see us. 

This would extend that time period to make sure that if those 

symptoms arise, we have an easy mechanism automatically allowing them access to care without copays for anything related to their 

combat service. We think that this is a positive thing to do and we 

will work with you to support that. 

Chairman AKAKA. Thank you. Dr. Cross and Mr. Hall, I note 

that VA has offered no legislative proposals concerning veterans’ 

health care. Am I to infer that there is nothing the Administration 

needs from Congress? I believe Congress has valuable input to offer 

and that we serve veterans best by working together, and I just 

wanted to mention the lack of by request legislation from VA. We 

55

look forward to, of course, working together with you to help the 

veterans. 

Dr. Cross, the Administration has chosen not to prepare official 

views on our TBI legislation introduced nearly one month ago. I am 

sure you would agree that enhancements can be made to the care 

received by veterans with TBI. What more do you think can be 

done on TBI care to improve services to veterans who suffer with 

this injury? Are you willing to work with us on improving VA TBI 

health care? 

Dr. CROSS. Senator, I would like to answer that absolutely yes. 

Of course, we are willing, and if I have a moment, sir, can I tell 

you where we are with TBI? We started TBI centers back in 1992 

and we developed four of them. We have expanded them now to encompass polytrauma because of the nature of the injuries that we 

are seeing coming back from OIF and OEF. Congress has been very 

much involved with us in that. We want to continue that

participation. 

We added on the OIF/OEF screen so that everyone that we see 

gets screened for TBI. We are screening everyone who comes in to 

see us for PTSD. We are screening everyone for depression. We are 

screening everyone for substance abuse. And I think that is the advantage of our integrated health care system, that we can do these 

kinds of things comprehensively, that we can, with our electronic 

health record, we can institute these types of screens so that we 

look for these conditions and when we identify them, help get those 

individuals into the kind of care they need. 

We are multi-disciplinary and we are working on new programs, 

such as the emerging consciousness program that I just mentioned, 

for individuals who were severely affected, who are in basically a 

non-responsive state to help them, shall we say, wake up. Our research, I think, will lead the way for the Nation in understanding 

these conditions. And so, yes, sir, we are very proud to work with 

you on any of these issues. 

Chairman AKAKA. Mr. Hall, I note that with regard to the legislation that would lift the ban on enrollment of Priority 8 veterans, 

you mentioned that enacting this measure would threaten VA’s 

ability to manage the priority system set forth in law. Would your 

concerns be addressed if we were merely to suspend the current 

prohibition for one year to test the impact it would have on the system in light of all the substantial funding increases VA is

slated for? 

Mr. HALL. Mr. Chairman, one of our concerns is that lifting the 

ban is going to create stress on our current infrastructure. There 

is going to be a significant delay in being able to provide all the 

services we would need to care for the veterans we are currently 

seeing, the new veterans coming back from OEF/OIF, particularly 

if S. 383 were enacted with the 5-year extension, as well as the 

new veterans that would be eligible if the ban were lifted. If we 

had the money, it would take a while to build the infrastructure 

up enough to provide care to all those folks. 

Chairman AKAKA. Thank you very much for your response. 

Senator Craig? 

56

STATEMENT OF HON. LARRY E. CRAIG, RANKING MEMBER,

U.S. SENATOR FROM IDAHO 

Senator CRAIG. Thank you very much, Mr. Chairman. 

Thank you for holding this hearing and looking at all of these 

important pieces of legislation. 

Let me focus—and let me ask unanimous consent that my full 

statement be a part of the record. 

Chairman AKAKA. It will be included in the record. 

[The prepared statement of Senator Craig follows:]

PREPARED STATEMENT OF HON. LARRY E. CRAIG, RANKING MEMBER, U.S. SENATOR FROM IDAHO

Thank you, Mr. Chairman, for holding this hearing and good morning ladies and 

gentlemen. 

Mr. Chairman, as you know, I have two bills on the agenda that I’ve introduced 

and one that I am very proud to have introduced along with you. Of course, I think 

our legislation on caring for veterans with Traumatic Brain Injuries is an important, bipartisan effort. 

I know everyone on this Committee shares our concern about the immediate, 

acute care needs of those veterans suffering with TBI as well as the long-term implications of living with a traumatic brain injury. With this bill, Mr. Chairman, I think 

we are attempting to address many of those concerns as well as focus on the need 

to do more research on traumatic brain injury. Unfortunately, the fact remains that 

medically there is so much we don’t know about TBI. I hope we can advance this 

bill quickly. 

As I mentioned earlier, I also have two other bills on the agenda: S. 815, the 

Health Care Empowerment Act and S. 1441, a bill to modernize our successful State 

Veterans Home program. 

First, Mr. Chairman, I am sure you have seen CBO’s preliminary cost estimate 

of S. 815. Needless to say, it came in much higher than I had expected. I want to 

assure my colleagues that I am still a fiscally conservative Senator. 

With that said, I still believe we must consider some way to ensure that those 

who receive care at VA have confidence in that care. And if they don’t have confidence, we should consider some recourse for them. 

Frankly, I have been heartened by the reaction S. 815 has received. I have gotten 

numerous letters and e-mails supporting the legislation. And, of course, a few witnesses, including those today, have offered positive comments as well as some 

thoughts on changes that should be considered. 

I intend to review all of those thoughts and others while I work to address the 

scope and cost of this bill before ever asking for a vote on it. 

Finally, Mr. Chairman, I’d like to say a word about the state home bill I’ve just 

introduced. I recognize that few people have had a chance to review it. As such, I 

anticipate receiving more comments in the future on the legislation. 

What’s important to me, Mr. Chairman, is the goal of the bill. That is—to transition the state home program from one focused heavily on beds to one that also offers 

the options of home and community-based care. 

I hope none of you see this bill as a shot of disapproval aimed at the state homes. 

It is nothing of the sort. Rather, it simply reflects my view that this program needs 

to have a more forward-looking, family oriented approach to long-term care. 

At the current rate of Congressional funding, it will take us 9 more years to fund 

all of the new construction on VA’s list today. That doesn’t include any new applications that will come in. I fear that if we don’t begin to transition to a more noninstitutional approach to care, we may find ourselves 15 years from now, staring 

at 30,000 state home beds wondering what to do with half of them. 

There’s an old saying that goes ‘‘when all you have is a hammer, the whole world 

looks like nails.’’ I fear that if the state homes only have beds, then beds will be 

the way we care for aging veterans. 

I believe we should begin to establish non-institutional care programs to complement the current institutional program. In this way, we will be able to offer veterans a less restrictive alternative long-term care setting while supporting the idea 

of aging gracefully in the home with one’s family. 

I hope my colleagues, VA, VSOs, and the States, are willing to work with me on 

this legislation. I welcome all suggestions and, of course, support. 

With that, Mr. Chairman, thank you again for holding this hearing. I look forward 

to receiving the testimony of our witnesses.

57

Senator CRAIG. Thank you, Mr. Chairman. Let me focus on one 

bill that I have introduced for a variety of reasons and that I think 

testimony over the last several months has proven has some significant value, but obviously cost-wise is prohibitive. I don’t want 

anybody on this Committee to feel I have lost my conservative feelings by introducing a bill that scores at $38 billion over two years. 

But it was to dramatize a concern that I have heard constantly 

expressed, and since the introduction of the bill more loudly expressed by some veterans, that there are services that VA can’t 

provide. And, in fact, we have heard it here, whether it is certain 

types of prosthetics, whether it is certain types of concerns about 

brain damage or mental problems. There is a private sector out 

there that in some areas is leading VA as it relates to certain types 

of care. 

But there seems to be an attitude that, in some instances, if VA 

doesn’t provide it, the veteran can’t have it, and that was where 

I drew a line. If we are concerned about providing care to veterans, 

and I think we are, and I think VA does a wonderful job; I don’t 

need to sing its praises—I do 24/7, and appropriately so. But I 

must tell you that in looking at some of your comments, I must 

say, Dr. Cross, I understand the Administration strongly opposes 

S. 815 and I appreciate some of your reasons. However, I am a little troubled by the tone of the statement which suggests that if VA 

offers care, then veterans should take what they offer. 

If veterans lose faith in care provided by VA, doesn’t it concern 

you that VA’s position is essentially that the veteran should be 

stuck with VA? Now, being stuck with a first-class health care system ain’t all bad. But where health care isn’t being provided in a 

New World and you are rushing to catch up with it, it is kind of 

like, stand in line and wait until we get good at it because you are 

only going to get it from us. 

And that was the intent of S. 815. I will fine-tune this a little 

bit. In fact, I would suggest that the Chairman’s bill of, which I am 

a cosponsor, S. 1233, moves us in that direction. And so I would 

like your views and comments on this type of an approach of nonVA-delivered care as it is reflected in S. 1233. I would like your 

comments on that. 

Dr. CROSS. Sir, may I start with S. 815? 

Senator CRAIG. Sure. 

Dr. CROSS. We are working with—we want to work with you and 

Congress to make sure that we remain the veterans’ first choice, 

the veterans’ first choice for care——

Senator CRAIG. And I don’t disagree with that. 

Dr. CROSS [continuing].—just as we believe we are now. What we 

are concerned about is something that is very serious to me as a 

physician and this is fragmentation of care. To promote individuals 

going out into other systems, whereas we have a comprehensive, 

integrated system with a unique fully integrated information system so that we have a complete picture of that individual, that 

causes us some concerns when that happens, that fragmentation, 

so that one system doesn’t necessarily know what the other is 

doing. That system doesn’t have electronic records, perhaps, in the 

private environment, and so that we don’t have access to what they 

58

are doing and perhaps they don’t have access to what we are doing 

with a veteran. 

The cost, of course, is an issue, and you have already addressed 

that. 

Senator CRAIG. Sure. 

Dr. CROSS. But I want to say this on the positive side. We are spending about $3 billion per year already to identify and care for 

individuals when they need something that we can’t provide inhouse. We are very much attuned to that. But we want to do it on 

a case-by-case basis. But I want to point out that we are already 

spending about $3 billion in this effort, not an insignificant 

amount, to make sure that when those cases arise, that we will 

reach out to the community and provide the care if there is something that the veteran needs that we don’t offer. 

And I want to emphasize again, comprehensive care, continuity 

of care, but we provide the care over the lifetime of the individual. 

We want to build that record for the lifetime care of the individual. 

And when you put this total package together, having the integrated system that we have, I think is what becomes so valuable 

to the individual. 

But yes, sir, we do recognize that there are cases that we can’t 

fully care for and we are quite willing, case by case, to spend the 

money and do what is necessary to care for them. 

Senator CRAIG. Well, I am trying to comprehend, Doctor, the extend of your comments in relation to safeguarding and protecting 

a health care system. You seem to be worried about fragmentation. 

You seem to be worried about continuity. I focus, and this is going 

to sound critical—I am worried about an individual veteran who 

cannot get the service from the system. I am not worried about 

fragmentation at that point and I am sure in the heck not worried 

about continuity. 

I am worried that veteran getting the state-of-the-art in prosthetics, state-of-the-art in mental care and brain damage treatment 

when we know there are facilities outside of the VA that are ahead 

simply because they have been dealing with the civilian sector, and 

now we have got a new kind of veteran patient coming in that is 

a product of this war that you have not dealt with in the past that 

is now being thrust upon you. And you are running to catch up, 

and we are going to fund you to the tune of billions to catch up. 

But in the meantime, are they going to stand in line and wait? 

I guess that is my concern. I am not worried about fragmentation 

at that point and I am certainly not worried about continuity. 

Those are all going to happen, because in the broad sense, in the 

broad sense, VA will remain the health care provider of first choice 

to all veterans. 

Dr. CROSS. Sir, I understand your concerns. I wanted to emphasize, we didn’t start treating TBI when the war started. We started 

our centers about 15 years ago and we were treating, of course, 

TBI before that. We started special centers for them about in 1991, 

1992. We looked at our outcomes. We looked at our quality. We 

measured that. We are very finely attuned to that. I think as an 

organizational characteristic, we do more in the way of quality and 

performance measures than anybody I am aware of. We have no intent to provide anything except the best treatment possible for the 

59

individual, and if we can’t, case by case, we will send them elsewhere. 

Senator CRAIG. Thank you. My time is up. Mr. Chairman, I guess 

I would say that my legislation, I hope, has provoked a reasonable 

and appropriate debate, as it should, because I know that Senator 

Murray and I have had discussions about the best and the highest 

of quality and making sure that it is out there, and I am not always convinced that just adding money into a current system that 

isn’t prepared and can’t handle it at the time is the way you get 

there when, in fact, there is a private system that can deliver it. 

And I know that I tread on sacred ground when I talk about any 

fragmentation whatsoever when it comes to VA health care. But 

frankly, at this point, I don’t care. I am caring about the veteran 

and I am going to continue to reflect that. I look forward to working with the Administration and certainly with VA to see where we 

can do those kinds of things and find alternative care when necessary and appropriate. 

Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you, Senator Craig. 

Senator Murray? 

Senator MURRAY. Thank you very much, Mr. Chairman. 

Dr. Cross, I wanted to ask you, when our veterans sign up for 

military service, they take an unqualified oath to serve our country 

and defend the Constitution, and in return for that service and 

their commitment, they are promised that they are going to receive 

all necessary veterans’ health care when they come home. There 

weren’t any asterisks on the paper they signed. There wasn’t any 

small print that I am aware of that they wouldn’t be eligible if 

their income reaches a certain level. So I wanted to ask you, if our 

promise to those who sign up when they serve is not restricted, 

why is it right to restrict benefits for some veterans? 

Dr. CROSS. Thank you, Senator. I understand your concern and 

I think you are, of course, referring to the Priority 8s——

Senator MURRAY. Correct. 

Dr. CROSS [continuing].—and you are referring to S. 1147, as 

well. We understand. Our focus was at the time on commitment to 

quality and continues to be, and our focus has been and continues 

to be on commitment to access. We wanted to put our priorities to 

make sure that those who were injured, who have some residual 

from their experience and service connection, some injury, some illness, we wanted to make sure that within our system, that we devoted the assets necessary to take care of them, and that is what 

we did. 

Senator MURRAY. Well, it seems to me that you had a choice at 

the time. The VA recognized that they were hitting a backlog of 

people and didn’t have the resources to deal with it. So rather than 

coming to Congress and telling us that we needed to keep a promise to our veterans and in order to do that, we needed additional 

dollars, you decided that you were going to change the system so 

that by whatever income you had, that you would be denied

service. 

I believe you should have come and told us, we need additional 

dollars, because as I just told you, when you sign up, there is no 

asterisk. There is no fine little line that says if you get a certain 

60

level—and in fact, as you know, some veterans who make less than 

$27,000 a year are denied service. Do you think that is high

income? 

Dr. CROSS. I don’t consider that to be high income, but I understand the threshold varies depending on marital status and the 

number of children. 

I would like to add two understandings to this that we can discuss for a bit. It is not really a matter of money. It is a matter of 

capacity, the physical facility, the staffing. All of those things 

would have to be modified to some degree. It would take time to 

do that. And so I wanted to emphasize it is not just simply a matter of money. 

Secondly, we are, in fact, expanding the Priority 8 enrollment 

through our eligibility under our 2-year provision, and if Congress 

passes it, the 5-year provision, because here is how it works. It is 

our policy that once a combat veteran returns and enters our system in the 2-year eligibility period, even though that person would 

ultimately be classified as a Priority 8, he does not lose his enrollment. He can stay with us permanently. 

Senator MURRAY. Well, let me ask you about that, but first, let 

me go back and comment that I still believe that what the VA 

should have done is come and said to us, we don’t have enough resources. We need to serve those who have signed up and we give 

a promise rather than making an eligibility based on income that 

they never signed up for. 

But on that 2-year that you are now referring to, you have the 

authority to enroll our Iraq and Afghani combat veterans, but that 

applies only to active duty. For our National Guard and Reserves, 

it is my understanding that under the current policy, if you are active duty, you are eligible. If you are in Guard and Reserve, you 

are not. Is that correct? 

Dr. CROSS. Senator, I don’t believe so. I think—I will ask Walt 

to support me on this, but I think that is incorrect. 

Senator MURRAY. I am told time and time again by our Guard 

and Reserve members who sit on the ground in Iraq doing the 

same thing as active duty that it only applies to active duty. 

Mr. HALL. I can confirm that, but I don’t believe that is correct, 

ma’am. 

Senator MURRAY. OK. I would like to get a written response from 

you on that. We need some clarification. 

Senator SANDERS. Would the gentle lady yield for that? 

Senator MURRAY. Well——

Senator SANDERS. I am sorry. 

Senator MURRAY. I want to ask one more question and I will let 

you get back to that on your time, because I did want to ask about 

the Gulf War study really quickly in my time remaining. Two recent studies—one was conducted by the DOD, one by VA and Boston University—told us that long-term brain damage among troops 

exposed to nerve agents from the bombing of an arms depot in Iraq 

in March 1991 caused significant brain damage. This is overwhelming, Mr. Chairman. This says that over 100,000 men and 

women were exposed to sarin gas in the Gulf War, to the so-called 

Gulf War syndrome, actually had brain damage that is caused to 

them. 

61

I wrote to you along with Senators Bond and Rockefeller asking 

you how the VA is going to notify these Gulf War veterans, many 

of them wondering for the last 14 years why they are so ill and 

what is wrong with them and how we were going to do better research and affect that. You have responded to me and basically the 

answer was, we are going to study this issue. 

Well, I can tell you as the daughter of someone with multiple 

sclerosis, a World War II veteran, you are told constantly, well, it 

is going to take another study. So I would like you to inform us 

what the VA is going to do. 

Dr. CROSS. Well, first of all, I would like to point out our role in 

the study, since we sponsored it. This was a proactive thing that 

the VA has done time and again and continues to do research to 

look at these questions, and I think no other organization is doing 

more of that toward the rest of these issues. 

I have read the study. My staff are continuing to evaluate it. I 

regret to use that phrase, but yes, we are continuing to study it. 

I noticed——

Senator MURRAY. I just have to tell you the frustration, because 

many of those Gulf War veterans came home. They were told, oh, 

it is all in your head. You are making it up. They have lived with 

that. They have struggled with this for a long time and now there 

is a study with a direct link. 

Dr. CROSS. Yes. 

Senator MURRAY. And I think it is imperative that it isn’t another study that takes another three or four years, but that we do 

this quickly and rapidly and get the information to those Gulf War 

veterans because there is nothing like being told it is all in your 

head when actually there is a real connection and they deserve to 

know the answer to that. 

Dr. CROSS. Senator, I agree. 

Senator MURRAY. Thank you very much, Mr. Chairman. I hope 

we can pursue that, as well, in the Committee. 

Chairman AKAKA. Thank you, Senator Murray. 

Senator Burr? 

Senator BURR. Thank you, Mr. Chairman. 

Dr. Cross, Mr. Hall, let me thank you for your service. 

What you do is very important. I think you can already sense the 

great frustration on this dais with the status quo, with maybe not 

the same urgency that we have displayed within the VA, and I will 

treat you as the messenger and not necessarily the evaluator of all 

the comments that are made today. 

Let me share with you some facts. One-third of our Nation’s 

homeless have served our country in the armed services. On any 

given day, approximately 200,000 veterans are living on the streets 

or in shelters. As many as 400,000 veterans experience homelessness at some point during the course of a year. This is the outcome. 

That is today. 

I presented to this Congress and to the VA, it is the same bill 

as I presented last year, where the VA had some concerns over the 

form of assistance we had provided and preferred grants over per 

diem payments. I said then, I say today, I am more than willing 

to change it. I have had no contact with the VA on the bill since 

last year when it was introduced, no effort on the VA’s part to 

62

reach out and to try to perfect a bill if, in fact, one felt that it was 

not perfect to start with. I have never written a perfect piece of legislation. It requires a degree of cooperation on both sides. I am not 

sure that that cooperation has existed. 

Now let me go to what you said earlier to Senator Craig. It is 

about outcome. Well, it is about outcome. Our veterans are living 

on the streets and in shelters. What I have proposed is not putting 

a shelter over their head, it is providing the services that are absolutely essential to make sure that that housing is permanent and 

not temporary. 

I would like to go through some of the points that you have 

raised that are objections. One, the application process fails to require applicants to demonstrate the need for services. Well, my legislation gives the VA full authority to establish the criteria for the 

selection of eligible entities to be provided financial assistance 

under this section. In fact, we empower the VA to determine what 

the criteria is, and you are being critical of us of not providing the 

criteria for you. Well, you are on the front line. Who better to

write it? 

Support services should not include health care because it is duplicative services already provided by the VA. My bill states that 

health care services can be provided only if such, and I quote the 

bill, ‘‘if such services are not readily available through the Department’s medical center serving the geographical area in which the 

veteran’s family is housed.’’ Well, if it is not available, then why 

wouldn’t we offer it? I think that is a pretty simple point. 

Next, supportive services provided by VA and other Federal programs typically include referrals to legal services but not actual 

legal services. Referral, but not services. My bill provides legal 

services to assist veterans with reconsiderations of appeals of veterans and public benefit claim denials and to resolve outstanding 

warrants that interfere with the family’s ability to retain housing 

or supportive services. If the attempt is to make sure that these individuals become permanently housed, then it is a heck of a lot 

cheaper for us to provide the legal services to end the dispute than 

it is for us to have these individuals homeless and actually not receiving the medical care that they need except when it is in an 

emergency case or a trauma case. 

The last point I want to make, the definition of veteran’s family 

differs from that used in 42 U.S. Code 11302, the McKinney-Vento 

Homeless Assistance Act. Actually veteran family is not defined in 

that section at all. McKinney-Vento defines homelessness and we 

use that definition of homelessness in our bill. A veteran family is 

not defined in U.S. Code there, but it does define a homelessness 

definition of which we use the exact definition. 

Gentlemen, I have got to share with you that I find the objections petty. They are not objections I would expect from a stakeholder who wishes to see legislation that addresses the problems. 

Instead, I think it suggests they come from an agency that would 

like to continue the band-aid approach to the services that affect, 

as I said, 200,000, 400,000 veterans who find a home not a permanent part of their life. 

We will work with you in every way, shape, or form to try to 

make sure that this bill meets the criteria, meets the definitions. 

63

But if we don’t have the same goal, and that is to make sure that 

individuals who are veterans don’t have the services that they need 

to be permanently housed versus temporary, then those conversations will end very quickly. I think that is a mission of the Veterans’ Administration. I believe the Secretary believes that we 

should do everything we can to put these individuals in permanent 

housing and I am committed to do that with or without the VA. 

I thank the Chair. 

Chairman AKAKA. Thank you very much, Senator Burr. 

Senator Tester? 

Senator TESTER. Thank you, Mr. Chairman, and I, too, want to 

thank the panelists for being here today. 

I want to go to S. 479 first. You had mentioned the name of a 

commission. This was the Omvig Act. You mentioned the name of 

a commission that you said you were following. They had made 

some observations and you were following up on their recommendations. Could you give me the name of that commission again? I 

didn’t get it? 

Dr. CROSS. It would be the President’s New Freedom Commission 

on Mental Health. 

Senator TESTER. The President’s what? 

Dr. CROSS. The President’s New Freedom Commission on Mental 

Health. 

Senator TESTER. New Freedom? And how many recommendations did they put forth? Do you know off the top of your head, and 

how many have been implemented? 

Dr. CROSS. It was a bunch, sir, but I don’t have the number off 

the top of my head. 

Senator TESTER. But they haven’t all been implemented? 

Dr. CROSS. No, but we have plans for implementation. 

They are well on the way. 

Senator TESTER. All right. Could you get me a list of the ones 

that have been implemented and the ones that are in process? 

Dr. CROSS. Yes, sir. We can do that. 

Senator TESTER. That would be good. I want to talk a little bit 

about S. 994, which is a bill that I have got for mileage reimbursement, and I would assume—I don’t want to put words in your 

mouth, but I would assume you are going to—I assume you oppose 

it because it takes away money from health care, that would otherwise be appropriated toward health care or used for health care? 

Is that correct? And if it is not, just tell me if you oppose it or

support it. 

Dr. CROSS. On S. 994, sir, we are not supporting that. We do 

have some concerns. I can go through those with you. 

Senator TESTER. OK. What are they? What are they, quickly? 

Dr. CROSS. Well, it eliminates the deductible and it relates to 

beneficiary travel. The size of this investment, I think, would be—

we haven’t fully costed it yet—would be certainly in the hundreds 

of millions of dollars. We think that would be better spent in direct 

health care for our veterans. 

Senator TESTER. OK. If there was a separate stream allocated for 

the travel reimbursement, would that take care of some of your 

problems with it? 

64

Dr. CROSS. There would still be some issues, particularly in regard to the deductible, which we think makes it an inefficient way 

to carry that out. We can work with your staff on that and go 

through some of the details of what our concerns are. 

Senator TESTER. OK. Well, my concern is that we have got people, especially in rural States like Montana, that have a long ways 

to drive to get health care, and last time I checked, gas went up 

about 30 cents a gallon this last month. And when you are talking 

about 11-cent reimbursement, you are talking about a veteran that 

needs health care and it takes away from their ability to get access 

to the program, which is something I think we are all concerned 

about on this panel. 

And so my question is, if we don’t reimburse them for reasonable 

costs on transportation, how do you propose that the veterans get 

the health care, the veterans that live in these rural communities 

that are 140, 150 miles away in some cases, round-trip, from health 

care? 

Dr. CROSS. We, of course, share that concern about the rural environment. We, in fact, had a separate hearing on that. Ninety-twopoint-five percent right now are within 60 minutes of a VA facility. 

Ninety-eight percent are within 90 minutes of a VA facility. That 

is a remarkable transition that we have executed over a period of 

years because we have gone from very much of a tertiary focus to 

more of an outpatient primary care focus. In that process, we have 

created 717 community-based outpatient clinics and we are going 

to create a bunch more and then go beyond them with what we call 

outreach clinics, part-time clinics that lease space reaching out 

even to smaller communities, and perhaps in the State of Montana 

that would be a good example. The State of Maine would be a good 

example. 

Senator TESTER. Could I see your plans for construction of these 

clinics, the additional clinics, where they are going to be and when 

they are going to be built? 

Dr. CROSS. Yes, sir. I think we have an announcement coming up 

on the community-based outpatient clinics here shortly, but we will 

share that with you immediately. 

Senator TESTER. I would love to see them. I can tell you that just 

from my perspective, 11 cents a mile doesn’t even begin to pay the 

gas, much less insurance, tires, depreciation, all that stuff, and this 

is for disabled veterans whom it applies to. It would seem to me 

that if you are concerned about taking money away from health 

care, which I think is a valid concern, you would also be promoting 

mandatory funding for the VA because as long as it is discretionary, if we build a cemetery, it takes money away from health 

care. If we put money into research for prosthetics, it will take 

money away from health care. And the list goes on and on and on. 

So I think that it is critically important, and what I have heard 

with the questions that go around this table is it deals with access 

to the system and it deals with our veterans getting the health care 

that they were promised. And I think that if some veterans happen 

to live in Scobey, Montana, they should still have access to that 

health care. 

And I will tell you point blank, unequivocally, they don’t. 

65

So I would hope that when you look at these bills, every one of 

them as it goes forth—whether I oppose them or I support them 

is irrelevant—you need to look at it from a standpoint of accessibility and improved veterans’ health care. I agree with what Senator Murray said. I hear it at home all the time. Once you get in 

the system, once you get through the door, it is very, very good and 

you need to be commended for that. Getting through the door oftentimes is very, very difficult for our veterans. 

Thank you very much. 

Chairman AKAKA. Thank you very much, Senator Tester. 

Senator Isakson, followed by Senator Sanders. 

STATEMENT OF HON. JOHNNY ISAKSON,

U.S. SENATOR FROM GEORGIA 

Senator ISAKSON. Thank you very much, Mr. Chairman, and I 

deeply apologize for being late and I apologize in advance for leaving early in just a minute, but I am in between about five different 

things. 

I have three quick points, Mr. Chairman. First is to thank the 

VA for the recent opening of the clinic in Rome, Georgia. These 

clinics provide immeasurable service, and that has been extremely 

helpful to the Atlanta VA and the Atlanta region. 

Secondly, Mr. Chairman, for the record, I have introduced

S. 1396, which is an authorization for a $20 million-plus renovation 

of the VA hospital on Clairmont Road in Atlanta. This is a repeat 

of an authorization that was made 6 years ago—I think it was 6 

years ago. It lapsed this past year while the VA was negotiating 

the final bids to actually do the work. The money has been appropriated, but because the bids that came in were higher than expected, the negotiations took longer and now we have a contract 

but no authorization. They are nodding their heads, so I think I am 

saying it right. 

I would appreciate the Chair and the Members of the Committee’s help in getting this authorization back through the Committee 

so this VA renovation can take place. The money is there, the need 

is great, as all of us have attested to in terms of health care, and 

we just have a technical problem that we have an expired authorization and money in the bank. So I would ask for the Chair and 

the other Members of the Committee to help in that if at all possible. 

And then last, on behalf of Senator Chambliss and myself, Senator Chambliss has introduced legislation to rename the Augusta 

VA medical facility for Congressman Charlie Norwood, who passed 

away of cancer earlier this year. Congressman Norwood was a Vietnam veteran, served as a medic and later as a physician in Vietnam, and worked tirelessly on behalf of the veterans of Georgia 

and the Veterans’ Administration. So we hope that, too, can be expedited through the Committee, and as I understand it, there is no 

opposition in the VA to doing that. 

Dr. CROSS. Sir, we note that Representative Norwood was a 

proud member of the military medical system. He was a military 

dentist and we will defer to Congress on the naming of facilities. 

Senator ISAKSON. Thank you very much. Thank you, Mr. Chairman. 

66

Chairman AKAKA. Thank you very much, Senator Isakson. 

Senator Sanders? 

STATEMENT OF HON. BERNARD SANDERS

U.S. SENATOR FROM VERMONT 

Senator SANDERS. Thank you very much, Mr. Chairman. 

Let me concur with Senator Murray. It seems to me that the fundamental issue that we are dealing with is the following, and I 

would like a comment from the representatives of the VA. We have 

had Secretary Nicholson coming before us and speaking with a 

good deal of pride about the very high quality health care that is 

provided by the VA for those people who get into the VA. We have 

also heard evidence that the VA is providing some of the most cost 

effective health care in the country at a time when health care 

costs are soaring. That is very good news. 

It would seem to me, given those basic premises, that what you 

should be coming before us and saying is, look, we have got very 

good quality health care. It is cost effective. Give us the money so 

that we can expand it to more veterans. That is what you should 

be

saying. 

And then what our job is as Members of the Senate is to say, 

well, we have got to get our priorities straight. Yes, there are a lot 

of needs out there. How much are we concerned about veterans as 

opposed to, for example, tax breaks for billionaires? That is not 

your job, that is our job. 

I happen to think that every person who served in this country 

is, in fact, entitled to the health care that they were promised. Like 

Senator Murray, I also have introduced legislation that says that 

there is something wrong when President Bush threw about 1.5 

million Category 8 veterans off of VA health care. 

Let me, Mr. Chairman, put into the record an e-mail I recently 

received. ‘‘Dear Senator Sanders, I read in the Rutland Herald yesterday about the veterans’ benefits and the veterans that fall into 

the Category 8. My husband applied and he fell into that category 

because he had not signed by 2003, but he was denied any medical 

benefits. He needs to have medical care because he has diabetes 

and we are unable to afford health insurance for him. I am hoping 

you can do something about this situation for veterans. Thank 

you.’’

Well, I am certainly going to try to do something about it. Once 

again, let me pick up from where Senator Murray left off. A million-and-a-half veterans, people who put their lives on the line, are 

no longer eligible for VA health care because they are too wealthy, 

i.e., according to the President, their incomes are over $27,000. I 

believe those Category 8s should be brought back into the system. 

Do you? 

Dr. CROSS. Sir, as we discussed earlier, I share your concerns. 

Our focus, though, is to make sure that the veterans that we do 

take care of, that we do the very best that we can, that we provide 

the adequate access and the adequate quality——

Senator SANDERS. A question. I have heard that answer for several years. How much more money do you need to provide the highest quality care for all of our veterans? Nobody here does not want 

67

the highest quality care for those returning from Iraq and Afghanistan. We also want Category 8 veterans to get care. How much 

more do you need to do that? 

Dr. CROSS. We are costing the bill. We haven’t arrived at the 

final number but we can give you that in writing. 

Senator SANDERS. Mr. Hall, do you have any thoughts on that? 

Mr. HALL. No, sir, I do not. 

Senator SANDERS. OK. I would like to receive as soon as possible 

your estimates as to what it would cost to make sure that every—

that this gentleman who put his life on the line for the country who 

now has diabetes, whose family cannot afford health care, be entitled to get into the VA. 

Dr. CROSS. Sir, I need to remind you of one thing. 

Senator SANDERS. Yes? 

Dr. CROSS. It is not merely a matter of money. It is a matter of 

capacity, the physical facility, the staffing, the equipment and so 

forth that would be—it wouldn’t be an instantaneous process even 

if the money were to arrive today. So——

Senator SANDERS. What you are saying is it could not be done 

tomorrow and it would take time. We appreciate that. But your job 

is to tell us how much money you would need to provide expanded 

capacity, because I start off again with the premise, the Secretary 

tells us that the care is excellent and it is cost effective. Why 

wouldn’t the U.S. Congress be supporting an expansion of a program which ultimately will save taxpayers money? So I would appreciate hearing from you as to your estimates as to how much providing health care to Category 8s will cost. 

Dr. CROSS. Yes, sir. We will get you that. 

Senator SANDERS. Number two, let me also ask for the information that Senator Tester asked for. Do I understand you are going 

to be expanding the community clinics? 

Dr. CROSS. Yes. 

Senator SANDERS. I think that is a very good idea. 

They work very well in Vermont. I would also like to know where 

those clinics will be. 

Thirdly, I want to pick up again on a point that Senator Murray 

raised. As somebody who in the House of Representatives was involved for many, many, many years on Gulf War illness issues, certainly the recent study coming from, I believe, Boston University, 

is a very significant one. I can well remember, Mr. Chairman, 

where the VA even denied that one soldier was impacted by sarin. 

They started off by denying there was any problem whatsoever. We 

have been, believe me, around the block with the VA on this for 

many, many years. 

But if this study is, in fact, accurate, it is, as Senator Murray indicated, very profound. It suggests that many soldiers may have 

suffered brain damage which was not—one didn’t know it instantaneously, unlike a large dose of sarin. And the impact not only for 

Gulf War soldiers but for the civilian population is important, as 

well, because a number of scientists have pointed out the similarity 

between various illnesses associated with the Gulf War as similar 

to those in the civil society, such as multiple chemical sensitivity, 

chronic fatigue, fibromyalgia, and other types of illnesses. So this 

is a very big deal and we hope that you will pursue that. 

68

Dr. CROSS. We absolutely will, Senator, and I wanted to point out 

again that we were involved in the research——

Senator SANDERS. Yes. 

Dr. CROSS [continuing].—and we were proactive in doing this. 

The way you characterize the findings may be a bit different than 

the way I read them. We would be happy to bring our experts over 

and sit down and talk with you or your staff and go through it in 

some more detail——

Senator SANDERS. What do you understand the key findings

to be? 

Dr. CROSS. One of the findings was a slight anatomical variation 

that was noted in one group more so than in the other. That was 

perhaps the lead finding. And whatever the consequences——

Senator SANDERS. That was brain——

Dr. CROSS. Yes. 

Senator SANDERS [continuing].—brain anomaly. 

Dr. CROSS. So we can go through that in more detail. It is a very 

technical issue. I would be happy to go through it——

Senator SANDERS. Is this consistent with the work that Dr. Haley 

in Texas was doing? 

Dr. CROSS. I don’t think it is involved with that, sir. 

Senator SANDERS. No, I know it is not involved, but are the conclusions somewhat similar, do you think? 

Dr. CROSS. I would be stretching my knowledge if I answered 

that one way or the other. 

Senator SANDERS. Mr. Hall, do you have any knowledge about 

that? 

Mr. HALL. No. 

Senator SANDERS. OK. Thank you very much, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Sanders. 

I want to thank our panelists. Thank you very much, Dr. Cross 

and Mr. Hall, for your testimony and your responses. We really appreciate it. It will be helpful to us. 

Mr. HALL. Mr. Chairman, if I could clarify one thing——

Chairman AKAKA. Mr. Hall? 

Mr. HALL. Senator Murray had the question about the eligibility 

for Reservists. Reservists are eligible. 

Combat veteran Reservists are eligible upon their discharge or 

separation for care on the same basis as——

Senator MURRAY. But after two years, the National Guard is not. 

Mr. HALL. If they are combat veterans, they are. 

Senator MURRAY. After two years? 

Mr. HALL. Upon their discharge. 

Senator MURRAY. We are talking about Priority 8? 

Mr. HALL. Pardon me? No, they are eligible under the current 

two-year basis. Oh, excuse me. You are talking about after the two 

years of——

Senator MURRAY. After two years, Priority 8 regular service get 

additional health care. Guard and Reserve do not. There is a difference between the two, after two years. 

Mr. HALL. No, ma’am. Once they are enrolled, once they are—

combat veterans would come back. They would have the eligibility 

as combat veterans to be enrolled as Priority 6s and then they 

would—once enrolled in the system, they would continue on as preVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00072 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
69

viously enrolled. If they qualified as 8s then, they would be previously enrolled and would continue their enrollment. 

Senator MURRAY. If you are correct, there are a lot of people who 

are misinformed throughout the system. If I am correct, there are 

a lot of people who aren’t getting what they should be getting. 

Dr. CROSS. Senator Murray, I think we will send you a written 

response to make sure we have got this absolutely clear for you. 

Chairman AKAKA. Thank you very much for that clarification 

and thank you again, Dr. Cross and Mr. Hall. 

I would like to now welcome the representatives of the second 

panel, the representatives of the veterans service organizations to 

our panel today, Carl Blake with the Paralyzed Veterans of America; Dennis Cullinan of the Veterans of Foreign Wars; Joy Ilem of 

the Disabled American Veterans; Shannon Middleton of the American Legion; and Bernard Edelman of Vietnam Veterans of America. 

I thank you all for appearing before the Committee today. Of 

course, your full statement will appear in the record of the hearing. 

Mr. Blake, will you please proceed with your testimony. 

STATEMENT OF CARL BLAKE, NATIONAL LEGISLATIVE 

DIRECTOR, PARALYZED VETERANS OF AMERICA 

Mr. BLAKE. Mr. Chairman, Members of the Committee, on behalf 

of Paralyzed Veterans of America, I would like to thank you for the 

opportunity to testify today. In light of the fact there are numerous 

bills on the agenda, I will limit my comments to only a few of the 

bills. 

The PVA supports S. 472 that would authorize the funding necessary to construct a new major medical facility in Denver, Colorado. PVA has been involved in the planning and development 

process for this new facility since the beginning. PVA also appreciates the fact that the Capital Asset Realignment for Enhanced 

Services, CARES, commission report identified the need for a new 

spinal cord injury center in the Denver area. We hope to remain 

an active partner in the development and completion of this project 

to ensure that the needs of veterans and SCI veterans are also 

being met. 

PVA fully supports S. 479, the Joshua Omvig Veterans Suicide 

Prevention Act. The instances of suicide among veterans, particularly OEF and OIF veterans, is a serious concern that needs to be 

addressed. PVA particularly appreciates the emphasis placed on 

peer support counseling. This is something that PVA as an organization does in all of the spinal cord injury centers around the country. Every PVA chapter designates individual members to pair up 

with newly injured veterans to help them get through the early 

stages of the recovery process. 

I know firsthand that being able to talk to someone who has experienced what you have experienced and has dealt with the same 

problems you are dealing with can help you overcome bouts of depression, anger, and sadness as you first come to grips with your 

condition. The peer counselor serves as a motivator to get you moving in the right direction. 

PVA finds it difficult to comprehend the rationale for establishing a precedent for veterans in the VA health care system to 

70

leave that system and seek services elsewhere, as S. 815 would do. 

Over the past year, we have read, and as I am sure every Member 

of Congress has, all of the accolades given to the VA health care 

system. While this legislation may be well intentioned, the potential unintended consequences far outweigh any benefit that this bill 

might provide. It would almost certainly be a diminution of established quality, safety, and continuity of VA care if veterans were 

to leave the system. 

While as a consequence of enactment of this bill some serviceconnected veterans might seek care in the private sector as a matter of personal convenience, they would lose the many safeguards 

built into the VA system through its patient safety program, its 

evidence-based medicine, the electronic medical records, and the 

medication verification program. These unique VA features culminate in the highest-quality care available, public or private. Loss 

of these safeguards that are generally not available in private sector systems would equate to diminished oversight and coordination 

of care and ultimately may result in lower quality of care for those 

who deserve it most. With all of these considerations, PVA opposes 

this proposed legislation. 

PVA fully supports S. 994, the Disabled Veterans Fairness Act, 

which would align the mileage reimbursement rate afforded to eligible veterans with the rate that all Federal employees get when 

they are on travel. It is wholly unacceptable that veterans have to 

live with the 11 cents per mile reimbursement rate that the VA 

currently provides when all Federal employees receive 48 cents per 

mile. In fact, PVA believes that some of the difficulty in providing 

care in rural and limited access areas, particularly rural areas, 

might be eliminated with a sensible reimbursement rate. We believe that veterans would be less likely to complain about access 

issues as a result of their geographic location if they know that 

they will not have to foot the majority of the travel expense out of 

their own pocket. This is a change that has been long overdue and 

we urge the Committee and all of Congress to take immediate action to correct this inequity. 

PVA fully supports S. 1147, the Honor Our Commitment to Veterans Act. The provisions of this legislation are in accordance with 

the recommendations of the Independent Budget. However, we 

must emphasize that if this policy is overturned, additional adequate funding must be provided to meet this demand. It would 

make no sense to make this change without providing the funding 

necessary. 

Finally, PVA generally supports the provisions of S. 1233, the 

Veterans Traumatic Brain Injury Rehabilitation Act. It is fair to 

say that TBI is considered the signature health crisis for OEF and 

OIF veterans. We believe that the provisions of this legislation will 

enhance the ability of the VA to provide comprehensive care for 

veterans with TBI. With this in mind, it only makes sense that the 

VA be required to develop a comprehensive treatment plan to address the individualized treatment needs of these veterans. We believe that this approach gives these severely disabled veterans the 

best chance to succeed in their recovery. 

71

Mr. Chairman, Senator Murray, again, I would like to thank you 

again for the opportunity to testify and I would be happy to answer 

any questions that you might have. 

[The prepared statement of Mr. Blake follows:]

PREPARED STATEMENT OF CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR, PARALYZED VETERANS OF AMERICA

Chairman Akaka, Ranking Member Craig, and Members of the Committee, on behalf of Paralyzed Veterans of America (PVA) I would like to thank you for the opportunity to testify today on the proposed health care legislation. The scope of issues 

being considered here today is very broad. We appreciate the Committee taking the 

time to address these many issues, and we hope that out of this process meaningful 

legislation will be approved to best benefit veterans. 

S. 117, THE ‘‘LANE EVANS VETERANS HEALTH AND BENEFITS IMPROVEMENT ACT’’

PVA supports the provisions of this legislation that allow veterans who experience 

mental health conditions to receive treatment from the Department of Veterans Affairs (VA). Likewise, despite the fact that it deals with Title 10 issues—an area that 

PVA does not typically work in—we support the requirement that post-deployment 

medical and mental health screening be conducted within 30 days. We would suggest that it should be done even sooner. PVA has expressed concerns repeatedly that 

pre-deployment and post-deployment screenings are not being handled properly. In 

fact, we believe that it should not be a screening, but instead, a full medical evaluation and physical. The only way to properly assess the men and women returning 

from combat theaters of operations is to examine them fully. 

PVA also supports the intent of Section 103 of the legislation that requires every 

servicememberber released from active duty to be given an electronic copy of his or 

her military records, to include military service, medical, and any other relevant 

records. We have long felt that electronic transfer of all military service and medical 

records from the Department of Defense to VA would expedite the claims process. 

This provision would certainly move the departments in that direction. However, we 

believe that this could take quite some time to implement and that additional resources should be provided to meet the demands of this legislation. 

S. 383

PVA fully supports this legislation which would extend the eligibility for hospital 

care, medical services, and nursing home care from 2 years to 5 years for a veteran 

who served on active duty in a theater of combat operations during a period of war 

after the Persian Gulf War or in combat against a hostile force after November 11, 

1998. This provision has proven especially important to the men and women who 

have recently served in Iraq and Afghanistan and have exited military service. 

However, PVA believes that the ability of the VA to provide this essential care 

will continue to be threatened as long as adequate funding is not provided to meet 

this specific demand. As we have stated in testimony previously, we believe that the 

VA is underestimating the number of men and women from the Global War on Terror who are seeking care in the VA, and by extension, has not requested sufficient 

funding to meet this demand. We appreciate that Congress has recognized the need 

for more funding than has been requested in recent years, and we hope that you 

will continue to do what is necessary to care for all of these men and women who 

choose to come to the VA. 

S. 472

PVA supports S. 472 that would authorize the funding necessary to construct a 

new major medical facility in the Denver, Colorado area. PVA has been involved in 

the planning and development process for this new facility since the beginning. PVA 

also appreciates the fact that the Capital Asset Realignment for Enhanced Services 

(CARES) commission report identified the need for a new spinal cord injury (SCI) 

center in the Denver area. We hope to remain an active partner in the development 

and completion of this project to ensure that the needs of SCI veterans are also 

being met. 

We must emphasize that a new spinal cord injury center should move forward 

along with any decisions concerning a new Denver VA medical center. Any new SCI 

center must be operated as all current centers are, with dedicated services and staff. 

The development of a new SCI center must follow the requirements of the Memorandum of Understanding between VA and PVA allowing for architectural review, 

72

must operate in compliance with all existing VA policies and procedures, and must 

continue the relationship between VA and PVA allowing for site visits of SCI center 

facilities. 

S. 479, THE ‘‘JOSHUA OMVIG VETERANS SUICIDE PREVENTION ACT’’

PVA fully supports S. 479, the ‘‘Joshua Omvig Veterans Suicide Prevention Act.’’ 

The incidence of suicide among veterans, particularly Operation Enduring Freedom 

and Operation Iraqi Freedom (OEF/OIF) veterans, is a serious concern that needs 

to be addressed. We believe that this legislation addresses one major hurdle by attempting to break the stigma of mental illness. Clearly, veterans with mental illness 

are at a higher risk for suicide. And yet, these veterans have been pushed to the 

edge because they believe they are looked down upon because of their mental conditions. If this program and outreach is going to succeed, it is absolutely essential that 

the providers, to include doctors, nurses, and other health professionals, are properly trained. In some cases, the first biggest challenge that veterans with mental 

illness face is a provider who does not handle such a delicate situation properly. 

PVA also appreciates the emphasis placed on peer support counseling. This is 

something that PVA as an organization does in all of the spinal cord injury centers 

around the country. Every PVA chapter designates individual members to pair up 

with newly injured veterans to help them get through the early stages of their recovery. I know firsthand that being able to talk to someone who has experienced 

what you have experienced and has dealt with the same problems you are dealing 

with can help you overcome bouts of depression, sadness, and anger as you first 

come to grips with your condition. The peer counselor serves as a motivator to get 

you moving in the right direction. I credit my own peer counselor while I went 

through spinal cord rehabilitation with driving me to help other veterans. 

S. 610

PVA has no objection to this legislation. The legislation is meant to correct an apparent inequity in the statute governing full-time retirement benefits for nurses who 

were recruited by the VA to do part-time work. If this was a benefit that was promised to these nurses, then we see no reason why they should be denied it. 

S. 692, THE ‘‘VA HOSPITAL QUALITY REPORT CARD ACT’’

Although PVA has no objection to the requirements for a Hospital Quality Report 

Card Initiative outlined in this legislation, we remain concerned that this wealth 

of information will go unused. Collecting this information and assessing it without 

acting on any findings from that information would serve no real purpose. We would 

hope that the congressional committees will use this information published in these 

reports each year to affect positive change within the VA. However, we must emphasize that additional resources should be provided to allow the VA to properly compile this information as we believe that this could be a major undertaking. 

S. 815, THE ‘‘VETERANS HEALTH CARE EMPOWERMENT ACT’’

PVA finds it difficult to comprehend the rationale for establishing a precedent for 

veterans in the VA health care system to leave that system and seek services elsewhere, as this proposed legislation would do. Over the past year we have read, as 

I am sure every Member of Congress has, all of the accolades given to VA health 

care by independent observers, newsweeklies and other publications. While we believe VA represents the best available care, oversight is needed to provide an additional guarantee that VA-provided services are of the highest quality for all veterans 

who use VA, especially for those with service-connected disabilities. 

While this legislation may be well intentioned, the potential unintended consequences far outweigh any benefit that this bill might provide. There would almost 

certainly be a diminution of established quality, safety and continuity of VA care 

if veterans were to leave the system. It is important to note that VA’s specialized 

health care programs, authorized by Congress and designed expressly to meet the 

needs of combat-wounded and ill veterans, such as the blind rehabilitation centers, 

prosthetic and sensory aid programs, readjustment counseling, polytrauma and spinal cord injury centers, the centers for war-related illnesses, and the national center 

for post-traumatic stress disorder, as well as several others, would be irreparably 

affected by the loss of service-connected veterans from those programs. The VA’s 

medical and prosthetic research program, designed to study and hopefully cure the 

ills of disease and injury consequent to military service, would lose focus and purpose were service-connected veterans no longer present in VA health care. Additionally, Title 38, United States Code, section 1706(b)(1) requires VA to maintain the 

73

capacity of these specialized medical programs, and not let their capacity fall below 

that which existed at the time when Public Law 104–262 was enacted. 

As a consequence of enactment of this bill some service-connected veterans might 

seek care in the private sector as a matter of personal convenience; however, they 

would lose the many safeguards built into the VA system through its patient safety 

program, evidence-based medicine, electronic medical records and medication 

verification program. These unique VA features culminate in the highest quality 

care available, public or private. Loss of these safeguards, that are generally not 

available in private sector systems, would equate to diminished oversight and coordination of care, and ultimately may result in lower quality of care for those who 

deserve it most. With all of these considerations, PVA strongly opposes this proposed legislation. 

S. 874, THE ‘‘SERVICES TO PREVENT VETERANS HOMELESSNESS ACT’’

PVA has no objection to the provisions contained in the proposed legislation. 

Clearly, the most important factor in combating the problem of homelessness among 

veterans is preventing homelessness in the first place. This legislation would seem 

to accomplish that task by offering financial assistance to organizations or entities 

that provide permanent housing and support services to very low income veteran 

families. In the mean time, we believe that additional resources should be invested 

in programs that actually target veterans and their families who are experiencing 

homelessness as well. With more than 200,000 veterans on the street on any given 

night, it is time to make real, meaningful efforts to end this problem. 

S. 882

PVA supports the concept of the proposed legislation that would establish ‘‘navigators’’ to assist veterans and disabled veterans as they enter the VA system for 

health care and benefits. This legislation would offer $25 million in grants over 5 

years to support these navigators. This legislation would particularly allow veterans 

service organizations and other organizations to apply for grants so that they could 

hire and train navigators to provide assistance, on an individualized basis, to members of the Armed Forces as they transition from military service to VA health care 

and as they seek benefits provided by VA. The only point that we must emphasize 

is that as the VA begins awarding these grants, it must ensure that the absolute 

best qualified entities are chosen for this assistance. The VA must ensure that rigorous qualification standards are established and subsequently met by organizations 

applying for the grants. This will ensure that veterans do not receive inadequate 

assistance as they navigate the VA system. 

S. 994, THE ‘‘DISABLED VETERANS FAIRNESS ACT’’

PVA fully supports S. 994, the ‘‘Disabled Veterans Fairness Act,’’ which would 

align the mileage reimbursement rate afforded to eligible veterans with the rate 

that all Federal employees get when they are on travel. It is wholly unacceptable 

that veterans have to live with the 11 cents per mile reimbursement rate that the 

VA currently provides when all Federal employees receive 48 cents per mile. In fact, 

PVA believes that some of the difficulty in providing care to veterans in limited access areas, particularly rural areas, might be eliminated with a sensible reimbursement rate. We believe that veterans would be less likely to complain about access 

issues as a result of their geographic location if they know that they will not have 

to foot the majority of the travel expense out of their own pocket. This is a change 

that has been long overdue, and we urge the Committee and all of Congress to take 

immediate action to correct this inequity. 

S. 1026

PVA generally concedes to the wishes of our local chapters, as well as other local 

veterans service organization members and State Congressional delegations on 

issues involving naming VA facilities. At this time, PVA has no position on S. 1026. 

S. 1043

PVA has no specific position on the proposed legislation. However, we do concur 

with the principle of the legislation that the needs of veterans in the Los Angeles 

area should trump any outside considerations. 

74

S. 1147, THE ‘‘HONOR OUR COMMITMENT TO VETERANS ACT’’

PVA fully supports S. 1147, the ‘‘Honor Our Commitment to Veterans Act.’’ The 

provisions of this legislation are in accordance with the recommendations of The 

Independent Budget. We have continued to advocate for this policy to be overturned 

since it was put into place. It is unacceptable that these veterans, many of whom 

have served in combat, are being denied access to health care simply because the 

Administration and Congress have been unwilling to provide the necessary funding 

to reopen the VA health care system to them. We believe this policy should be overturned and that adequate resources should be provided to overturn this policy decision. 

VA estimates that more than 1.5 million category 8 veterans will have been denied enrollment in the VA health-care system by Fiscal Year 2008. Assuming a utilization rate of 20 percent, in order to reopen the system to these deserving veterans, 

The Independent Budget estimates that VA will require approximately $366 million 

in discretionary dollars. 

S. 1205

PVA supports this proposed legislation that would establish a pilot program to assist veterans service organizations and other organizations in developing and implementing peer support programs. The peer support program would help veterans reintegrate into their local communities. As we stated in our testimony regarding suicide prevention and peer support, the benefits of any type of peer support or counseling are invaluable. PVA chapters lead the charge at each spinal cord injury center to provide peer counseling to newly injured veterans coming through the system. 

The program authorized by this legislation could allow these local level veterans 

service organization representatives to expand their reach and provide better support to the veterans who need the most assistance. 

Veterans service organizations understand better than any other entity that community reintegration is vital because most of their members have likely experienced 

this situation. We believe it makes perfect sense to tap into this knowledge and expertise to help new veterans return to civilian life easier. 

S. 1233, THE ‘‘VETERANS TRAUMATIC BRAIN INJURY

REHABILITATION ACT’’

PVA generally supports the provisions of S. 1233, the ‘‘Veterans Traumatic Brain 

Injury Rehabilitation Act.’’ It is fair to say that traumatic brain injury (TBI) is considered the signature health crisis for Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. We believe that the provisions of this legislation will enhance the ability of the VA to provide comprehensive care for veterans 

with TBI. With this in mind, it only makes sense that the VA be required to develop 

a comprehensive treatment plan to address the individualized treatment needs of 

these veterans. We believe that this approach gives these severely disabled veterans 

the best chance to succeed in their recovery. 

PVA is concerned about the authority provided by Section 4 of the legislation. We 

understand that outside facilities and programs can bring some level of expertise 

to this population of veterans. However, we would hope that the VA would see fit 

to invest the majority of its resources in improving its own TBI programs, even as 

it taps into outside expertise. We do appreciate the effort of the legislation to ensure 

that outside facilities meet certain standards before the services are acquired. We 

would hope that this provision would ensure a level of care that should be expected 

from any facility treating these veterans. 

Meanwhile, we think that the legislation also unnecessarily rewrites contracting 

authority that already currently exists in the fee basis statute. The legislation 

seems to explain medically unfeasible and geographic inaccessibility in new language, when the VA already has authority to follow these guidelines under fee basis. 

This would simply require the VA to more judiciously apply its own regulation. 

PVA supports the establishment of a research, education, and clinical care program to provide intensive neuro-rehabilitation to veterans with severe traumatic 

brain injury. We would hope that this program will be coordinated with the 

polytrauma centers that are currently providing complex care to severely disabled 

veterans, to include veterans with TBI. 

Likewise, we support the provision for a pilot program to assess the effectiveness 

of assisted living services for these veterans. PVA believes that age-appropriate VA 

non-institutional and institutional long-term care programming for young OIF/OEF 

veterans, particularly the severely disabled including veterans with TBI, must be 

a priority for VA. New VA non-institutional care programs must come on line and 

75

existing programs must be re-engineered to meet the various needs of a younger 

veteran population. VA’s non-institutional long-term care programs will be required 

to assist these younger severely injured veterans who need a wide range of support 

services such as: personal attendant services, programs to train attendants, peer 

support programs, assistive technology, hospital-based home care teams that are 

trained to treat and monitor specific disabilities, and transportation services. These 

younger veterans need expedited access to VA benefits such as VA’s Home Improvement/Structural Alteration (HISA) grant, and VA’s adaptive housing and auto programs so they can leave institutional settings and go home as soon as possible. PVA 

also believes that linking these assisted living programs to the polytrauma centers 

and possibly the proposed research, education, and clinical care program is a must. 

Lastly, we fully support the inclusion of research on TBI as part of existing research programs. If the long-term effects of the injuries of these veterans have not 

even been identified yet, it is essential that the VA makes its best effort to stay 

ahead of the needs of these men and women as they arise. The best way to accomplish that is through additional research. 

THE ‘‘COMPREHENSIVE VETERANS BENEFITS IMPROVEMENT ACT’’

As with S. 1147, PVA supports the provision of this proposed legislation that 

would overturn the policy decision to prohibit Category 8 veterans from enrolling 

in the VA health care system. However, we must emphasize that if this policy is 

overturned additional adequate funding must be provided to meet this demand. It 

makes no sense to make this change without providing the funding necessary to 

meet the new demand. 

PVA fully supports Section 102 of the proposed legislation in accordance with the 

recommendations of The Independent Budget. We are particularly pleased with the 

emphasis that Category 4 veterans with catastrophic disabilities that are non-service connected be exempted from paying copayments and fees. This has been a longstanding initiative of PVA. The veterans affected by this proposal are not casual 

users of VA health care services. Because of the nature of their disabilities they require substantial, ongoing care and a lifetime of services. Private insurers don’t offer 

the kind of sustaining care for spinal cord injury found at the VA even if the veteran 

is employed and has access to those services. Other Federal or state health programs fall far short of VA. In most instances, VA is the only and the best resource 

for a veteran with a spinal cord injury, and yet, these veterans, supposedly placed 

in a priority enrollment category, have to pay fees and copayments for every service 

they receive as though they had no priority at all. It is certainly time for Congress 

to correct this financial penalty. 

Mr. Chairman and Members of the Committee, PVA once again thanks you for 

the opportunity to testify. We look forward to working with you to ensure that veterans continue to have access to the best health care services in America. 

I would be happy to answer any questions that you might have.

Chairman AKAKA. Thank you very much, Mr. Blake. 

Mr. Cullinan? 

STATEMENT OF DENNIS CULLINAN, DIRECTOR, NATIONAL 

LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF 

THE UNITED STATES 

Mr. CULLINAN. Chairman Akaka, Senator Murray, on behalf of 

the 2.4 million men and women of the Veterans of Foreign Wars 

and our Auxiliaries, I thank you for this opportunity to testify at 

today’s hearing on veterans’ health care legislation. 

The VFW has no objections to S. 610 and S. 1233. We support 

all other bills under discussion today with the exception of S. 815, 

which I will address momentarily. On behalf of the VFW membership, I will be very pleased to outline our strong support for S. 

1233. For the sake of timeliness, I will limit my presentation to 

these two initiatives. 

S. 815, the Veterans Health Care Empowerment Act, the VFW 

strongly opposes this legislation, which would allow any veteran to 

elect to receive contracted care basically wherever and whenever 

they choose. As we have acknowledged in our comments on preVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00079 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
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vious legislation, there are certainly cases where contract care is 

appropriate, even essential. Indiscriminate use of it, however, will 

place the utilization of VA’s own health care resources at risk. 

First, we reiterate our concerns with the cost of such care. Feebased care is more expensive than that of VA and we believe that 

it would do great harm to those veterans who elect to stay in the 

high-quality VA health care system by taking funding away from 

the system as a whole. 

Second, we have strong concerns about the viability of the health 

care system should this bill be enacted. VA has four essential missions, all of which depend on one another and which greatly improve the quality of care for all Americans, not just veterans. It 

serves as the health care system for its Nation’s sick and disabled 

veterans, first and foremost. Second, it acts as the primary education and training ground for America’s health care professionals. 

Third, it provides world class research opportunities in the development of new medical technologies. And fourth is the back-up to 

the Department of Defense health care system during times of national emergency. We cannot lessen one of these missions without 

sacrificing elements of the others. Reducing the number of veterans 

seeking care from VA would undermine the others, affecting all 

Americans. 

Further, contract care would present problems especially with 

the continuum of care and VA’s ability to monitor and track the 

health care needs of veterans over their entire lives. It would also 

potentially erode the quality of the care VA provides, especially 

with respect to illnesses and disabilities veterans suffer such as 

gunshot wounds, the use of prosthetics, SCI, and so forth. VA is 

uniquely qualified to treat these particular maladies. 

Although this legislation aims to expand the coverage available 

to veterans, we believe it would only dilute the quality and quantity of services provided to new and existing veterans today and 

into the future. 

Next under discussion is S. 1233, the Veterans Traumatic Brain 

Injury Rehabilitation Act of 2007. The VFW is pleased to support 

this legislative initiative introduced by you, Chairman Akaka, as 

well as Ranking Member Craig, to provide enhanced intervention, 

rehabilitative treatment, and services to veterans with traumatic 

brain injury. Traumatic brain injury, or TBI, is the signature 

wound of the current war in Iraq and Afghanistan. Improvements 

in body armor and more rapid and effective medical interventions 

are resulting in individuals surviving bomb blasts and the like and 

other concussive injuries that would not have been possible in the 

previous conflicts. 

Tragically, though, along with amputations, many of these survivors now suffering with TBI, resulting in varying degrees of cognitive impairment, reduced concentration and ability to focus on 

more than one thing at a time, and emotional distress. This has 

profoundly negative implications for these injured warriors as well 

as their families and dependents. 

While in all likelihood, TBI has been one of the injuries of modern warfare, it went unrecognized and there may be no doubt that 

it has never been as prevalent as it is today. The severity of the 

resulting impairment, the psychological and physiological conVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00080 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
77

sequences, and the duration of the disability are at this point in 

time but vaguely understood. Modern medicine and medical science 

are just now addressing TBI. 

It is for this reason that the measures called for in S. 1233 are 

so important. The VFW supports all the recommendations and 

findings contained in this bill. We place special emphasis on Section 3’s requirement that the Secretary develop and implement individual rehabilitation plans, as well as Section 5’s establishment 

of severe traumatic brain injury research, education, and a clinical 

care program under the Department of Veterans Affairs. 

Mr. Chairman, this concludes my testimony. Thank you. 

[The prepared statement of Mr. Cullinan follows:]

PREPARED STATEMENT OF DENNIS M. CULLINAN, DIRECTOR, NATIONAL LEGISLATIVE

SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED STATES

Mr. Chairman and Members of This Committee: 

On behalf of the 2.4 million men and women of the Veterans of Foreign Wars of 

the United States (VFW) and our Auxiliaries, I would like to thank you for the opportunity to testify at today’s hearing on veterans health care legislation. 

S. 117

The VFW is pleased to support this legislation, introduced by Senator Obama, 

which makes a number of improvements in the care and treatment of those servicemen and women who are separating from service. 

Title I of this bill would require these men and women to receive a mental health 

evaluation within 30 days of their return from deployment, and would extend medical care and services to these veterans based upon the results of these evaluations 

regardless of whether they are directly connected with a service connection if they 

seek treatment within 5 years of separation. 

This is important because it gives the benefit of the doubt to these veterans for 

their illnesses and mental health problems they may suffer, and provides them access to these essential services without having to endure the VA disability claims 

process for access to care beyond their initial 2 years of eligibility. The bottom line 

is that if veterans are having problems, under this legislation, they would be cared 

for. 

We support other sections of this legislation that would require the Department 

of Defense to provide servicemembers with an electronic copy of their medical and 

military records. This has been a long-time goal of the VFW, and we view it as an 

essential component of the seamless transition. We understand that DOD has made 

limited progress in this regard, but the time for action is now. We also support this 

bill’s efforts to improve outreach to members of the National Guard and Reserves, 

and its reporting requirements to provide meaningful statistics on the health care 

and services provided to veterans of the Global War on Terrorism. 

S. 383

Introduced by Senator Akaka, the VFW is pleased to support S. 383, legislation 

that would extend the period of eligibility for health care for combat service during 

the Persian Gulf War from 2 years to 5 years. 

Currently, veterans OEF/OIF veterans who enroll in the VA health care system 

are included as category six veterans and are entitled to use VA as their health care 

provider for 2 years following their discharge. For those who enroll after this 2-year 

period, they are enrolled as any other veteran would be and, if they fall in category 

8, are excluded from the system. 

As we learn more about the illnesses, disabilities and health care needs of those 

returning, this is an important change, and would allow many of these veterans to 

receive the care and benefits they need. For those suffering from mental health 

issues—such as PTSD—the symptoms they show might not immediately manifest 

themselves, or they may need time to come to terms with the knowledge that they 

need treatment. If they fall outside the 2-year window and qualify for health care 

under category 8, they cannot access VA health care unless they can demonstrate 

a service connection—a process that takes, on average, 6 months or more. 

78

For those suffering from the effects of mental health illnesses, or for veterans who 

are affected by Traumatic Brain Injuries, changing the law to extend their eligibility 

is a compassionate and right thing to do. 

S. 472

The VFW is pleased to support this legislation, introduced by Senator Allard that 

would authorize $523 million to construct a replacement VA Medical Center in Denver, CO. This facility, to be built on the former Fitzsimons Army hospital site, has 

received prior year’s authorization for a portion of the construction costs. 

The VFW has long supported the Capital Asset Realignment for Enhanced Services process (CARES) and we continue to support the process, especially in how it 

prioritizes VA’s construction needs. Table 4–9 of VA’s 5-Year Capital Plan identifies 

and prioritizes VA’s construction needs, and Denver’s project is ranked 3rd on the 

list. Accordingly, Congress must authorize and appropriate sufficient funding to 

complete this project. 

S. 479—THE JOSHUA OMVIG SUICIDE PREVENTION ACT

The VFW is pleased to support this legislation, which aims to create a comprehensive program of suicide prevention among veterans. Due to the nature of high-stress 

combat in the current war and the beginning of a de-stigmatization of mental-health 

disorders, many veterans are beginning to seek the care they need, and diagnosis 

of post-traumatic stress disorder (PTSD) are on the increase, but more can be done. 

This legislation, introduced by Senator Harkin, would require VA to train its employees to identify suicide risk factors and protocols for responding to veterans who 

are at risk. Additionally, it would create programs of outreach among veterans 

and—importantly—their families, a critical system of support. 

These programs are essential because we can and must do more to ensure that 

no veteran slips through the cracks, and that they all have access to the highest 

quality mental health services they need to make them whole. It is a national tragedy that so many are suffering, but with a proactive VA, we can all make a positive 

impact on the lives and care of thousands of our returning heroes. 

S. 610

The VFW has no objection to this legislation, introduced by Senator Rockefeller 

that would make changes to the retirement annuity for certain health-care professionals within VA. 

S. 692

Introduced by Senator Obama, the VFW is pleased to support the VA Hospital 

Quality Report Card Act, legislation that would require VA to develop and implement a system to measure data about its health care facilities. 

This data would be of great service. It would allow veterans to compare the quality of service VA provides, letting them make informed judgments about their health 

care. It would allow VA to identify areas of improvement, and it would provide essential data for Congress to better use its essential oversight authority. 

S. 815—VETERANS HEALTH CARE EMPOWERMENT ACT

The VFW strongly opposes this legislation, which would allow any veteran to elect 

to receive contracted care whenever they choose. As we have acknowledged in our 

comments to previous legislation, there are certainly cases where contract care is 

appropriate. Indiscriminate use of it in place of utilizing VA’s own health care resources, however, is misguided. 

First, we reiterate our concerns with the costs of such care. Fee-basis care is more 

expensive than that of VA, and we believe that it would do great harm to those veterans who elect to stay in the high-quality VA health care system by taking away 

funding for the system as a whole. 

Second, we have strong concerns about the viability of the health care system 

should this bill be enacted. VA has four essential missions, all of which depend on 

one another, and which greatly improve the quality of care for all Americans, not 

just our veterans. (1) It serves as the health care system for this Nation’s sick and 

disabled veterans; (2) It acts as the primary education and training grounds for 

America’s health care professionals (48,000 medical residents and students receive 

training at VA each year); (3) It provides world-class research opportunities and the 

development of new medical technologies, and; (4) It is the backup to the Department of Defense health system in national emergencies. 

79

We cannot lessen one of these missions without sacrificing the others. Reducing 

the number of veterans seeking care from VA would do irreparable damage to the 

others, affecting all Americans. 

Further, contract care would present problems, especially with the continuum of 

care and VA’s ability to monitor and track the health care needs of veterans over 

their entire lives. It would also potentially erode the quality of care VA provides, 

especially with respect to the illnesses and disabilities veterans suffer from, such 

as gunshot wounds or prosthetics, and for which VA is uniquely qualified to treat. 

Although this legislation, introduced by Senator Craig, aims to expand the coverage available to veterans, it would only dilute the quality and quantity of the 

services provided to new and existing veterans today and into the future. That is 

unacceptable. 

S. 874

The VFW supports S. 874, ‘‘The Services to Prevent Veterans Homelessness Act 

of 2007,’’ introduced by Senator Burr of this Committee. A great tragedy and embarrassment, now confronting, this Nation is the high level of homelessness among the 

veteran population. This legislation, directing the Secretary of Veterans Affairs to 

provide financial assistance to eligible private nonprofit organizations or consumer 

cooperatives to provide and coordinate the provision of various supportive services 

for very low-income veteran families occupying permanent housing, addresses this 

issue. It is directed toward preventing homelessness from occurring in the first 

place. We also support that the Secretary is required to conduct a 2-year study of 

the effectiveness of the assistance program in meeting the needs of very low-income 

veteran families. 

S. 882

The VFW supports this legislation, introduced by Senator Menendez, which would 

create a pilot program to improve the seamless transition for separating 

servicemembers. It would award grants to organizations who help veterans, especially those with serious wounds, women and members of the Guard and Reserves 

with applying for benefits and services within VA. 

Expanding outreach efforts so that all our veterans understand the benefits that 

they are entitled to is a worthy goal, and would be of great benefit to those who 

truly need VA’s services to transition back into society. 

S. 994

The VFW supports and appreciates S. 994, the Disabled Veterans Fairness Act 

introduced by Senator Tester together with Senator Salazar. This bill eliminates a 

$3 per round trip deductible charged by the Secretary of Veterans Affairs in connection with the veterans beneficiary travel program. It further directs the Secretary, 

in determining the amount of such allowance or reimbursement, to use the mileage 

reimbursement rates for the use of privately owned vehicles by government employees traveling on official business. For many veterans who live far from a VA hospital 

or community health center, transportation remains the single biggest obstacle to 

care. Today, disabled veterans are eligible to have only a small fraction of their 

transportation costs reimbursed. 

This legislation will go a long ways in addressing this unfortunate situation. 

S. 1026

The VFW supports this bill introduced by Senator Chambliss to designate the Department of Veterans Affairs Medical Center at 1 Freedom Way in Augusta, Georgia, as the ‘‘Charlie Norwood Department of Veterans Affairs Medical Center.’’ Congressman Norwood was a lifetime VFW member and a staunch supporter of veterans as well as our active duty military. 

S. 1043

The VFW has no objection to this legislation introduced by Senator Feinstein directing the Secretary of Veterans Affairs to report to Congress on the master plan 

of the Department of Veterans Affairs (VA) relating to the use of VA lands of the 

West Los Angeles Department of Veterans Affairs Medical Center, California, as 

originally required under the Veterans Programs Enhancement Act of 1998. This 

bill also requires an alternative report, on the development of the master plan, if 

the master plan does not exist as of the date of enactment of this Act and further 

prohibits the Secretary from implementing any portion of the master plan until 120 

days after its receipt by the congressional veterans’ and appropriations committees. 

80

S. 1147

The VFW applauds the introduction of S. 1147 by Senator Murray of this Committee. The Honor Our Commitment to Veterans Act directs the Secretary of Veterans Affairs to administer the health care enrollment system of the Department 

of Veterans Affairs so as to enroll any eligible veteran who applies. The fact that 

tens of thousands of so called category 8 veterans are denied access to VA medical 

care simply because their incomes exceed an unreasonably low threshold is a travesty. This bill would rectify this situation. 

S. 1205

The VFW supports S. 1205. A bill, introduced by Senator Smith, to require a pilot 

program on assisting veterans service organizations and other veterans’ groups in 

developing and promoting peer support programs that facilitate community reintegration of veterans returning from active duty. The effectiveness of peer support 

has been well documented in the wake of the Vietnam conflict. Specifically, for mental health disorders like PTSD and depression, peer-support programs have shown 

that participation yields improvement in psychiatric symptoms and decreased hospitalizations, the development of larger social support networks, enhanced self-esteem and social functioning, as well as lower services costs. Unfortunately peer support is not as readily available as might be expected. This bill to increase the presence of the VFW and other VSOs and members of the veteran’s community in this 

vital area is a very sound initiative to provide much needed support to veterans in 

need on a highly cost effective basis. 

S 1233

The final bill under discussion today is S. 1233, the Veterans Traumatic Brain 

Injury Rehabilitation Act of 2007. The VFW is pleased to support this legislative initiative introduced by Chairman Akaka and Ranking Member Craig to provide enhanced intervention, rehabilitative treatment and services to veterans with traumatic brain injury. Traumatic Brain Injury or TBI is the signature wound of the 

current war in Iraq. Improvements in body armor and more rapid and effective medical interventions are resulting in individuals surviving bomb blasts and other concussive injuries that would not have been possible in previous conflicts. Tragically, 

though, along with amputations many of these survivors now suffer from TBI resulting in varying degrees of cognitive impairment, reduced concentration and ability 

to focus on more than one thing at a time and emotional distress. This has profoundly negative implications for these injured warriors as well as their families and 

dependents. 

While in all likelihood TBI has always been one of the injuries of modern warfare, 

it went unrecognized. And there may be no doubt that it has never been as prevalent as it is today. The severity of resulting impairment, the physiological and psychological consequences and the duration of this disability are at this point in time 

but vaguely understood. Modern medicine and medical science are just now addressing TBI. 

It is for this reason that the measures called for in S. 1233 are so important. 

The VFW supports all of the recommendations and findings contained in this bill. 

We place special emphasis on Section 3’s requirement that the Secretary develop 

and implement individual rehabilitation plans as well as Section 5’s establishment 

of severe traumatic brain injury research, education and clinical care program within the Department of Veterans Affairs. 

Mr. Chairman, this concludes my testimony. I would be happy to respond to any 

questions you may have. 

Thank you.

Chairman AKAKA. Thank you very much, Mr. Cullinan. 

Ms. Ilem? 

STATEMENT OF JOY J. ILEM, ASSISTANT NATIONAL 

LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS 

Ms. ILEM. Thank you, Mr. Chairman and Members of the Committee. We appreciate the opportunity to testify on behalf of the 

Disabled American Veterans. As your staff requested, I am focusing 

on only a few of the proposals being considered by the Committee 

81

today, specifically the measures of special interest to DAV and its 

members. 

I will begin with S. 383, a bill that would extend combat veterans’ eligibility for VA health care from two to five years. DAV 

has a resolution calling for this extension of eligibility. This bill 

would help to ensure that our newest generation of combat veterans, those from Iraq and Afghanistan, are given ample time to 

access VA’s specialized programs and services, if needed. We believe this is especially important with regard to mental health as 

well as for veterans with mild traumatic brain injuries. Therefore, 

DAV fully supports this measure and we look forward to its

enactment. 

We are also pleased to support. S. 479, the Joshua Omvig Veterans Suicide Prevention Act. The hearing recently held by this 

Committee clearly illustrated the need to address this issue of suicide in the veteran population, especially among our newest generation of combat veterans. The testimony provided by Joshua 

Omvig’s parents and other members of that particular witness 

panel was very moving and brought out the need for improvement 

in VA’s programs designed to help veterans who are struggling 

with readjustment issues following wartime service. Every possible 

thing that can be done to prevent such personal tragedies is warranted. This measure is very thorough and highlights the need to 

provide targeted outreach, mandatory training, and peer counseling 

for veterans who may be at risk. We commend the Committee for 

its efforts on addressing this very difficult issue. 

Likewise, DAV is pleased to support S. 994, the Disabled Veterans Fairness Act. DAV has a longstanding resolution supporting 

repeal of the beneficiary travel reimbursement deductible for service-connected veterans and to increase travel reimbursement rates. 

The lack of travel reimbursement can act as a barrier to gaining 

essential health care for sick and disabled veterans. S. 994 offers 

a fair and equitable resolution to this problem. We would recommend, however, that the Committee authorize funding for VA’s 

travel reimbursement program in an appropriation separate from 

medical services. 

Mr. Chairman, we are also pleased to support S. 1233, the Veterans Traumatic Brain Injury Rehabilitation Act of 2007. We commend you and Senator Craig for working together on this very important issue. This comprehensive measure would enhance and 

strengthen VA’s rehabilitation programs for veterans with severe 

and moderate traumatic brain injury, or TBI. S. 1233 would help 

VA to develop the needed expertise, programs, and capacity to meet 

the lifeline needs of veterans with these devastating injuries. 

Finally, Mr. Chairman, I would like to call your attention to

S. 815, the Veterans Health Care Empowerment Act. DAV, along 

with the other veterans service organizations that author the Independent Budget, have already expressed our concerns to the Committee about the potential negative consequences of this bill, if enacted, but let me summarize them again today. 

S. 815 would authorize health care for veterans with serviceconnected disabilities at virtually any private medical facility rather than requiring VA to meet their needs. If this bill were enacted, 

some service-connected veterans might, in fact, choose private care 

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in lieu of VA as a personal convenience. But in doing so, they 

would lose the many safeguards built into the VA system for their 

benefit. VA is well known for its patient safety program, use of evidence-based medicine, and reliance on the electronic medical 

record. These unique qualities, along with VA’s policies, combine to 

produce the highest documented quality of care, public or private. 

We fear loss of these critical safeguards would equate to diminished clinical oversight and coordination of service-disabled veterans’ care and ultimately might result in a lower quality of care 

for those who need it most. 

Additionally, VA has to its credit done an excellent job of holding 

down costs by effectively managing in-house health programs and 

services. We know this Committee wants to ensure service-disabled 

veterans have timely access to the best care available. We believe 

VA can deliver that level and quality of care. We recognize and acknowledge that VA is not always perfect in addressing veterans’ 

needs, but we believe it is working hard to address identified shortcomings. Congress has historically protected VA’s specialized medical programs, such as its world renown PTSD, spinal cord injury, 

amputation, and blind rehabilitation programs. If enacted, this bill 

may negatively impact those unique programs. For this and other 

reasons, we cannot support this bill. We do, however, encourage 

Congress to continue thorough oversight of VA programs and services rather than authorize outsourcing of care as a solution. 

That completes my statement. Thank you. 

[The prepared statement of Ms. Ilem follows:]

PREPARED STATEMENT OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, 

DISABLED AMERICAN VETERANS

Mr. Chairman, Ranking Member Craig and other Members of the Committee: 

Thank you for inviting the Disabled American Veterans (DAV) to testify at this 

important legislative hearing of the Committee on Veterans’ Affairs. DAV is an organization of 1.4 million service-disabled veterans, and along with its auxiliary, devotes its energies to rebuilding the lives of disabled veterans and their families. 

You have requested testimony today on fifteen bills primarily focused on health 

care services for veterans under the jurisdiction of the Veterans Health Administration, Department of Veterans Affairs (VA). While my oral remarks will focus on only 

those bills about which we are particularly concerned, this statement reviews our 

position on all of the proposals before you today. The comments are expressed in 

numerical sequence of the bills, and we offer them for your consideration. 

S. 117—LANE EVANS VETERANS HEALTH AND BENEFITS

IMPROVEMENT ACT OF 2007

S. 117 would establish eligibility for a mental health evaluation on demand by 

any veteran who served on or after September 11, 2001, and would require VA to 

provide that evaluation within 30 days of its request. It would also establish eligibility for these veterans for hospital, outpatient and nursing home care, and for 

marital and family counseling, for a 2-year period from commencement of such services. Remaining sections of the bill would require a series of data gathering and reporting by the Secretaries of Veterans Affairs and Defense, of the populations of active duty personnel and veterans defined in the bill as ‘‘Global War on Terror’’ veterans—essentially those who have served in a number of theaters of war, conflicts 

and other deployments since September 11, 2001. 

DAV is generally supportive of any effort to improve access to care for sick and 

disabled veterans. Also, accurate data to aid understanding of these populations’ 

needs by the agencies responsible for their care is beneficial in any population that 

benefits from Federal programs. Nevertheless, some of the emphases of this bill 

seem problematic. The bill would require a comprehensive medical and mental 

health evaluation by a qualified professional within thirty days of request. We appreciate the intent of the provision to secure timely assessments, but based on our 

83

review of VA’s general efforts to meet its workload requirements within those constraints, it is doubtful VA could routinely meet this requirement within available 

resources. 

With respect to the data gathering and reporting requirements of the bill, we believe thousands of staff hours and millions of dollars for other support likely would 

be necessary to enable VA and DOD to comply with these requirements, assuming 

they would be able to comply. Also, some of the reporting cycles in the bill would 

be highly challenging for both agencies to meet, given the amount of work the bill 

would require to assemble the databases that would reveal those facts. Since these 

new requirements would need to be accomplished from within available funding, 

this bill troubles us. We ask the Committee to further study the proponent’s goals 

to see if other approaches may be fashioned to produce the desired results sought. 

S. 383—A BILL TO EXTEND THE PERIOD OF ELIGIBILITY FOR HEALTH CARE FOR COMBAT

SERVICE IN THE PERSIAN GULF WAR OR FUTURE HOSTILITIES, FROM 2 YEARS TO 5

YEARS AFTER DISCHARGE OR RELEASE

Servicemembers after having served in combat theaters often experience unique 

health care challenges related to military service. Therefore, the DAV believes these 

brave men and women deserve open access to the unique and specialized services 

provided by VA. This bill would help ensure that our newest generation of combat 

veterans returning from Operations Iraqi Freedom and Enduring Freedom (OIF/

OEF) gains access by extending the period of eligibility for VA health care services 

and programs. 

The members of our most recent National Convention in Chicago, Illinois, passed 

Resolution No. 217 supporting legislation to extend the period of eligibility for free 

health care for combat veterans for conditions potentially related to their combat 

service from 2 years to 5 years after military service. Especially in regard to mental 

health sequalae related to combat exposure, veterans may not recognize within the 

current 2-year window allowed that they need VA services. This bill gives such veterans and their families the benefit of the doubt and is in the best spirit of supporting veterans’ needs without pre-judging or shortchanging them. Therefore, the 

DAV proudly supports this measure and looks forward to its enactment. 

S. 472—A BILL TO AUTHORIZE A NEW MAJOR MEDICAL FACILITY PROJECT IN DENVER, 

COLORADO, IN THE AMOUNT OF $523 MILLION

S. 472 would authorize a major medical facility project in Denver, Colorado. The 

DAV has no resolution from its membership concerning this issue; however, we 

would not oppose the enactment of this bill. 

S. 479—THE JOSHUA OMVIG VETERANS SUICIDE PREVENTION ACT

S. 479 would establish a broad based suicide prevention initiative in the VA. We 

support the goals of this bill and are pleased to endorse it. We do ask that the Committee consider modifying the bill to make clear that the suicide prevention programs the bill would establish are intended to be applied to programs within the 

Department and for veterans who are enrolled in VA health care under section 1705 

of Title 38, United States Code, and to veterans otherwise in close contact with 

other programs of the Department (i.e., the Veterans Benefits Administration regional offices, the Readjustment Counseling Service Vet Centers, etc.). We do not 

believe the bill is intended to be applied to all veterans, irrespective of their circumstances. 

S. 610—A BILL TO ESTABLISH JANUARY 23, 2002, AS THE EFFECTIVE DATE OF THE MODIFICATION OF TREATMENT FOR RETIREMENT ANNUITY PURPOSES OF PART-TIME SERVICE PERFORMED BEFORE APRIL 7, 1986, BY VA NURSES, PURSUANT TO THE VA HEALTH

CARE PROGRAMS ENHANCEMENT ACT OF 2001

S. 610 would retroactively authorize full-time work credits for Federal retirement 

purposes for VA registered nurses who worked part-time and retired from active 

service prior to April 7, 1986. This bill would address the opinion of the Office of 

Personnel Management that a prior act of Congress failed to establish clear policy 

that these nurses be included in Congressionally mandated service recalculations for 

part-time VA nurses. Although these particular VA nurses retired long ago, in equity DAV believes these individuals, who provided vital services to sick and disabled 

veterans during their professional careers, deserve this benefit as accorded to other 

VA part-time nurses at that time. We applaud the sponsor’s efforts to champion this 

cause for this small group of VA retirees. 

84

S. 692—THE VA HOSPITAL QUALITY REPORT CARD ACT OF 2007

S. 692 would establish a ‘‘hospital report card’’ covering a variety of activities of 

hospital care occurring in the medical centers of the Department. Validation of the 

delivery of high quality care to service-disabled veterans is important. Therefore, we 

support this bill. We believe that veterans under VA care have the same rights as 

private sector patients to review the quality and safety of the care they receive 

while hospitalized. We do note, however, that the purposes of this bill do not cover 

the grand majority of overall patient care workload in VA health care, namely primary (outpatient) care and extended care services provided in VA’s nursing home 

care units and its various contracted programs. Nevertheless, this is a good bill and 

one that is supported by DAV. We do note for the Committee’s purposes, that the 

term ‘‘VA hospital’’ was supplanted by the term ‘‘VA medical center’’ in prior legislation. You may wish to consider conforming this bill accordingly, should the Committee decide to approve and report it. 

S. 815—THE VETERANS HEALTH CARE EMPOWERMENT ACT OF 2007

This measure, which seeks to provide health care benefits to veterans with service-connected disabilities at virtually any private medical facility, raises a number 

of concerns for the DAV. We and several other veterans service organizations sent 

a letter describing our concerns about this measure, which I will outline. 

While well intentioned, this measure could result in a series of potential unintended consequences chief of which is the diminution of established quality, safety 

and continuity of VA care, as well as to rekindle debate on the so-called ‘‘Medicare 

subvention’’ policy proposal that Congress and the Administration have been unable 

to resolve in 10 years. 

It is important to note that VA’s specialized health care programs, authorized by 

Congress and designed expressly to meet the special needs of combat wounded and 

ill veterans, such as the blind rehabilitation centers, prosthetic and sensory aid programs, readjustment counseling, polytrauma and spinal cord injury centers, the centers for war-related illnesses, and the national center for post-traumatic stress disorder, as well as several others, would be irreparably affected by the loss of serviceconnected veterans from those programs. The VA’s medical and prosthetic research 

program, designed to study and hopefully cure the ills of disease and injury consequent to military service, would lose focus and purpose were service-connected 

veterans no longer present in VA health care. Additionally, Title 38, United States 

Code, section 1706(b)(1) requires VA to maintain the capacity of these specialized 

medical programs, and not let their capacity fall below that which existed at the 

time when Public Law 104–262 was enacted. 

In light of the escalating costs of health care in the private sector, VA has, to its 

credit, done an excellent job of holding down costs by effectively managing its inhouse health programs and services for veterans. While as a consequence of enactment of this bill some service-connected veterans might seek care in the private sector as a matter of personal convenience, they would lose the many safeguards built 

into the VA system through its patient safety program, evidence-based medicine, 

electronic medical records and medication verification program. These unique VA 

features culminate in the highest quality care available, public or private. Loss of 

these safeguards, that are generally not available in private sector systems, would 

equate to diminished oversight and coordination of care, and ultimately may result 

in lower quality of care for those who deserve it most. 

An additional possible consequence if this measure were enacted would be to most 

likely shift care for service-connected veterans from discretionary to mandatory 

spending. While we are devoted to proposals that Congress move VA health accounts into the mandatory funding arena, we could not support a bill that would 

move VA from a primary provider of health care to an insurer, even if funding for 

that function were made mandatory. 

We believe that mixing complex chronically ill service-disabled veterans with 

other veterans in VA care creates a needed critical mass and properly balanced case 

mix. A diverse case mix with the variety of acute and chronic clinical patients that 

motivates excellence in the academic health center environments cements solid relations between those tertiary VA facilities and their health professions schools—another guarantor of quality of care. 

We know this Committee wants to ensure service disabled veterans have access 

to the best care available. We believe VA can deliver that level of care. We recognize 

that VA is not always perfect, but we believe VA is working hard to address its 

shortcomings and in the long term offers the highest quality care available to veterans with special needs. If there are problems with VA care we would encourage 

85

VA to address these problems and for Congress to support critical oversight of programs and services, rather than recommending outsourcing of care as a solution. 

S. 874—THE SERVICES TO PREVENT HOMELESSNESS ACT OF 2007

S. 874 would direct the VA to provide financial assistance for supportive services 

for very low-income veterans’ families in permanent housing. Under the bill VA 

would provide grants to certain eligible entities such as private nonprofit organizations or consumer cooperatives to provide various supportive services. 

Funding for the supportive services would be taken from amounts appropriated to the VA for medical care. Amounts would be $15 million for Fiscal Year 2008; $20 

million for Fiscal Year 2009; and, $25 million for Fiscal Year 2010. 

The DAV statement of policy specifies that we will not oppose legislation unless 

it is evident that it will jeopardize benefits for service-connected disabled veterans. 

As such, while we support the intent of the bill to better address homeless veterans’ 

needs, and to help them move toward independent living, we would strongly oppose 

offsetting the costs associated with S. 874 against other vital VA health care programs. Also, with regard to the health care and counseling services this bill would 

provide, we are concerned that as well-intentioned as it may be, that a grant under 

which health care services would be provided by private providers versus VA providers raises questions about cost, quality, continuity and safety similar to our views 

on other proposals with these goals. 

S. 882—A BILL TO REQUIRE A PILOT PROGRAM ON THE FACILITATION OF THE TRANSI- TION OF MEMBERS OF THE ARMED FORCES TO RECEIPT OF VETERANS HEALTH CARE

BENEFITS UPON COMPLETION OF MILITARY SERVICE

This measure seeks to ensure that military servicemembers receive a continuity 

of care and assistance in and after the transition from military service to veteran 

status. Specifically, this bill would require the VA to conduct a 5-year pilot program 

to assess the feasibility and advisability of awarding grants to ‘‘eligible entities’’ to 

assist transitioning military servicemembers, particularly those with serious 

wounds, injuries, or mental disorders, women members, and members of the National Guard and Reserves, in applying for and receiving VA health care benefits 

and services. 

Further, this bill requires at least one location of the pilot program to be in the 

vicinity of: (1) a military medical treatment facility that treats OIF/OEF 

servicemembers who are seriously wounded; (2) a VA medical center located in a 

rural area; and (3) a VA medical center located in an urban area. 

The DAV believes that both VA and DOD have complementary and critical roles 

in ensuring servicemembers and returning combat veterans scheduled for discharge, 

receive prompt, comprehensive quality care and services from each agency; however, 

there remains a clear need for additional services and better coordination for 

transitioning servicemembers from military to veterans status and reintegration 

into the community as a productive member of society. However, DAV has no resolution on this issue, and does not accept grants from the U.S. Government. 

S. 994—THE DISABLED VETERANS FAIRNESS ACT

S. 994 would make significant changes to the VA beneficiary travel program, authorized under section 111 of Title 38, United States Code. The VA beneficiary travel program is intended by Congress to assist veterans in need of VA health care to 

gain access to that care. As you are aware, the mileage reimbursement rate is currently fixed at eleven cents per mile, but actual reimbursement is limited by law 

with a $3.00 per trip deductible capped at $18.00 per month. The mileage reimbursement rate has not been changed in 30 years, even though the VA Secretary 

is delegated authority by Congress to make rate changes when warranted. The law 

also requires the Secretary to make periodic assessments of the need to authorize 

changes to that rate. Unfortunately, no Secretary has acted to make those changes, 

despite the obvious need to update the rate of reimbursement to reflect rises in travel and transportation costs. 

In 1987, the DAV, in coordination with VA’s Voluntary Service Program, began 

buying and donating vans to VA for the purpose of transporting veterans for outpatient care. Since that time, the DAV National Transportation Network has formed 

a very significant and successful partnership with VA and DAV. We have donated 

almost 1,800 vans to VA facilities at a cost exceeding $20 million. These vans and 

their DAV volunteer drivers and medical center volunteer transportation coordinators have transported nearly 520,000 veterans over 388 million miles. We plan to 

continue and enhance this program, not only because the VA beneficiary travel rate 

is so low, but also we have found our transportation network serves as a truly vital 

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link between veterans and crucial VA health care. Its absence would equate to the 

actual denial of care for many eligible veterans. 

DAV has a long-standing resolution (Resolution No. 212) supporting repeal of the 

beneficiary travel pay deductible for service-connected veterans and to increase travel reimbursement rates for all veterans who are eligible for reimbursement. We believe S. 994 offers a fair and equitable resolution to this dilemma about which we 

have been concerned for many years. We urge this Committee to approve and enact 

legislation this year to reform the VA beneficiary travel program. Bringing reimbursement rates into line with those paid to Federal officials and Federal employees, is a fair resolution. 

Mr. Chairman, given the situations and dislocations of the families of severely injured veterans of OIF/OEF who now are in VA facilities for long-term rehabilitation, 

DAV hopes Congress also will address and appropriate funding consistent with enabling the immediate family members of these several hundred veterans to be reimbursed their travel and lodging expenses while their loved ones remain incapacitated. These families are suffering greatly and are making extreme sacrifices in relocating to be close to their loved ones, often far from home, without good accommodations, and without any authorized reimbursement for their expenses. We believe consideration of some relief, even if temporary, is warranted. 

S. 1026—A BILL TO DESIGNATE THE VA MEDICAL CENTER IN AUGUSTA, GEORGIA, AS THE

‘‘CHARLIE NORWOOD DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER’’

S. 1026 would name the VA medical center in Augusta, Georgia, as the Charlie 

Norwood Department of Veterans Affairs Medical Center. The DAV has no resolution from its membership concerning this issue; however, we would not oppose the 

enactment of this bill. 

S. 1043—A BILL TO REQUIRE THE SECRETARY OF VA TO SUBMIT A REPORT TO CONGRESS

ON PROPOSED CHANGES TO THE USE OF THE WEST LOS ANGELES, CALIFORNIA, VA

MEDICAL CENTER

S. 1043 would require the VA to submit a report to Congress on proposed changes 

to the use of the West Los Angeles Department of Veterans Affairs Medical Center 

in California. Since this deals with a local matter, we do not have a resolution on 

this issue. 

S. 1147—HONOR OUR COMMITMENT TO VETERANS ACT

This bill would legislatively moot Title 38, section 1705, thereby rescinding the 

Secretary’s authority to establish and operate a system of annual enrollments for 

VA health care, and it would make every American veteran entitled to enrollment 

for VA health care on request. Over 1,000,000 veterans have unsuccessfully attempted to enroll in VA health care since the cutoff of new enrollments for Priority 

8 veterans occurred in 2003. While we certainly support the proponent’s premise 

that every veteran who wants it should be able to enroll in VA health care, without 

a major infusion of new funding, enactment of this bill would worsen VA’s financial 

situation, not improve it, and would likely have a negative impact on the system 

as a whole. We recommend the Committee defer action on this bill until after Congress enacts mandatory, guaranteed or assured funding for VA health care. 

S. 1205—A BILL TO REQUIRE A PILOT PROGRAM ON ASSISTING VETERANS SERVICE ORGANIZATIONS AND OTHER VETERANS GROUPS IN DEVELOPING AND PROMOTING PEER

SUPPORT PROGRAMS THAT FACILITATE COMMUNITY REINTEGRATION OF VETERANS RETURNING FROM ACTIVE DUTY, AND FOR OTHER PURPOSES

This bill would establish a pilot grant program with veterans service organizations, and other organizations, to provide ‘‘navigators’’ to aid veterans in obtaining 

the VA health care services they need. While we appreciate the sponsor’s intention 

to provide veterans service organizations more means to outreach to and provide 

veterans greater opportunity to reintegrate after serving their deployments, DAV 

does not accept grants from the U.S. Government. 

Our programs are operated by the generosity of private donors and through paid 

memberships by our members and their families. DAV already employs a cadre of 

260 National Service Officers, whose job is to outreach to veterans in every community. Also, DAV has an army of volunteers on the ground in VA health and benefits 

offices and working in our National Transportation Network nationwide. Our DAV 

members and volunteers are in touch with literally millions of veterans to help raise 

awareness about VA benefits and services. 

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S. 1233—VETERANS TRAUMATIC BRAIN INJURY

REHABILITATION ACT OF 2007

Mr. Chairman, we commend your efforts in crafting S. 1233. The provisions of S. 

1233 would greatly enhance and strengthen VA’s rehabilitation program for veterans with severe and moderate Traumatic Brain Injury (TBI). TBI is a life-altering 

and devastating injury. Even with the best of care and the most seamless transition 

back to home, TBI can disrupt and test the resources of even the most resilient and 

financially secure families. 

The consequences of TBI usually involve a range of disabilities and symptoms, 

which are often not clearly delineated. Indeed, the International Classification of 

Diseases and Health Problems, commonly known as ICD, does not list a single code 

for TBI but does contain codes for many of the common consequences of TBI, such 

as epilepsy. The neurological, cognitive, and behavioral changes due to TBI are complex, varied, and diverse and may change in severity or develop over time. Longerterm neurological problems often include movement disorders, seizures, headaches, 

and sleep disorders. Common residual cognitive problems include memory, attention 

and concentration impairments. Depending on the area of the brain injured, judgment, planning, problem-solving and other executive functioning skills may also be 

impaired. Visual perception problems and language impairments are usual but often 

go undiagnosed. Prevalent behavioral issues include personality changes, aggression, agitation, learning difficulties, shallow self-awareness, altered sexual functioning, impulsivity, and social dis-inhibition. Many individuals self-medicate with 

alcohol to deal with the dis-inhibitory symptoms and disruption to their sleep cycle. 

S. 1233 would take many significant steps to ensure that veterans with TBI receive high quality rehabilitation in their communities and to encourage VA to develop the needed expertise and capacity to meet the lifelong needs of veterans with 

this injury. Therefore, DAV supports this bill. 

Rehabilitation and Community Reintegration Plan 

Section 3 of the bill would require VA providers to develop and implement a detailed comprehensive multidisciplinary and individualized rehabilitation and community reintegration plans. This plan would be based upon an assessment, and periodic reassessment, of the physical, cognitive, vocational, and psychosocial impairments of veterans and the family support needs of veterans after discharge from inpatient care. 

It is appropriate that the individualized plan be developed and discussed with the 

injured veteran and his or her family, to the maximum extent feasible, before the 

veteran is discharged from inpatient acute rehabilitation. This provision would be 

empowering for veterans and their families and could help improve rehabilitation 

outcomes. 

Section 3 also would give veterans and their families the option to trigger a review of the rehabilitation and reintegration plan and its implementation. Affording 

an injured veteran, and in cases of incapacity, family members or guardians, with 

an opportunity to request a review of the rehabilitation plan would ensure that veterans and families, have a systemic way to maximize an injured veteran’s functioning. 

In developing a rehabilitation plan for an active duty servicemember, S. 1233 

would require VA providers to collaborate with Department of Defense (DOD) providers. We support the clear objective of this provision to address a significant vulnerability in injured active duty servicemembers must navigate a labyrinth to receive continued post-acute rehabilitative care from VA, with DOD approval. Implicit 

in the provision is the promise that collaboration would prompt each agency to address any challenges in coordinating the delivery of services before the 

servicemember is transferred. 

Access to High Quality and Community Based Rehabilitative Services 

Section 4 of S. 1233 would require the VA to implement the individualized rehabilitation plan through non-VA providers in situations where VA lacks the capacity 

to provide the intensity of required care or the distance from the veteran’s home 

to a VA facility renders treatment infeasible. The provision also requires that nonVA providers be accredited by an independent peer-review program for specialized 

TBI programs. This provision clarifies that veterans have a right to community 

based rehabilitation, but only when VA cannot provide the care and when the nonVA provider is accredited. 

We support the two key implied presumptions in this provision; (1) that the VA 

must have the capacity to be the provider of choice and (2) that proximity to care 

is a key component to ongoing rehabilitation and community reintegration. 

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We support the implicit goal of this bill to give VA an incentive to develop its capacity to provide high quality care. VA’s four lead Polytrauma Rehabilitation Centers have achieved and maintained, without qualification, accreditation from the 

Commission on the Accreditation of Rehabilitation Facilities for acute inpatient TBI 

rehabilitation program but not a single VA facility has achieved accreditation for 

outpatient, home-based, residential or community based TBI rehabilitation. We urge 

this Committee to encourage VA to seek such accreditation at Level II and Level 

III polytrauma sites. 

Research, education, and clinical care program on TBI 

Sections 5 and 8 of S. 1233 would expand VA’s TBI research, education and clinical programs. Section 5 would give VA providers, in collaboration with the Defense 

and Veterans Brain Injury Center, the incentive to conduct innovative research and 

intensive treatment to increase the functioning of such veterans with severe TBI, 

who are minimally conscious. While the number of veterans in this population is 

small, it is imperative that we care for these very vulnerable veterans. This proposed program for intensive neuro-rehabilitation is highly commendable. 

Because the screening, diagnosis and treatment of mild or moderate TBI is so significant we would urge the Committee to address the issue of education on this 

issue in a separate and more expansive provision. We would welcome the opportunity to work with the Committee to discuss ways to enhance VA’s current screening program, to establish a VA TBI registry which would include OEF/OIF veterans 

at risk for TBI, to develop outreach programs to target veterans with mild TBI, and 

identify effective treatments for veterans with mild TBI. 

Section 8 also improves VA’s research program on two prevalent conditions which 

result from TBI, seizures and visually related neurological conditions, by encouraging the VA to use its research programs to study the diagnosis, treatment and 

prevention of these conditions. The proposed provision also leverages the expertise 

of federally funded model TBI treatment systems by requiring the VA to collaborate 

with these academic and non-VA based programs. We support this provision and 

also support expanding VA’s capacity to diagnose and treat veterans who develop 

epilepsy. Given our understanding of the relationship between TBI and epilepsy, we 

believe VA needs a national program for epilepsy care, and we encourage the Committee to support the revitalization of VA Epilepsy Centers of Excellence. 

Expanding Residential and Long-term Care Options for Veterans with TBI 

Section 6 of S. 1233 would establish a 5-year pilot TBI assisted living program 

to assess the effectiveness of assisted living programs in enhancing the rehabilitation, quality of life and community integration of veterans with TBI. The provision 

also ensures that VA continues to provide case management for the care of these 

veterans. We support this provision, since it will help veterans with TBI to have 

more independent lives in their communities. In that connection, we call your attention to the July 2004 VA report to Congress in response to Public Law 106–117, The 

Veterans Millennium Health Care and Benefits Act, which authorized VA to establish a pilot program to determine the ‘‘feasibility and practicability of enabling veterans to secure needed assisted living services as an alternative to nursing home 

care.’’ We believe veterans suffering from mild-to-moderate TBI, as well as their 

families, would benefit from assisted living arrangements. We also believe the report to Congress in 2004 validated an important role for assisted living facilities in 

VA long term care. 

Section 7 would require VA to provide age-appropriate nursing home care for 

younger veterans who need such care. While it is our hope that the number of young 

veterans who are so disabled by TBI as to require nursing home care is small, we 

applaud the Committee for ensuring that these disabled veterans have care that is 

consistent with their needs. 

Other Issues in Need of Legislative Action 

S. 1233 is an important bill which takes significant and bold steps toward improving access and quality of care for veterans with TBI. As the Committee moves forward during this Congress to continue its oversight and legislative efforts in the 

area of TBI we would welcome the opportunity to work with the Committee on the 

following areas:

• Ensuring all enrolled (new and established) OIF/OEF veterans are screened, assessed and treated for their mild or moderate TBI. 

• Expanding vocational rehabilitation programs for veterans with TBI. 

• Development of specialized substance use disorder programs to help veterans 

with TBI who self-medicate. 

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• Develop specialized outreach and education programs related to TBI for members of the National Guard and Reserves. • Developing an independent patient advocacy system for veterans with TBI. • Development of support programs to help families of veterans with TBI.

Mr. Chairman, again, the members and auxiliary of DAV appreciate being represented at this hearing today, and I appreciate being asked to testify on these bills. 

I will be pleased to respond to any of your or other Members’ questions.

Chairman AKAKA. Thank you very much, Ms. Ilem. 

Ms. Middleton? 

STATEMENT OF SHANNON MIDDLETON, DEPUTY DIRECTOR, 

VETERANS AFFAIRS AND REHABILITATION COMMISSION, 

THE AMERICAN LEGION 

Ms. MIDDLETON. Mr. Chairman and Members of the Committee, 

thank you for this opportunity to present the American Legion’s 

views on the several pieces of legislation being considered by the 

Committee today. The American Legion commends the Committee 

for holding a hearing to discuss these very timely and important 

issues. I will address just a few of the bills in my comments. 

The American Legion supports the intent of S. 117, the Lane 

Evans Veterans Health and Benefits Improvement Act of 2007. 

Specifically, the American Legion is in support of tracking veterans 

who serve in the Global War on Terror in a new database. This bill 

will make data on these veterans more accessible upon request and 

these veterans require their own tracking system since the exposures and experiences they encounter are different from veterans 

of the First Gulf War. They have experienced more combat time, 

multiple deployments, continuous urban warfare, and blast traumas. Also, more women have participated. Differentiating veterans 

who served in OIF and OEF, those who served in both, and those 

who served in neither will also be important when anticipating 

long-term health effects. 

S. 479, the Joshua Omvig Veterans Suicide Prevention Act, seeks 

to reduce the incidence of suicide among veterans. This bill contains very important components that will likely mitigate the incidence of suicide among veterans by promoting outreach to educate 

veterans and their families about available services, making services available on a continuous basis, and training VA employees on 

suicide prevention. 

Family education and outreach is significantly important, since 

family members may notice changes in the veterans before anyone 

else. When the family and the veteran know what services are 

available, it is easier to seek assistance. It is even more important 

that VA ensures that these veterans gain access to mental health 

services when they need them. 

Designating a point of contact at each VA medical facility that 

will work with local emergency rooms, law enforcement, local mental health organizations, and veterans service organizations will 

make mental health coordination easier and timely. Outreach into 

those who will provide support to veterans and making the community more aware of VA’s mental health services will also facilitate 

the goals of research and help to establish best practices. 

S. 1147, Honor Our Commitment to Veterans Act, seeks to lift 

the health care enrollment restriction on Priority Group 8 veterans 

that has been instituted since 2003. The American Legion opposes 

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any decision to deny enrollment to any eligible veteran. A more efficient method of ensuring that VA can continue to provide quality 

care to veterans would be to ensure that VA is sufficiently funded 

to care for their needs, not limiting access for those who have incomes that fall above means test thresholds. The American Legion 

supports the lifting of the current health care enrollment restriction for Priority Group 8. 

The American Legion supports the provisions of S. 1233, the Veterans Traumatic Brain Injury Rehabilitation Act of 2007. Among 

other things, the bill mandates that VA establish a research, education, and clinical care program to address severe traumatic brain 

injury. This is a very important component in providing the best 

quality of care for those who suffer from this type of injury. Since 

not much information is available on long-term effects of combatrelated traumatic brain injury, research on the current war’s veterans will be beneficial in establishing standards of care provided 

to veterans. 

The American Legion supports research that would improve care 

available for veterans with service-connected injuries and that 

would attempt to ascertain possible secondary health outcomes. 

Since many of the symptoms of secondary conditions have delayed 

onset or have subtle manifestations, research on improving the diagnosis, treatment, and prevention on traumatic brain injury will 

ensure the best quality care for future generations of combat

veterans. 

Again, thank you, Mr. Chairman, for giving the American Legion 

this opportunity to present its views on such important issues. We 

look forward to working with you and the Committee to enhance 

the access to quality health care for all veterans. 

[The prepared statement of Ms. Middleton follows:] 

Chairman AKAKA. Thank you very much, Ms. Middleton.

PREPARED STATEMENT OF SHANNON MIDDLETON, DEPUTY DIRECTOR FOR HEALTH, 

VETERANS AFFAIRS AND REHABILITATION COMMISSION, THE AMERICAN LEGION

Mr. Chairman and Members of the Committee: 

Thank you for this opportunity to present The American Legion’s view on the several pieces of legislation being considered by the Committee today. The American 

Legion commends the Committee for holding a hearing to discuss these very important and timely issues. 

S. 117, THE LANE EVANS VETERANS HEALTH AND BENEFITS IMPROVEMENT ACT OF 2007

The American Legion supports the intent of S. 117. Specifically, The American Legion is in support of tracking veterans who serve in the Global War On Terrorism 

(GWOT) in a new database. This bill would make data on these veterans more accessible upon request. GWOT veterans require their own system, since the exposures and experiences they encountered are different from veterans of the first Gulf 

War. GWOT veterans experience more combat time, multiple deployments, continuous urban warfare, blast traumas and more women have participated. The veterans of the 1991 Gulf War experienced widespread oil well fires, possible nerve 

agent exposure and a shorter combat time. 

This bill also addresses the need to differentiate veterans who served in OIF and 

OEF, those who served in both and those who served in neither. The environmental 

exposures may differ and the combat experiences may differ. The American Legion 

suggests that under the Health, Counseling and Related Benefits section (section 3), 

the conditions should also be tracked according to whether the veteran served in 

OIF, OEF or both or in neither—not just by inpatient outpatient status. This would 

demonstrate trends in illnesses developing among the groups. It should also show 

a breakdown by gender to determine if there are manifestations of illnesses specific 

to each gender, i.e., birth defects or developmental disorders in their offspring. 

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S. 383, A BILL TO EXTEND THE PERIOD OF ELIGIBILITY FOR HEALTH CARE FROM TWO

YEARS TO FIVE YEARS AFTER DISCHARGE OR RELEASE

The American Legion has no official position on extending the period of eligibility 

for healthcare for combat veterans after discharge or release. However, past combat 

experiences—to include the Vietnam War and the Gulf War—demonstrated that 

many ailments have delayed manifestation and may be difficult to associate with 

military service years later. Extending the eligibility period would increase the likelihood that subtle symptoms of combat-related ailments would be detected by professional who have the expertise to recognize the relationship between the veteran’s 

combat experience and symptoms that manifest later. 

S. 472, A BILL TO AUTHORIZE A NEW MAJOR MEDICAL FACILITY PROJECT

IN DENVER, CO

Although The American Legion has no official position on this proposal, we believe 

that VA should do everything in its power to improve access to its health care benefits. 

S. 479, THE JOSHUA OMVIG VETERANS SUICIDE PREVENTION ACT

This bill seeks to reduce the incidence of suicide among veterans. It contains very 

important components that will likely mitigate the incidence of suicide among veterans by promoting outreach to educate veterans and families about available services, making services available on a continuous basis and training VA employees on 

suicide prevention. 

Family Education and Outreach is significantly important, since family and 

friends may notice changes in the veteran’s mental health first. The American Legion receives contact from veterans themselves who openly admit they need immediate help because of thoughts of harming themselves. When the family and the veteran know what services are available, it is easier to seek assistance. It is even 

more important that VA ensures that these veterans gain access to mental health 

services when they need them. 

Designating a point of contact—like a suicide prevention counselor—at each VA 

medical facility that will work with local emergency rooms, law enforcement, local 

mental health organizations and veterans service organizations will make mental 

health coordination easier and timely. 

Outreaching to those who provide support to veterans and making the community 

more aware of VA’s mental health services will also facilitate the goals of research 

and establishing best practices. The more veterans seek VA care, the more research 

opportunities VA will have to develop strategies to enhance prevention mechanisms. 

S. 610, A BILL TO ESTABLISH JANUARY 23, 2002, AS THE EFFECTIVE DATE OF THE MODIFICATION OF TREATMENT FOR RETIREMENT ANNUITY PURPOSES OF PART-TIME SERVICE PERFORMED BEFORE APRIL 7, 1986, BY VA NURSES, PURSUANT TO THE VA HEALTH

CARE PROGRAMS ENHANCEMENT ACT OF 2001

The American Legion has no position on this issue. 

S. 692, THE VA HOSPITAL QUALITY REPORT CARD ACT OF 2007

This bill seeks to establish the Hospital Quality Report Card to ensure quality 

measures data on VA hospitals are readily available and accessible. 

The state of VA health care/medical facilities are an important issue for The 

American Legion. Each year the organization is mandated by resolution to conduct 

a series of site visits to various VA medical facilities and submit a report to the 

President, Congress and the VA. 

The bill is similar in scope to our report—A System Worth Saving. Periodic assessments would enable VA to get a clearer picture of its system-wide needs and 

assist lawmakers in determining adequate funding for the VA health care system. 

S. 815, THE VETERANS HEALTH CARE EMPOWERMENT ACT OF 2007

This bill seeks to provide health care benefits to veterans with service-connected 

disabilities at non-VA medical facilities that receive payments under the Medicare 

program or the TRICARE Program. Although The American Legion has no official 

position on this issue, we believe that veterans should receive their medical care 

from the VA—except when there is very limited access to VA health care, as in the 

case of rural veterans. 

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S. 874, THE SERVICES TO PREVENT HOMELESSNESS ACT OF 2007

The American Legion would like to submit its views on this bill for the record 

at a later date. 

S. 882, A BILL TO REQUIRE A PILOT PROGRAM ON THE FACILITATION OF THE TRANSITION

OF MEMBERS OF THE ARMED FORCES TO RECEIPT OF VETERANS HEALTH CARE BENEFITS UPON COMPLETION OF MILITARY SERVICE

This bill would establish a pilot program for facilitating the receipt of VA health 

care benefits for those separating from the military. The American Legion supports 

efforts to assist servicemembers with transitioning to VA and accessing their veteran benefits. The bill—which targets the severely injured, women veterans, rural 

veterans, the National Guard and Reserves, and those with mental health conditions—may improve access to timely care for many who would otherwise face difficulty receiving coordinated care. 

Services offered by veterans service organizations can enhance the ability of the 

‘‘Veteran Navigator,’’ since they are linked to the communities and provide other 

means of assisting veterans. For instance, The American Legion has a program designed to assist severely injured servicemembers reintegrate into their communities 

by linking veterans and their families to local resources to address many of their 

needs. 

S. 994, THE DISABLED VETERANS FAIRNESS ACT

This bill seeks to eliminate the deductible and to change the method of determining the mileage reimbursement rate under the beneficiary travel program administered by the Secretary of VA in an effort to increase it to the rate authorized 

for government employees on official business. 

Although The American Legion has no official position on the beneficiary travel 

program, we have historically supported an increase in the mileage reimbursement 

rate paid to veterans for travel to medical appointments. It is currently 11 cents 

and has not increased since 1978. With the rising cost of gas, this rate presents a 

hardship for veterans who have to travel long distances for their appointments. The 

American Legion has encountered many veterans over the years who expressed 

frustration, anger, and desperation due to financial strain caused by accommodating 

this inadequate reimbursement rate. 

S. 1026, A BILL TO DESIGNATE THE VA MEDICAL CENTER IN AUGUSTA, GA, AS THE

‘‘CHARLIE NORWOOD DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER’’

The American Legion has no position on this initiative. 

S. 1043, A BILL TO REQUIRE THE SECRETARY OF VA TO SUBMIT A REPORT TO CONGRESS

ON PROPOSED CHANGES TO THE USE OF WEST LA VA MEDICAL CENTER

The American Legion has no official position on this issue. However, since the 

issue of land at West LA VA Medical Center has had no resolution for decades, The 

American Legion would support a mandate requiring VA to submit a master plan 

detailing its intended utilization of the land. 

S. 1147, HONOR OUR COMMITMENT OF VETERANS ACT

In 2003, former VA Secretary Anthony Principi instituted a restriction for enrollment of new Priority Group 8 veterans, therefore, prohibiting access to VA medical 

care to hundreds of thousands of Priority Group 8 veterans due primarily to limited 

resources. The American Legion disagrees with the decision to deny access to any 

eligible veterans. 

The American Legion believes that a more effective method of ensuring that VA 

can continue to provide quality care to veterans would be to ensure that VA is sufficiently funded to care for their needs, not limiting access for those who have incomes that fall above means tests thresholds. These veterans are required to make 

copayments, in addition to identifying their third-party health insurance that will 

reimburse VA for reasonable charges. Many of these Priority Group 8 veterans may 

very well be VA employees, Medicare beneficiaries, TRICARE or TRICARE for Life 

beneficiaries, or enrolled in the Federal Employees Health Benefits Program. The 

American Legion supports the lifting of the current prohibition on healthcare enrollment restriction for Priority Group 8 and exploring effective means to improve 

third-party reimbursement collections. 

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S. 1205, A BILL TO REQUIRE A PILOT PROGRAM ON ASSISTING VETERANS SERVICE ORGANIZATIONS AND OTHER VETERANS GROUPS IN DEVELOPING AND PROMOTING PEER

SUPPORT PROGRAMS THAT FACILITATE COMMUNITY REINTEGRATION OF VETERANS RETURNING FROM ACTIVE DUTY AND FOR OTHER PURPOSES

The American Legion has no position on this issue. However, there is concern that 

the bill does not mention any standardized training or oversight to ensure that the 

organizations selected are qualified to provide peer support services. 

S. 1233, VETERANS TRAUMATIC BRAIN INJURY

REHABILITATION ACT OF 2007

The American Legion supports the provisions of this bill. 

Section 3 discusses community reintegration plans for veterans with traumatic 

brain injury. It requires the Secretary of VA to develop an individualized plan for 

each veteran to address his or her specific rehabilitation needs. This plan must be 

available prior to the veteran’s discharge for the medical facility. It prescribes for 

the designation of a case manager who would be responsible for implementing the 

plan. Identification of a case manager and reintegration plan would ensure that 

these veterans receive the necessary rehabilitation in a timely manner and provide 

a contact that could coordinate on behalf of the veterans in the event that the plan 

needs to be enhanced or amended. It also assigns accountability in the event that 

the veterans does not receive the care he or she was promised. 

Section 4 requires VA to authorize the use of non-VA facilities under very specific 

conditions: if the VA is unable to provide needed treatment for any reason and if 

the veteran lives at a distance that would make it difficult to implement the plan. 

The American Legion believes that it is acceptable for veterans to receive medical 

care from non-VA facilities in the absence of available VA healthcare, or when traveling presents a hazard or hardship for the veteran. 

Section 5 mandates VA establish a research, education, and clinical care program 

to address severe traumatic brain injury. This is a very important component in providing the best quality of care for those who suffer from this type of injury. Since 

not much information is available on long-term effects of combat-related traumatic 

brain injury, research on the current war’s veterans would be beneficial in establishing standards of care provided to veterans of future conflicts. 

Section 6 discusses the creation of a pilot program to assess the effectiveness of 

providing assisted living services for veterans with traumatic brain injury to enhance rehabilitation, quality of life and community integration of veterans. This will 

be especially important in rural areas where there may be a lack of specialty care 

and veterans may be forced to travel long distances. 

Section 7 discusses age-appropriate nursing home care. Younger veterans are generally more technologically advanced. Facilities providing long term care for them 

should provide an environment that reflects their interests. 

Section 8 discusses research on traumatic brain injury. The American Legion supports research that would improve care available for veterans with service-connected 

injuries and that would attempt to ascertain possible secondary health outcomes. 

Since many of the symptoms of secondary conditions have delayed onset or have 

subtle manifestations, research on improving the diagnosis, treatment and prevention on traumatic brain injury will ensure the best quality care for future generations of combat veterans.

Again, thank you Mr. Chairman for giving The American Legion this opportunity 

to present its views on such an important issue. The hearing is very timely and we 

look forward to working with the Committee to enhance access to quality health 

care for all veterans.

Mr. Edelman? 

STATEMENT OF BERNARD EDELMAN, DEPUTY DIRECTOR, 

POLICY AND GOVERNMENT AFFAIRS, VIETNAM VETERANS 

OF AMERICA 

Mr. EDELMAN. Good morning, Mr. Chairman, Senator Murray. 

Vietnam Veterans of America appreciates the opportunity to testify 

before you here this morning on behalf of our officers, our Board 

of Directors, our members, and their families who want to thank 

you and your colleagues for the work you are doing and the initiatives you are taking on behalf of our Nation’s veterans. 

94

This morning, I would like to focus our comments on three bills 

that we support and endorse and one bill that we have major concerns about. 

S. 1147, the Honor Our Commitment to Veterans Act, would reopen the VA health care system to Priority 8 veterans. I think 

some history is instructive here. Back in 1996, when Congress 

passed the Veterans Health Care Eligibility Reform Act, the VA 

was able to implement major cornerstones of its plan to reform how 

it provided health care. The rationale behind this initiative was to 

ensure a patient base that would support the infrastructure that 

was needed to develop a modern, integrated health care system. 

This the VA has accomplished, and in the process a mediocre and 

inefficient system has been transformed into a national model. 

However, the law gave the Secretary of Veterans Affairs the authority and indeed the responsibility to determine eligibility for enrollment based on available resources in any given fiscal year. Although the law did not mandate a level of funding or standard of 

care, it did establish an annual enrollment process and categorized 

veterans into priority groups. 

In January 2003, as you all know, the Secretary of Veterans Affairs made a decision to temporarily suspend priority veterans from 

enrolling. This temporary decision is hardly temporary. No VA 

planning document that we have read accepts or accommodates 

Priority 8s in the near future. 

We strongly urge that this Committee and your colleagues get 

behind this most important piece of legislation and truly honor the 

commitment we as a Republic have made to those who have 

donned the uniform and served our country. Of course, we recognize the bottom line is funding and the funding Congress provides 

to enable the VA to accommodate those Priority 8 veterans who 

want to avail themselves of the VA’s health care services. We recognize the realities of pay-go, but we hope you will recognize the 

inherent justice in reopening the VA health care system to those 

who have earned the right to utilize it. They also will not, we believe, overly burden the system. In fact, it is our understanding 

that Priority 7 and 8 veterans account for some 40 percent of thirdparty collections by the VA. 

S. 1233, the Veterans Traumatic Brain Injury Treatment Act, 

would be instrumental in assuring troops afflicted with this debilitating condition that help is there for them. We believe it is a sensible, comprehensive piece of legislation for long-term TBI rehabilitation and it should go a long ways toward healing the wounded 

from these latest military ventures. 

S. 479, the Joshua Omvig Veterans Suicide Prevention Act, attempts to grapple with one of the tragic consequences of war. Too 

many of our young people whom we have sent off to fight halfway 

around the globe return markedly different. Some of them, as you 

know, have taken their lives. This is a tragedy for their family. It 

is a tragedy for this country. We heartily endorse S. 479. 

We have major issues, though, with S. 815, the Veterans Health 

Care Empowerment Act of 2007, because it has a great potential 

to undercut the VA health care system and it is simply not worth 

the risk. If enacted, this bill would effectively erode the VA’s ability 

to service veterans by permitting service-connected veterans to reVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00098 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
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ceive care and medical services for any condition at any hospital or 

medical facility or from any medical provider eligible to receive 

payments under Medicare or TRICARE. We do not believe the VA 

health care system is inefficient or corrupt. It is at a point in time 

when the VHA is meeting the needs of the veterans it serves. 

One out of ten VA health care dollars today goes to clinicians and 

facilities outside the VA system through what is called fee-basis. 

The VA is also instituting a scheme called Project HERO, which is 

the acronym for Healthcare Effectiveness through Resource Optimization. The VA is attempting to get a better handle on the dollars spent by VA medical centers for care provided outside the system. We believe that HERO and S. 815 will only serve to hurt what 

has developed into one of the best and finest managed-care systems 

in the world. 

Please keep this in mind. The VA’s electronic health record system is simply not matched by other public sector or private sector 

hospitals, clinics, or doctors. If you want to create an administrative nightmare, try to maintain an effective, efficient VA health 

care system and at the same time let veterans go wherever they 

wish for their health care. This is only going to create chaos, we 

believe, and more problems than it solves, and it solves very little. 

That concludes my oral testimony. Thank you for the opportunity 

to speak with you today. 

[The prepared statement of Mr. Edelman follows:]

PREPARED STATEMENT OF BERNARD EDELMAN, DEPUTY DIRECTOR, POLICY AND

GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA

Chairman Akaka, Ranking Member Craig, and Members of the Senate Committee 

on Veterans’ Affairs, Vietnam Veterans of America (VVA) appreciates the opportunity to testify before you here today. On behalf of our officers, our Board of Directors, our members and their families, we want to thank you for the important work 

you are doing, and the initiatives you are taking, on behalf of our Nation’s veterans. 

We would like to focus our comments this morning on four of the bills up for your 

consideration that we endorse: S. 117, the ‘‘Lane Evans Veterans Health and Benefits Improvement Act of 2007’’; S. 479, the ‘‘Joshua Omvig Veterans Suicide Prevention Act’’; S. 1233, the ‘‘Veterans Traumatic Brain Injury Rehabilitation Act of 

2007’’; and, most assuredly, S. 1147, the ‘‘Honor Our Commitment to Veterans Act.’’ 

And also one bill, S. 815, the ‘‘Veterans Health Care Empowerment Act of 2007,’’ 

that we feel will only serve to undermine the VA health care system. 

S. 1147, the ‘‘Honor Our Commitment to Veterans Act,’’ would re-open the VA 

health care system to Priority 8 veterans. These are veterans with an income of less 

than $28,000 a year who are not afflicted with a service-connected disability and 

who agree to make a copayment for their health care and prescription drugs. 

Back in 1996, when Congress passed the Veterans Health Care Eligibility Reform 

Act, the VA was able to implement major cornerstones of its plan to reform how 

it provided health care. The rationale behind this initiative was to ensure a patient 

base that would support the infrastructure needed to develop a modern, integrated 

health care system. This the VA has accomplished, and in the process a mediocre, 

inefficient system has been transformed into a national model. 

However, the law—that’s Public Law 104–262—gave the Secretary of Veterans Affairs the authority and responsibility to determine eligibility for enrollment based 

on available resources in any given fiscal year. Although the law did not mandate 

a level of funding or a standard of care, it did establish an annual enrollment process and categorized veterans into ‘‘priority groups’’ to manage enrollment. 

On January 17, 2003, the Secretary made the decision to ‘‘temporarily’’ suspend 

Priority 8 veterans from enrolling. While this decision may be reconsidered on an 

annual basis, every budget proposal from the Administration since has omitted 

funding for Priority 8 veterans not previously enrolled and has attempted to discourage use by and enrollment of those ‘‘higher income’’ veterans. 

Priority 8 veterans are, for the most part, working- and middle-class Americans 

without compensable disabilities incurred during their military service. In its budgVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00099 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
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et proposal for Fiscal Year 2007, the VA estimated that some 1.1 million of these 

‘‘higher income’’ veterans would be discouraged from using their health care system 

because of an enrollment fee and increased copays for prescription drugs. Thankfully, you in Congress have not let this scheme get much beyond the proposal phase. 

We strongly urge that you get behind this most important piece of legislation and 

truly honor the commitment we have made that honors our veterans. Of course, we 

recognize that the bottom line is funding—the funding Congress provides—to enable 

the VA to accommodate those Priority 8 veterans who want to avail themselves of 

the VA’s health care services. We recognize the realities of ‘‘pay-go.’’ But we hope 

you will recognize the inherent justice in reopening the VA health care system to 

those who have earned the right to utilize it. They will not overly burden the system; in fact, Priority 7 and 8 veterans account for some 40 percent of all third-party 

collections by the VA. 

TBI/Traumatic brain injury suffered by our troops in Afghanistan and Iraq has 

become so relatively common that its acronym, TBI, is becoming almost as infamous 

as PTSD. This affliction is not new; it has only been so codified because of the carnage caused by IEDs, improvised explosive devices, and another acronym that has 

been incorporated into the dialect of war. 

It is our understanding that the Administration is going to order the military to 

screen all returning troops for mild to moderate cases of TBI; those whose brain injuries are more serious are quite obvious to clinicians. S. 1233, the ‘‘Veterans Traumatic Brain Injury Treatment Act of 2007,’’ would be instrumental in assuring 

troops afflicted with this debilitating condition that help will be there for them. It 

is a sensible, comprehensive piece of legislation for long-term TBI rehabilitation; it 

should go a long way toward healing the wounded from these latest military ventures. 

S. 479, the Joshua Omvig Veterans Suicide Prevention Act, attempts to grapple 

with one of the unfortunate consequences of war. Too many of our young men and 

women whom we’ve sent off to fight halfway around the globe return markedly different. The lingering trauma of things they’ve experienced haunts them. These 

memories affect their daily living, and too many succumb to the emotional numbing 

and hurt. To not support this bill would do a grave injustice to those troops still 

fighting their demons. 

The potential of S. 815, the ‘‘Veterans Health Care Empowerment Act of 2007,’’ 

to harm veterans by undercutting the VA health care system is simply not worth 

the risk. If enacted, this bill would effectively erode the Veterans Health Administration (VHA) by permitting service-connected veterans to receive hospital care and 

medical services for any condition at any hospital or medical facility or from any 

medical provider eligible to receive payments under either Medicare or the 

TRICARE program. If you want to destroy the VA system, S. 815 is a good start. 

We do not believe the system is inefficient or corrupt. It is at a point in time when 

the VHA is meeting the needs of the veterans it serves. Besides, one out of every 

ten VA health care dollars today goes to clinicians and facilities outside the VA system, and through a scheme called Project HERO—the acronym for Healthcare Effectiveness through Resource Optimization—the VA is attempting to get a better handle on the dollars spent by VA medical centers for care provided outside of the system. We believe that HERO—and S. 815—would only serve to hurt what has developed into one of the best managed-care systems in the Nation. 

And keep this in mind: The VA’s electronic health records are not matched by 

other public sector and private hospitals, clinics, and doctors. If you want to create 

an administrative nightmare, try to maintain an effective, efficient VA health care 

system and at the same time let veterans go wherever they wish for their health 

care. This will only create more problems than it solves, and it solves very little. 

As for the other bills under consideration by the Committee today:

• VVA supports wholeheartedly S. 383, which would extend the period of eligibility for VA health care for combat service from two years to five. This is a nobrainer. With a shooting war going on, we have the obligation and responsibility of 

keeping our promises to those who don the uniform. When they come home, when 

they leave the military, they need to know that their government hasn’t forgotten 

about them, that as they establish themselves in civilian life they can avail themselves of VA health care. 

• We understand that Congress has previously sought to fix a glitch that occurred 

in calculating the retirement pay for annuitants who worked part-time as VA 

nurses. S. 610 would accomplish this. VVA has no opposition to this provision. 

• S. 692, the ‘‘VA Hospital Quality Report Card Act of 2007,’’ would require the 

VA to provide grades for its medical centers on measures such as effectiveness, safety, timeliness, efficiency, patient-‘‘centeredness’’ and equity. Health care quality researchers have long thrived trying to objectively define some of these measures. As 

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this Committee knows, the VA has a number of performance measures it regularly 

assesses in order to reward its medical center and network directors, among others. 

Some of these outcomes, such as immunizations for flu, foot care and eye care for 

diabetics, set the ‘‘benchmark’’ for care in the community. In addition to these internal performance measures, VHA voluntarily submits to Joint Commission on Accreditation of Healthcare Organizations, Commission on Accreditation of Rehabilitation Facilities, and managed care quality review standards. 

VVA understands the importance of quality measurement; there is an expression 

with which we agree, ‘‘what’s measured, matters.’’ We also agree that VA officials 

should be held to the highest degree of accountability, and whatever measures are 

available to allow this to better occur we wholeheartedly endorse. But perhaps before enacting this clearly well intended legislation, which could require significant 

retooling of quality measurement systems in VA, the Committee should hold a hearing to identify gaps and deficiencies in current performance and quality measurement systems. It would also be useful to understand how report cards would be used 

and reported to improve VHA processes and performance rewards. Would poor 

grades be dealt with by changes in management? With more funding? How would 

good grades be rewarded? Such questions should be addressed before requiring a 

significant new quality measurement program to be installed. • VVA understands that S. 874 would pay certain providers for delivering medical 

care, mental health care, case management and other services to very low-income 

veterans who have permanent housing. VVA supports efforts to target veterans who 

may be at risk of becoming homeless, but these individuals are often difficult to 

identify until it is too late. In addition, funding for VA mental health, in addition 

to homeless grant and per diem providers, is also already too scarce. VVA supports 

the addition of this benefit if VA is funded appropriately to provide it without taking 

resources away from these other programs. • While the VA Secretary has had the discretion to raise beneficiary travel rates, 

no Secretary has chosen to do so in decades. The result is an almost meaningless 

benefit for veterans who seek it. S. 994 would allow the VA to reimburse certain 

veterans for travel at a rate that the government pays its own employees. That 

sounds fair to VVA. • VVA has no objection to S. 1043, under which Congress would require a report 

on proposed land use changes on the campus of the West LA VA Medical Center. • S. 1205 would require the VA to develop a pilot program to make grants to veterans service organizations and other veterans groups to develop peer-support 

groups to assist with veterans’ reintegration. As an organization whose creed is 

‘‘Never again will one generation of veterans abandon another,’’ VVA has expended 

considerable resources in assisting newly minted veterans as well as some new veterans groups—particularly Veterans of Modern Warfare—in developing a robust 

program to advocate for their members’ needs. We have certainly not done so contemplating financial gain. Assisting veterans’ reintegration with peer-support 

groups is and should be a function of VSOs; organizations should not have to compete for funding for providing veterans’ services, which would significantly change 

the nature of the game. • Designating the VA medical center in Augusta, Georgia, the ‘‘Charlie Norwood 

Department of Veterans Affairs Medical Center’’ acknowledges the contributions of 

a recently deceased Member of Congress who served in the military as well as in 

the House of Representatives. VVA applauds the spirit and endorses the intent of 

this bill. • Additional legislation to enhance the VA’s programs for homeless veterans, introduced by Senator Akaka, deserve support, too. It is a national disgrace that so 

many veterans—upwards of 200,000, according to most estimates—do not have a 

place to call home. There are many causes of homelessness; in the case of too many 

veterans, their experiences in combat are likely one of the reasons they have 

‘‘dropped out’’ of society and self-medicate with alcohol and other drugs. Furthermore, it is our position that VA Homeless Grant and Per Diem funding must be considered a payment rather than a reimbursement for expenses, an important change 

that will enable the community-based organizations that deliver the majority of 

these services to operate effectively.

Per Diem dollars received by service centers are not capable of supporting the 

‘‘special needs’’ of the veterans seeking assistance. Currently they are receiving less 

than $3.50 per hour per veteran that the veteran is onsite. The work of assisting 

the homeless veterans who utilize these services goes on long after they have left 

the service center, a center that is providing a full array of services and case management. 

These service centers are unique and indispensable in the VA process. In many 

cases they are the front and first exposure to the VA and VA Homeless Grant and 

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Per Diem programs. They are the door from the streets and shelters to substance 

abuse treatment, job placement, job training, VA benefits, VA medical and mental 

health care and treatment, and homeless domiciliary placement. Veteran-specific 

service centers are vital in that most city and municipality social services do not 

have the knowledge or capacity to provide appropriate supportive services that directly involve the treatment, care, and entitlements of veterans. Additionally, since 

many local municipalities have removed ‘‘supportive services’’ from their HUD Continuums of Care, providing staffing dollars through a VA Homeless Grant and Per 

Diem staffing grant program, similar to the Special Needs Grant process, to those 

agencies operating service centers, would allow the service centers to provide these 

vital services with appropriate level of qualified personnel. Without consideration of 

staffing grants the result may well be the demise of these critical services centers. 

Some are currently assisting upwards of 50 veterans a day, with more than 900 individual veterans seeking services annually. 

The VA acknowledges this problem exists. It is yet to be specifically identified by 

them as to how many awarded service center grantees have been affected by either 

the inability to establish these centers or retain operation because of this very funding issue. If we intend to fully address the issue of veterans who remain on the 

streets, then we urge you to not make light of this very important element in this 

bill. It will be especially critical to the new veterans who find themselves in this 

very disturbing situation of life. They deserve our best efforts. 

In addition, as highlighted in the 2006 recommendations made by the Secretary’s 

Advisory Committee on Women Veterans, a survey of homeless women veterans 

showed that fewer women veterans are seeking services in VA domiciliary settings 

and residential treatment facilities because of concerns about safety, privacy, and 

what is a male-dominated environment. Ideally, separate area/space designed for 

women veterans will support this need. Flexibility in design will allow appropriate 

utilization of space. 

We also advocate that all VA domiciliary settings be evaluated with regard to gender-specific needs related not only to the safety and security, but also to positive 

therapeutic environments and successful treatment modalities. 

This concludes our testimony. VVA is appreciative of having been afforded the opportunity to testify on the merits of these bills. We would be pleased to respond to 

any questions you might have. 

VIETNAM VETERANS OF AMERICA’S VIEWS ON RURAL VETERANS HEALTH CARE

The topic of accessibility to VA medical services for veterans who live in rural 

areas has been percolating of late. We believe that S. 1146, the ‘‘Rural Veterans 

Health Care Improvement Act of 2007,’’ offers pragmatic solutions to address the 

problems of access to health care experienced by too many rural veterans. The bill 

would increase travel reimbursement for veterans who travel to VHA facilities to 

the rates paid to Federal employees. The current reimbursement rate was established decades ago and does not adequately compensate for the costs of gasoline, 

‘‘wear and tear’’ on the vehicle or increased insurance that might be necessary in 

order to travel to distant medical centers. In the same vein, the grant program for 

rural veterans service organizations to develop transportation programs could be an 

innovative way to strengthen community resources that may already assist with 

veterans’ travel needs. 

The establishment of centers of excellence for rural health research, education, 

and clinical activities, another component of this bill, should fill a gap in VA health 

care and should lead to innovation in long-distance medical and telehealth care. 

These centers have brought the synergies of clinical, educational and research experts to bear in one site. Such centers have allowed VA to make significant contributions to the fields of geriatric medicine and mental illness. It would require 

demonstrations of rural treatment models. Demonstrations on treating rural veteran 

populations would be extremely useful in assessing effective ways to offer health 

care to individuals who are generally poorer, more likely to be chronically ill, and 

almost, by definition, more likely to have challenges in access to regular health care. 

And establishing partnerships—with the Indian Health Service and with the Department of Health and Human Services—also should add to greater cooperation 

and collaboration in meeting the needs of rural veterans. 

We would caution, however, that we would not like to see these demonstration 

projects exploring more opportunities to do widespread contracting out of veterans’ 

health care services. Demonstration models should be assessed according to a number of outcomes such as quality of care, cost, and patient satisfaction and the results 

reported to Congress.

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Chairman AKAKA. Thank you very much, Mr. Edelman. I thank 

all of you. 

I would like to ask one question and then ask Senator Murray 

for any questions she might have. This question is to all of you. 

While the bills being considered today address very, very different 

issues, many have a common thread of pushing VA to contract for 

more and more care in the community. My question to you is, do 

you each believe that VA care should and can be the very best? 

When is it desirable for VA to purchase outside care? Mr. Blake? 

Mr. BLAKE. Well, I would say the short answer, Mr. Chairman, 

is yes, it should be and it is the best. We have testified on a number of occasions as it relates to fee-basis, and kind of as a way to 

quickly address Senator Craig’s question earlier about individual 

veterans who maybe are not able to get a particular kind of service, 

it has been our contention all along, and we have testified to this 

also on the issue of rural health care, that the VA has the authority to meet the needs of these veterans if it is not being met within 

the VA health care system now under their fee basis regulations. 

However, we have testified in the past that we don’t believe the 

VA is very judicious in how it applies its regulations. It is overly 

conservative, if anything, which on its face goes against principally 

what we believe against contracting out health care. But we also 

recognize that there are situations where it is absolutely necessary. 

Now, doing it on a broader basis is far more problematic in our 

eyes for reasons that we have outlined here in our testimony and 

in previous forums. 

Chairman AKAKA. Thank you. Mr. Cullinan? 

Mr. CULLINAN. Thank you, Mr. Chairman. It is the VFW’s contention, as well, that the VA must be maintained as the premier 

health care provider in the world. Having said that, I would associate myself with something Senator Craig said earlier, that when 

it comes to the individual needs of veterans in need, by all means, 

we should take advantage of such things as contract care, fee-basis 

care, and so forth. Our objection, as you know, with S. 815 was the 

fact that it was too broad in scope and has the very definite potential of undermining the system. But when it comes to those cases 

where the care is not accessible or in those instances when the care 

is—VA is simply unable to provide a certain care modality, then 

fee-basis contract care is the way to go. 

Chairman AKAKA. Ms. Ilem? 

Ms. ILEM. I would echo my colleagues’ comments, but just add to 

that that in terms of contracting care, especially for PTSD or some 

other mental health issue, one of the concerns that we would have 

is if there is the cultural competence. VA is a unique system. They 

have done a lot of work in very specialized areas in terms of mental 

health and combat-related trauma and the most effective treatments. And so at all times, whenever possible, we want VA to provide that care because we feel they are the very best, and as Dr. 

Cross pointed out, as well, within traumatic brain injury, the 

unique setting is that these veterans have a polytrauma, often 

other very severe injuries associated with their brain injury which 

the private sector likely hasn’t seen, as well, and they are very 

complicated cases. 

100

But in individual cases, if VA is unable to provide that care for 

some reason, you know, certainly we want veterans to get access 

to that care. We just don’t want that to be—we want the VA to 

take primary responsibility. If there is a problem with a veteran in 

getting some type of care or they are not doing a good job, that 

issue should be addressed and it should be maintained within the 

system. VA should be responsible for that care and continue that 

lifetime relationship with that patient who will ultimately be responsible for their care, most likely. Thanks. 

Chairman AKAKA. Ms. Middleton? 

Ms. MIDDLETON. Yes, sir. Well, I will have to echo all three of 

my colleagues. The American Legion also believes that when absolutely necessary, care should be provided by non-VA health care 

providers in the community, and that is in the case of maybe rural 

veterans or in the case where travel for the veteran might present 

a danger to him. If coordinating care might be just complicated because of the special needs of the veteran, then non-VA care would 

be appropriate. But we, as I said, echo the other VSOs that it 

should be provided by the VA. They are the people who can provide 

the best quality care for those who have military-related injuries. 

Chairman AKAKA. And Mr. Edelman? 

Mr. EDELMAN. Yes, sir. I will associate our position with that of 

my colleagues here. There is a need for fee-basis care when the 

care cannot be provided by VA, particularly for individual veterans’ 

needs, particularly for rural veterans. We have no problem with 

that, nor should we. At the same time, the integrity of the VA 

health care system, which we have all worked to buildup over these 

past several years, should not be undermined by indiscriminate use 

of fee basis or outsourcing of contract care. 

Chairman AKAKA. Thank you very much. 

Senator Murray? 

Senator MURRAY. Thank you, Mr. Chairman. I just have a couple 

of questions. 

One of them is on a bill that we were not able to get on the calendar today but it has to do with veterans who live in rural areas. 

We heard several Senators talk about the challenges that they face, 

and last year, we recognized the disparity for our veterans who live 

in more remote communities with the passage of the Office of Rural 

Health to put an office within the VA to start looking at how we 

better implement care and policies for veterans who live in more 

rural communities. It was a good start. I think much more needs 

to be done. 

And Senator Salazar has introduced legislation, Rural Veterans 

Health Care Improvement Act, to build on that and to develop 

some demonstration projects and centers of excellence and a transportation grant program and I just wondered if any of you could 

comment quickly on whether or not you support that. I know you 

weren’t prepared for it. It is not on the agenda. But I wanted to 

make sure we were all aware of it. 

Mr. CULLINAN. Senator Murray, on behalf of the VFW, we are familiar with that issue and how problematic it really is and we are 

certainly supportive as described of an initiative which would have 

VA undertake a look into what can be done. 

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And the thing I would add to that, and one thing that should be 

done right away is Senator Tester’s bill, which would provide for 

increased beneficiary travel. That alone would solve the problem 

for many, many veterans in the——

Senator MURRAY. Right, and I believe that is incorporated in 

Senator Salazar’s legislation, as well. 

Does anyone else want to comment on that? Mr. Blake? 

Mr. BLAKE. Senator, I think this sounds a lot like a bill that he 

introduced in the previous Congress and we worked with Senator 

Salazar’s office and made some comments about concerns that we 

had, particularly as it relates to broader contracting, recognizing 

that we have concerns there. Having not seen the bill, I won’t comment as far as an actual position, but we certainly will work with 

you and Senator Salazar and all the Members of the Committee to 

develop the best bill. I mean, we recognize that rural health care 

is probably one of the most important issues facing this Committee 

and all of Congress right now and how to address the needs of the 

men and women who are kind of scattered to the four winds,

so to speak. 

Senator MURRAY. Well, maybe if I could ask, Mr. Chairman, if 

I could just get some quick written comments back from all of you 

on that legislation, that would be great, because I did want to ask 

one other question on the Priority 8 veterans. 

The issue of funding has come up over and over again, and the 

VA, although they didn’t testify to it today, has estimated it to be 

a cost of over a billion dollars. The Independent Budget estimated 

it at $366 million. Can anyone comment on why the disparity

in that? 

Mr. BLAKE. Well, Senator, I don’t necessarily know what exactly 

the disparities would be other than to say that our cost estimate 

is based on the assumption of needed discretionary dollars, considering that those new Category 8s would also add money into the 

system through their co- pays and associated fees that may be necessary, whereas I believe the VA’s estimate—I believe, I am not absolutely certain—is just an actual total cost for that group of

veterans. 

Senator MURRAY. It doesn’t count into their third-party

insurance? 

Mr. BLAKE. As I understand it. The other thing to consider is, 

and I would have to go back and review the budget, the Administration’s budget submission from earlier this year, but our dollar 

figure reflects the fact that although most estimates pinpoint more 

than a million veterans being denied enrollment since this policy 

was put into place in 2003, the real factor is that the utilization 

rate for Category 8 veterans is only about 20 percent. 

So you can cost out a cost for the million-plus veterans that 

would be denied enrollment, but looking back at historically how 

it has worked out, you would only assume that about 20 percent 

of those veterans would use the system. So there would be a cost 

associated with 20 percent of that million-plus veterans. So our 

cost estimate for the Independent Budget reflects that, as well. 

Senator MURRAY. OK. I really appreciate that, and maybe the 

VA could give us back a response, as well, on that, because that 

102

is a critical issue and I do think we have to really look at the reality of what that would do. 

So I appreciate your comment. 

Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Murray. 

We may have follow-up questions that we will include in the 

record. I want to thank you all again. You know that we look to 

you to hear your ideas about our bills and I thank you so much, 

for what you have testified before us and responded to us will certainly help. Thank you very much. 

Now, I would like to call on our third panel to come forward. Our 

third panel of witnesses to today’s hearing is Meredith Beck of the 

Wounded Warrior Project; Dr. John Booss, representing the American Academy of Neurology; and Jerry Reed, Executive Director of 

Suicide Prevention Action Network USA. 

I thank you all for appearing before the Committee today. You 

know that your full statements will appear in the record of the 

hearing. 

Meredith Beck, will you please proceed with your statement. 

STATEMENT OF MEREDITH BECK, NATIONAL POLICY 

DIRECTOR, WOUNDED WARRIOR PROJECT 

Ms. BECK. Mr. Chairman, thank you for the opportunity to testify before you today regarding pending health legislation. The 

Wounded Warrior Project is a nonprofit, nonpartisan organization 

dedicated to assisting the men and women of the Armed Forces, 

who have been severely injured during the recent conflicts. As a result of our direct daily contact with these wounded warriors, we 

have gained a unique perspective on their needs and the obstacles 

they face as they attempt to recover and reintegrate into their respective communities. 

First, WWP is pleased that the Chairman and Senator Craig 

have highlighted the issues surrounding traumatic brain injury 

with the introduction of S. 1233, the Veteran Traumatic Brain Injury Rehabilitation Act of 2007. The signature wound of the war, 

as it has come to be known, TBI is an extremely challenging injury 

to treat and poses some new and complex issues for the Department of Veterans Affairs. 

As such, and because the families of wounded servicemembers 

have named increased access to treatment options as their number 

one request, WWP supports the concept included in the legislation 

allowing TBI patients to use private facilities for rehabilitation. At 

the same time, however, we would like to see a provision added authorizing and encouraging the VA to collaborate with experienced 

private sector hospitals in addition to medical universities so that 

the Department can continue to develop long-term rehabilitation 

capabilities and perhaps one day become the facility of choice for 

severely injured TBI patients. 

We are also extremely concerned with the method by which the 

legislation determines the TBI patients’ eligibility for such a health 

care benefit. According to the provision as currently written, the 

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cation. But no care criteria for the participating private facilities 

are enumerated. 

Even more importantly, by determining eligibility based on geographic proximity to a VA facility and the discretion of the Secretary for the Department’s ability to provide the necessary services, the legislation would limit the range of patients who can qualify for placement in a private facility and thus not provide the options for care that our wounded warriors and their families are 

seeking. 

While WWP does not question the intent or the effort of the VA 

to care for these patients, we are concerned that the understandable need to further develop their capability for the benefit of future patients may disqualify current patients who would otherwise 

benefit from private rehabilitation. 

For example, several weeks ago, many of you heard the testimony of Denise Mettie before this Committee regarding her son, 

Evan’s, experiences in both DOD and VA facilities. As you may recall, Evan bypassed the VA polytrauma system for a period of time 

and experienced several setbacks once he finally reached the VA’s 

Tier 1 facilities. After much discussion, debate, and effort, Evan 

was finally sent to the Kessler Institute for Rehabilitation, a private facility in New Jersey where only after a few weeks it had 

been discovered that Evan is not blind in one eye, as it was believed. His nystagmus has almost completely stopped, and he even 

gave a physical therapist a thumbs up with his left hand, which 

he has not used for almost a year. Of course, no one can guarantee 

that type of progress for every wounded veteran, but whether in a 

VA facility or a private rehabilitation hospital, every one of them 

deserves the chance to try. 

For these and other reasons, WWP is grateful for Senators 

Akaka’s and Craig’s leadership on this legislation and we would 

like to continue to work with you to enhance S. 1233 to better meet 

the needs of the severely wounded servicemembers, veterans, and 

their families. 

With respect to S. 383, a bill to extend the period of eligibility 

for health care for 2 years to 5 years after discharge, WWP is generally supportive of the provision. Often, especially in cases of delayed onset PTSD or mild to moderate TBI, veterans do not quickly 

recognize that they are in need of assistance or care. In other 

cases, veterans are simply not prepared to navigate another bureaucratic system after having just escaped the burdensome and 

administrative process of the Department of Defense. 

WWP cautions, however, that while we want to make sure that 

every service-connected veteran is able to access the care he or she 

needs, extending the period of presumptive eligibility for VA care 

will add more veterans to an already overburdened system. Therefore, if this provision is adopted, Congress must ensure that the required resources are added, as well. 

In theory, WWP generally supports the concept behind S. 815, 

the Veterans Health Care Empowerment Act of 2007, but has concerns about the implementation of and the long-term effects of such 

action on the VA. This legislation would allow service-connected 

veterans to receive health care at any facility or through any provider eligible to receive Medicare or TRICARE payments. As menVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00107 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
104

tioned previously in our testimony, the top request of wounded veterans and their families is to have more involvement and choice in 

their care and this legislation would certainly help to accomplish 

that goal. 

However, we are concerned that, as written, the VA would play 

no role in the coordination of care for the veterans who choose outside facilities, and without proper management by the VA, such a 

system could lead to confusion and contradiction among physicians 

in the provision of the care to the wounded. In addition, the legislation does not include any specifics on the implementation of such 

a large policy shift and therefore the final plan could differ greatly 

from that sought by Congress. 

At this time, WWP unfortunately has grave concerns regarding 

S. 1147, the Honor Our Commitment to Our Veterans Act, which 

would require the Secretary to lift the current freeze on the enrollment of Category 8 veterans into the VA health care system. According to the Veterans Health Care Eligibility Reform Act of 1996, 

the legislation would first authorize the VA to provide health care 

services to veterans without service-connected disabilities or low income. If sufficient resources are not available to provide care that 

is timely and acceptable in quality for all priority groups, the Act 

requires VA to limit enrollment based on the priority groups

themselves. 

Just over the past several weeks, many in this room have identified waiting times for appointments, quality of care, and limited resources as just some of the challenges facing the VA. With the addition of relatively higher-income non-service-connected veterans, 

Congress would be placing an additional strain on a system it has 

called overburdened and complicated. With that said, those at the 

VA are working very hard to accommodate their current patients 

and WWP asks that we work with them to improve the care for 

those currently in the system, especially those who are severely injured, before adding another category of veterans. 

Mr. Chairman, thank you again for this opportunity to testify 

and I look forward to your questions. 

[The prepared statement of Ms. Beck follows:]

PREPARED STATEMENT OF MEREDITH BECK, NATIONAL POLICY DIRECTOR,

WOUNDED WARRIOR PROJECT

Mr. Chairman, Senator Craig, Members of the Committee, thank you for the opportunity to testify before you today regarding pending health legislation. 

The Wounded Warrior Project (WWP) is a non-profit, non-partisan organization 

dedicated to assisting the men and women of the United States Armed Forces who 

have been severely injured during the War on Terrorism in Iraq, Afghanistan and 

other hot spots around the world. Beginning at the bedside of the severely wounded, 

WWP provides programs and services designed to ease the burden of these heroes 

and their families, aid in the recovery process and smooth their transition back 

home. As a result of our direct, daily contact with these wounded warriors, we have 

gained a unique perspective on their needs and the obstacles they face as they attempt to recover and reintegrate into their respective communities. 

Today, I would like to comment on several pieces of legislation listed on the hearing agenda. First, WWP is pleased that the Chairman and Senator Craig have highlighted the issues surrounding Traumatic Brain Injury (TBI) with the introduction 

of S. 1233, Veterans Traumatic Brain Injury Rehabilitation Act of 2007. The ‘‘signature wound of the war’’ as it has come to be known, TBI is an extremely challenging 

injury to treat and poses some new and complex issues for the Department of Veterans Affairs (VA). As accurately stated in the legislation, those who are severely 

injured require individualized, comprehensive care, and, while the VA has made treVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00108 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
105

mendous progress in a short period of time, they are still in the process of establishing an extensive, long term continuum of care that can be accessed throughout 

the Nation. As such, and because the families of wounded servicemembers have 

named increased access to treatment options as their number one request, WWP 

supports the concept included in the legislation allowing TBI patients to use private 

facilities for rehabilitation. At the same time, however, we would also like to see 

a provision added authorizing/requiring the VA to collaborate with experienced private sector hospitals in addition to medical universities so that the Department can 

continue to develop long-term rehabilitation capabilities and, perhaps, one day become the facility of choice for severely injured TBI patients. 

We are also extremely concerned with the method by which the legislation determines the TBI patient’s eligibility for such a health care benefit. According to the 

provision as currently written, the Secretary would have the discretion to enter into 

individual agreements with facilities to provide care based on in part on geographic 

location, but no care criteria for the participating private facilities are enumerated. 

Even more importantly, by determining eligibility based on geographic proximity to 

a VA facility and the discretion of the Secretary for the Department’s ability to provide the necessary services, the legislation will limit the range of patients who can 

qualify for placement in a private facility and thus not provide the options for care 

that our warriors and their families are seeking. 

While WWP does not question the intent or effort of the VA to care for these patients, we are concerned that their need to further develop their capability for the 

benefit of future patients may disqualify current patients who would otherwise benefit from private rehabilitation. For example, several weeks ago many of you heard 

the testimony of Denise Mettie before this Committee regarding her son, Evan’s, experiences in both DOD and VA facilities. As you may recall, Evan bypassed the VA 

Polytrauma System for a period of time and experienced several setbacks once he 

finally reached one of the VA’s Tier I facilities where he had seemed to plateau, if 

not regress, in terms of improvement. After much discussion, debate, and effort 

Evan was finally sent recently to the Kessler Institute for Rehabilitation, a private 

rehabilitation facility in New Jersey where, after only a few weeks it has been discovered that Evan is NOT blind in one eye as was believed, his Nystagmus has almost completely stopped, and he even gave his physical therapist a thumbs up with 

his left hand which he has not used for almost a year. Of course no one can guarantee that type of progress for every wounded veteran, but, whether in a VA facility 

or a private rehabilitation hospital, every one of them deserves the chance to try. 

For these and other reasons, WWP is grateful for Senators Akaka and Craig’s leadership on this legislation and we would like to continue to work with you to enhance 

S. 1233 to better meet the needs of severely wounded servicemembers, veterans, and 

their families. 

With respect to S. 383, a bill to extend the period of eligibility for health care from 

2 years to 5 years after discharge or release from the Armed Forces, WWP is generally supportive of the provision. Often, especially in cases of delayed-onset Post 

Traumatic Stress Disorder or mild to moderate Traumatic Brain Injury, veterans do 

not quickly recognize that they are in need of assistance or care. In other cases, veterans are simply not prepared to navigate another bureaucratic system after having 

just ‘‘escaped’’ the burdensome administrative process of the Department of Defense. 

WWP cautions, however, that while we want to make sure that every service-connected veteran is able to access the care he or she needs, extending the period of 

presumptive eligibility for VA care will add more veterans to an already overburdened system. Therefore, if this provision is adopted, Congress must ensure that the 

required resources are added as well. 

In theory, WWP generally supports the concept behind S. 815, The Veterans 

Health Care Empowerment Act of 2007 but has concerns about the implementation 

of and the long-term effects of such action on the VA. This legislation would allow 

service-connected veterans to receive healthcare at any facility or through any provider eligible to receive Medicare or TRICARE payments. As mentioned previously 

in our testimony, the top request of wounded veterans and their families is to have 

more involvement and choice in their care, and this legislation would certainly help 

accomplish that goal. However, we are very concerned that, as written, the VA 

would play no role in the coordination of care for the veterans who choose outside 

facilities. Without proper management by the VA, such a system could lead to confusion and contradiction among physicians in the provision of care to the wounded. 

In addition, the legislation does not include any specifics on the implementation of 

such a large policy shift, and, therefore, the final plan could differ greatly from that 

sought by Congress. 

At this time, WWP has grave concerns regarding S. 1147, The Honor Our Commitment to Veterans Act, which would require the Secretary to lift the current 

106

freeze on the enrollment of Category 8 veterans into the VA healthcare system. According to The Veterans’ Health Care Eligibility Reform Act of 1996, the legislation 

which first authorized VA to provide health care services to veterans without service-connected disabilities or low incomes, if sufficient resources are not available to 

provide care that is timely and acceptable in quality for all priority groups, the Act 

requires VA to limit enrollment based on the priority groups. 

Just over the past several weeks, many in this room have identified waiting times 

for appointments, quality of care, and limited resources as just some of the challenges facing the VA. With the addition of relatively higher income, non-service connected veterans, Congress would be placing an additional strain on a system it has 

called overburdened and complicated With that said, those at the VA are working 

very hard to accommodate their current patients, and WWP asks that we work with 

them to improve the care for those currently in the system, especially those who 

are severely injured, before adding another category of veterans. 

Finally, WWP is concerned that while well-intentioned, S. 882, requiring a pilot 

program to facilitate the transition of members of the Armed Forces to VA 

healthcare upon completion of service, and S. 1205, requiring a pilot program to assist veterans service organizations in developing peer support programs would create programs redundant to those already provided by the government or non-profit 

groups. For example, each of the services within the DOD operates its own organization to care for their respective wounded servicemembers. The Marine for Life Program currently offers services to transitioning Marines including job opportunities 

and information on veterans’ benefits. In addition, many non-profits, including 

WWP, operate successful peer support programs funded through individual donations. This type of assistance is not only beneficial to the warrior, but is also an 

important means by which those in the community can support our returning veterans. Because many of our families often state they are confused by the number 

of different entities approaching them and, ‘‘need a case manager to manage their 

case managers,’’ WWP would suggest improved coordination and integration among 

existing organizations and agencies before adding more layers and a review of current services, both governmental and non-profit to determine the best use of limited 

funds. 

Mr. Chairman, thank you again for this opportunity to testify, and I look forward 

to your questions.

Chairman AKAKA. Thank you very much for your testimony. 

Dr. Booss? 

STATEMENT OF JOHN BOOSS, M.D., PROFESSOR EMERITUS OF 

NEUROLOGY AND LABORATORY MEDICINE, YALE UNIVERSITY SCHOOL OF MEDICINE; ON BEHALF OF THE AMERICAN 

ACADEMY OF NEUROLOGY 

Dr. BOOSS. Thank you and good morning. 

Chairman AKAKA. Good morning. 

Dr. BOOSS. I am John Booss, an Air Force veteran and the 

former National Director of Neurology for the Department of Veterans Affairs. I am proud to have had over 30 years of service to 

the VA. I am Professor Emeritus of Neurology and Laboratory 

Medicine at Yale University School of Medicine and a fellow of the 

American Academy of Neurology, the AAN. 

On behalf of the AAN and the more than 20,000 neurologists and 

neuroscience professionals we represent, I applaud you for introducing S. 1233. It will improve the rehabilitation of veterans with 

traumatic brain injury, or TBI. 

TBI involves neurological cognitive behavioral changes which are 

complex and diverse and may change in severity or develop over 

time. Longer-term neurological problems include post-traumatic 

epilepsy, headache, sleep disorders, and sensory complications. 

First, some general comments on S. 1233. We strongly support 

the team approach. Individualized rehabilitation plans based on a 

comprehensive assessment of a veteran’s physical, cognitive, vocaVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00110 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
107

tional, and psycho-social impairments using a multi-disciplinary 

team that includes specialists in neurology are essential to the rehabilitative process. We endorse involving the veteran and the family in the plan. TBI is a devastating and life-altering condition for 

veterans and their families. Families of veterans with TBI need 

support and education and they should be part of the rehabilitative 

team. 

Families also should not have the burden of traveling significant 

distances to access VA quality care. The AAN supports the use of 

non-VA facilities in cases where the VA is unable to provide easily 

accessible care as long as those facilities conform to the high standards of VA care. 

We underscore the importance of the sections of the bill which 

provide for long-term care needs of those veterans for assisted living and long-term care. 

I turn now to Section 8. Section 8 improves research on visually 

related neurological conditions and seizure disorders, which are frequent complications from TBI. The American Academy of Neurology is particularly supportive of the bill’s recognition that seizure disorders will be a significant and frequent problem of TBI 

and that research on treatment is necessary. We do not have longterm data on post-traumatic epilepsy from the current conflicts, but 

the statistics from the Vietnam era are alarming. 

Research in VA and DOD found that 53 percent of veterans who 

suffered a penetrating head wound in Vietnam developed epilepsy 

within 15 years. The relative risk for developing epilepsy more 

than 10 to 15 years after the injury was 25 times higher than their 

age-related civilian counterparts. Indeed, 15 percent did not manifest epilepsy until 5 or more years after their combat injury. 

Neurologists are concerned, too, that the rate of post-traumatic 

epilepsy from blast TBI will also be high. 

Given the high rate of post-traumatic epilepsy that veterans with 

TBI are likely to endure, the VA must have a strong national epilepsy program. We believe that Section 8 takes a step in recognizing that need. 

Decades ago, the VA was, in fact, the national leader in the care 

and research for patients with epilepsy, but since that time, the VA 

epilepsy centers have languished due to a lack of funds. We appreciate S. 1233’s proactive recognition of epilepsy as a significant consequence of TBI and support VA research in this area. The Academy believes that this could help lead the way to centers of excellence much in the way the VA leads on Parkinson’s disease and 

multiple sclerosis. This could restore the VA to its earlier prominence in taking care of veterans with epilepsy. 

In conclusion, the Academy wholeheartedly supports S. 1233 as 

needed legislation. Epilepsy is a major concern for those with TBI 

and we look forward to working with you to ensure that America’s 

veterans who suffer TBI have access to a system that provides lifelong care and support. 

Thank you for the opportunity to provide our support and comments on S. 1233. 

[The prepared statement of Dr. Booss follows:]

108

PREPARED STATEMENT OF JOHN BOOSS, M.D., PROFESSOR EMERITUS OF NEUROLOGY

AND LABORATORY MEDICINE, YALE UNIVERSITY SCHOOL OF MEDICINE; ON BEHALF

OF THE AMERICAN ACADEMY OF NEUROLOGY

Good morning, Mr. Chairman and Members of the Committee. My name is Dr. 

John Booss. I am a veteran of the Air Force and the former National Director of 

Neurology at the Department of Veterans Affairs (VA), and proud to have over thirty years of service to the VA. I am currently a Professor Emeritus of Neurology and 

Laboratory Medicine at Yale University and a fellow of the American Academy of 

Neurology (AAN). On behalf of the AAN, I am pleased to present our support of S. 

1233. The AAN, which represents over 20,000 neurologists and neuroscience professionals, believes that our veterans deserve the best possible care for neurological injuries sustained in their service to our country. 

I applaud this Committee for holding hearings earlier on how the conflicts in Iraq 

and Afghanistan have created an emerging epidemic of traumatic brain injury (TBI) 

among combat veterans. TBI, which has been called the signature wound of the 

wars, involves neurological, cognitive and behavioral changes which are complex, 

varied, diverse and may change in severity or develop over time. Longer-term neurological problems often include post-traumatic epilepsy, headaches, sleep disorders 

and sensory complications. 

The AAN strongly supports the ‘‘team approach’’ laid out in section 3 of S. 1233. 

Each veteran who suffers a TBI should receive ongoing individualized, comprehensive and multidisciplinary rehabilitation after inpatient services. Rehabilitation 

plans that are based upon a comprehensive assessment of the veteran’s physical, 

cognitive, vocational, and psychosocial impairments, using a multidisciplinary team 

that includes neurologists (as required by S. 1233), are essential to rehabilitative 

success. 

We support the provision in section 3 which requires involving the family and veteran in the development and review of the rehabilitation plan. TBI is a devastating 

and life-altering event which affects the veteran and his or her family. Families of 

veterans with TBI need support and education, and should be part of the rehabilitative team to the greatest extent possible. 

We also support the periodic assessment of the rehabilitation plan. The consequences of a TBI may change over time and new symptoms may develop. For example, individuals with TBI may develop post-traumatic seizures months or years 

after the injury. Epilepsy requires regular monitoring. For many patients, changes 

in their anti-seizure medications are required. This makes this periodic assessment 

crucial. 

The AAN also appreciates the recognition of seizure disorders as a common outcome of TBI in S. 1233. Post-traumatic epilepsy is going to be a significant longterm consequence of TBI. 

Although we do not have data on post-traumatic epilepsy from the current conflicts, the statistics from the Vietnam era are alarming. VA-funded research conducted in collaboration with the Department of Defense found that 53 percent of 

veterans who suffered a penetrating TBI in Vietnam developed epilepsy within 15 

years. For these service-connected veterans, the relative risk for developing epilepsy 

more than 10 to 15 years after their injury was 25 times higher than their age-related civilian cohorts. Indeed, 15 percent did not manifest epilepsy until five or more 

years after their combat injury. As neurologists, we believe that the rate of epilepsy 

from blast TBI will also be high. 

Given the high rate of post-traumatic epilepsy that veterans with TBI are likely 

to endure, the AAN believes that Congress should authorize and the VA must establish a strong national epilepsy program with Research, Education and Clinical Centers, to include Epilepsy Centers of Excellence. We are concerned that the VA lacks 

a national program for epilepsy with clear guidelines on when to refer patients for 

further assessment and treatment of epilepsy. VA Centers of Excellence have been 

the model of innovation in the delivery of highly specialized health care and research for other disabling and chronic diseases in the veteran population. VA has 

infrastructure to address many of the other common consequences of TBI, such as 

psychosocial changes and vision problems but not post-traumatic epilepsy. 

At one point, the VA was a national leader in care and research for patients with 

epilepsy. As early as 1972 the VA recognized the need for VA health centers that 

specialized in epilepsy. But starting in the 1990s these epilepsy centers have languished due to lack of funds. 

Six strategically located facilities could develop the necessary capacity to function 

as centers of excellence in research, education, and training in diagnosis and treatment of epilepsy. For example, a VA health care facility affiliated with a medical 

school that trains residents in the diagnosis and treatment of epilepsy, including 

109

epilepsy surgery, would be able to attract the participation of clinicians and scientists capable of driving innovation in the prevention and treatment of post-traumatic epilepsy. 

Because so many of our recent veterans are returning to rural areas, access to 

state-of-the art care for post-traumatic epilepsy will be a challenge of the VA. Epilepsy Centers for Excellence could help address this challenge by expanding the 

VA’s telemedicine capacity. Through the transmission and review of neurological diagnostic tests, such as EEGs and MRIs, the VA Epilepsy Centers of Excellence could 

provide a nationwide monitoring program to improve the quality of life for veterans 

with post-traumatic epilepsy who live in rural areas. 

We appreciate that S. 1233 contains a provision to establish a broad TBI research, 

education and clinical care program. Still, more research into epilepsy is needed. 

Without a strong national program on epilepsy, post-traumatic epilepsy may not receive adequate focus and support. As you move S. 1233 forward in the legislative 

process, we ask that you clarify that these centers must include a significant focus 

on the prevention, diagnosis and treatment of epilepsy. We ask that you give the 

VA an incentive to establish the VA Epilepsy Centers of Excellence with a clear 

statutory foundation and the authorization of appropriations. 

Both the American Academy of Neurology and I thank you for the opportunity to 

provide our support and comments on S. 1233.

Chairman AKAKA. Thank you very much, Dr. Booss. 

Mr. Reed? 

STATEMENT OF JERRY REED, EXECUTIVE DIRECTOR,

SUICIDE PREVENTION ACTION NETWORK USA 

Mr. REED. Chairman Akaka, thank you for inviting me to speak 

regarding the Joshua Omvig Veterans Suicide Prevention Act,

S. 479. My name is Jerry Reed and I serve as the Executive Director of the Suicide Prevention Action Network, USA. SPAN USA is 

the Nation’s only suicide prevention organization dedicated to 

leveraging grassroots support among suicide survivors, those who 

have lost a loved one to suicide, and others to help advance public 

policies that help prevent suicide. We strive to turn grief to action 

by engaging those touched by suicide to help us open minds, 

change policy, and ultimately to save lives. 

Before I begin, I would like to thank Randy and Ellen Omvig for 

their courage in speaking out on this important public health issue. 

Like other survivors, their courage will make a difference. I would 

also like to thank your Committee and Senators Harkin and Grassley for their leadership on this issue here in the Senate. 

The Veterans Health Administration estimates that of the approximately 31,000 suicides in the United States each year, 1,000 

of these suicides occur among veterans receiving care within the 

VHA, and as many as 5,000 suicides per year among all living veterans. These figures suggest that at least 16 percent of suicides in 

this country in a given year are veterans. Other studies suggest a 

slightly higher rate. 

What the statistics show us is that suicide is not just a mental 

health problem experienced by one. It is a public health problem 

experienced by many. As the recent VA OIG report states, suicide 

is not a single illness with one true cause. It is a final outcome 

with multiple potential antecedents, percipients, and underlying 

causes. 

Regarding substance abuse and suicide, it is estimated that 25 

percent of those who die by suicide are intoxicated at the time of 

death, and studies suggest that between 34 and 56 percent of individuals who die by suicide met the criteria for alcohol abuse or dependence. Accordingly, I wish to state my agreement with the VA 

110

OIG report recommendation that the VA ensure that sustained sobriety should not be a barrier to treatment in specialized mental 

health programs for veterans, returning combat veterans. This specific recommendation may be a provision to consider for inclusion. 

A majority of veterans who complete suicide are not currently receiving medical care through the VHA. Therefore, family members 

and friends of veterans need to recognize the warning signs for suicide and learn about services for their loved ones before it is too 

late. The VA’s awareness and outreach program must be focused 

not just on veterans who seek care at the VA, but also on veterans 

who have returned to their home communities, family members of 

veterans, and veterans service organizations. 

Beyond outreach and education, I support the provisions in S. 

479 that encourage peer support programs. While there is no substitute for licensed mental health professionals with respect to diagnosis and treatment of PTSD, depression, and anxiety, it is often 

fellow veterans who provide the support needed to convince a veteran to visit a licensed professional. 

With respect to the provision that each VA facility designate a 

suicide prevention counselor, my understanding is that the VA is 

in the process of filling these positions as we speak. I would recommend that any report on VA suicide prevention programs and 

activities as outlined in Section 4 of the bill include information on 

the total number of suicide prevention counselors to date, where 

they are located, what their job descriptions entail, and how they 

are reaching out to veterans who do not receive care through the 

VHA. In short, what are the counselors expected to accomplish and 

how do we measure if they are successful? Having outcomes is key. 

Regarding best practices, agencies and departments of the Federal Government should work together and not act in a vacuum 

with respect to information sharing. These entities should also 

work with the Suicide Prevention Resource Center. The SPRC is a 

federally funded and already established center to provide prevention support, training, and resources to assist organizations and individuals to develop suicide prevention programs, interventions, 

and policies. The capacity of the SPRC to conduct these activities 

with respect to veterans should be increased. 

With respect to the telephone hotline provision, an additional 800 

number has been recommended by some. I do not believe adding 

an additional hotline is the correct approach or the only approach. 

For most individuals in suicidal crisis, what is most important 

when utilizing a hotline is simply knowing that someone is listening and that they are not alone. A caller needs a competent counselor at the other end of the line who can conduct a lethality assessment and provide direction on next steps. 

Already in existence, the federally funded National Suicide Prevention Lifeline is a 24-hour, toll-free suicide prevention service 

available to all those in suicidal crisis who are seeking help. Individuals seeking help can simply dial 1–800–273–TALK. They will 

be seamlessly routed to the certified provider of mental health and 

suicide prevention services nearest to where they are calling from. 

The network is currently comprised of over 120 individual crisis 

centers around the country. I think we should build on what ConVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00114 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
111

gress has already funded and let 1–800–273–TALK be the door all 

callers in crisis, including veterans, enter. 

Once callers dial the number, an option can easily be provided 

to be transferred to a VA call center if the individual wants the 

services and support of the VHA. For the non-VA crisis centers, the 

VA could easily provide up-to-date information on all VA suicide 

prevention counselors, hospitals, medical centers, CBOCs, and peer 

support groups where appropriate. This national network of crisis 

centers should reliably be able to transfer cases to a VHA call center as appropriate. 

I want to close by restating my strong support for the Joshua 

Omvig Veterans Support Act and look forward to its inclusion in 

a larger veterans’ health care bill. We can all work together to open 

minds, change policy, and save lives. Enactment of the provisions 

in S. 479 will hopefully bring us one step further in this journey 

with respect to veteran suicide prevention. 

Thank you for the opportunity to speak with you today. 

[The prepared statement of Mr. Reed follows:]

PREPARED STATEMENT OF JERRY REED, EXECUTIVE DIRECTOR, SUICIDE PREVENTION ACTION NETWORK USA 

Chairman Akaka, Ranking Member Craig and Members of the Committee: 

Thank you for inviting me to speak regarding the Joshua Omvig Veterans Suicide 

Prevention Act (S. 479). My name is Jerry Reed and I serve as the Executive Director of the Suicide Prevention Action Network USA. SPAN USA is the Nation’s only 

suicide prevention organization dedicated to leveraging grassroots support among 

suicide survivors (those who have lost a loved one to suicide) and others to advance 

public policies that help prevent suicide. We strive to turn grief to action by engaging those touched by suicide to help us open minds, change policy and ultimately 

to save lives. 

Before I begin I would like to thank Randy and Ellen Omvig for their courage 

in speaking out on this important public health issue. Like other survivors, their 

courage will make a difference. 

The Veterans Health Administration (VHA) estimates that of the approximately 

31,000 suicides in the U.S. each year, 1,000 of these suicides occur among veterans 

receiving care within the VHA and as many as 5,000 suicides per year among all 

living veterans. These figures suggest that at least 16 percent of suicides in a given 

year are veterans. Other studies suggest a slightly higher rate. 

What the statistics show is that suicide is not just a mental health problem experienced by one; it is a public health problem experienced by many. As the recent 

VA OIG report states ‘‘[s]uicide is not a single illness with one true cause, it is a 

final outcome with multiple potential antecedents, percipients, and underlying 

causes.’’

While the text of S. 479 does not address the issue of substance abuse specifically, 

it is estimated that 25 percent of those who die by suicide are intoxicated at the 

time of death and studies suggest that between 34 and 56 percent of individuals 

who die by suicide met the criteria for alcohol abuse or dependence. Accordingly, I 

wish to state my agreement with the VA OIG report recommendation that the VA 

ensure that sustained sobriety should not be a barrier to treatment in specialized 

mental health programs for returning combat veterans. This recommendation may 

be a provision to consider for inclusion. 

A majority of veterans who complete suicide are not currently receiving medical 

care through the VHA. Therefore, family members and friends of veterans need to 

recognize the warning signs for suicide and learn about services for their loved ones 

before it is too late. The VA’s awareness and outreach program must be focused not 

just on veterans who seek care at the VA, but also on veterans who have returned 

to their home communities, family members of veterans, and veterans service organizations (VSO). 

Beyond outreach and education, I support the provisions in S. 479 that encourage 

peer support programs. While there is no substitute for licensed mental health professionals with respect to diagnosis and treatment of PTSD, depression, and anxiety, 

it is often fellow veterans who provide the support needed to convince a veteran to 

visit a licensed professional. 

112

With respect to the provision that each VA facility designate a suicide prevention 

counselor, my understanding is that the VA is in the process of filling these positions. I’d recommend that any report on VA suicide prevention programs and activities, as outlined in Section 4 of the bill, include information on: the total number 

of suicide prevention counselors to date; where they are located; what their job description entails; and how they are reaching out to veterans who do not receive care 

through the VHA. In short, what are these counselors expected to accomplish and 

how do we measure if they are successful. Having outcomes is key. 

Regarding best practices, agencies and departments of the Federal Government 

should work together and not act in a vacuum with respect to information sharing. 

These entities should also work with the Suicide Prevention Resource Center 

(SPRC). The SPRC is federally funded and already established to provide prevention 

support, training, and resources to assist organizations and individuals to develop 

suicide prevention programs, interventions and policies. The capacity of SPRC to 

conduct these activities with respect to veterans should be increased. 

With respect to the telephone hotline provision, an additional ‘‘800 number’’ has 

been recommended by some. I do not believe adding an additional hotline is the correct approach. 

For most individuals in a suicidal crisis, what is most important when utilizing 

a hotline is simply knowing that someone is listening and that they are not alone. 

A caller needs a competent counselor at the other end of the line who can conduct 

a lethality assessment and provide direction on next steps. 

Already in existence, the federally funded National Suicide Prevention Lifeline 

(NSPL) is a 24-hour, toll-free suicide prevention service available to all those in suicidal crisis who are seeking help. Individuals seeking help can dial 1–800–273–

TALK (8255). They will be seamlessly routed to the certified provider of mental 

health and suicide prevention services nearest to where they are calling from. The 

network is comprised of over 120 individual crisis centers across the country. 

I think we should build upon what Congress has already funded and let 1–800–

273–TALK be the door all callers in crisis, including veterans, enter. Once a caller 

dials the number, an option can be provided to be transferred to a VA call center 

if the individual wants the services and support of the VHA. For the non-VA crisis 

centers, the VA should be providing up-to-date information on all VA suicide prevention counselors, hospitals, medical centers, outpatient clinics, and peer support 

groups and, where appropriate, this national network of crisis centers should reliably transfer cases to the VHA call center. 

I want to close by restating my strong support for the Joshua Omvig Veterans 

Suicide Prevention Act and look forward to its inclusion in a larger veterans’ health 

care bill. We can all work together to open minds, change policy, and save lives. Enactment of the provisions in S. 479 will hopefully bring us one step further in this 

journey with respect to veterans’ suicide prevention. 

Thank you for the opportunity to speak with you today.

Chairman AKAKA. Thank you very much, Mr. Reed. 

My first question is for Dr. Booss and Ms. Beck. This has to do 

with working with the private sector, collaborating with them. In 

your view, how can VA better collaborate with the private sector 

in order to adopt and exchange best practices for TBI and rehabilitation care? 

Dr. Booss, and Ms. Beck after him. 

Dr. BOOSS. Thank you, Mr. Chairman. I think that is an extremely important point, because I think that it is vitally important that the VA and the private sector and the university sector 

interact so that there is a mutually supportive integration of the 

advancement of care. 

I think one of the ways that the VA has worked very well has 

been to work to integrate private practitioners and also university 

practitioners into their outpatient clinic systems, often on a WOC—

that is a without compensation basis—and I think that is a benefit 

to veterans and I think it is also a benefit to the broader community. 

In terms of specific initiatives, I think that as the Congress goes 

forward, I think looking toward those areas that would best benVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00116 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
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efit, I think there is a risk. The risk is if the VA is not doing something as well as might be wished by the private sector, that the 

push ought to be to push VA to do it better rather than to push 

it out into the private sector. So I think that is a very important 

question. 

Chairman AKAKA. Thank you very much for that. Ms. Beck? 

Ms. BECK. I agree with Dr. Booss on his final point that our 

whole goal in this is to encourage the VA to become the facility of 

choice for these servicemembers, and by working together with the 

private sector on a broad and constant basis, we think that they 

can do that. The VA has excellent capabilities in many areas and 

they have made tremendous progress in TBI, especially in their 

Tier 1 facilities. 

But as they have said and as they are establishing their Tier 2 

and Tier 3 components, we would strongly encourage them to work 

with the private sector, whether it is developing criteria for the private sector hospitals that would be treating veterans and TBI patients, but exchanging ideas on those. Exchanging doctors is a possibility, and that is, as I have said, the number one request of our 

servicemembers and their families. 

Chairman AKAKA. Thank you so much for your responses. 

Mr. Reed, we like to look for the best ways of preventing suicide, 

and the question that comes to mind, and this is a searching one, 

what more can be done that is being done already, specifically in 

areas of outreach and education, as you mentioned in your testimony, to let veterans know what services and assistance are available to them so that we can prevent the tragedy of suicide? So we 

are looking at outreach and education. What more can be done? 

Mr. REED. Senator, I think the Congress back in the 105th Congress took a very bold step when they passed a resolution that said 

suicide is a national problem that warrants a national solution. 

That really opened up the dialogue for this country to talk about 

something that has been claiming 32,000 people a year for a long, 

long time and another 1.4 million who make an attempt every single year. The stigma and the barriers to even talk about suicide or 

thoughts of suicide were enormous, and I think we have begun to 

talk about it, and we have done some national polling to measure 

our success. The American people are willing to talk about it. When 

you talk about it, then you encourage research into it and you promote access to services for those conditions. 

We know that 90 percent of suicides have a mental illness or a 

substance abuse relationship. Just like any other organ that has an 

illness, when the brain has an illness, those who suffer should be 

just as eligible for treatment and for services. 

So I think we are starting to talk about it. A veteran should 

know there is no shame in these feelings. There are services available and there should be no more stigma for that intervention than 

there should be for a heart ailment, a kidney ailment, or a liver 

ailment. So I think we just have to give the Nation permission 

when they struggle to go for help. It is a completely normal and 

acceptable thing to seek help for. 

Chairman AKAKA. I want you to know that I really appreciate 

your presence and your testimonies, your responses, as well. Our 

attempt here is to try to bring as many voices as we can to help 

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us ensure that VA can provide the kinds of services that we need. 

I like your statements about helping VA do the best they can before we move on to look at other sectors, as well. We are trying to 

make many improvements, as you know, by raising the funding 

level of VA, and that is not the only answer but it helps. We have 

addressed that by passing a budget resolution that increases VA 

health care by more than $3 billion. 

So we are looking towards working together with the VA and all 

of you to try to help our veterans across the country. We have a 

tremendous task before us. As we all know, we owe it to our veterans, and we are going to do the best we can to do that. 

In closing, I again want to thank all of our witnesses for appearing today. We truly appreciate your taking the time to give us your 

views on all of the issues and the legislation we have before us. I 

reiterate that the hearing record will remain open for 2 weeks to 

provide time for additional views. 

Again, I want to say thank you for being with us and the hearing 

is now adjourned. 

[Whereupon, at 11:38 a.m., the Committee was adjourned.] 

(115)

A P P E N D I X 

PREPARED STATEMENT OF HON. WAYNE ALLARD, U.S. SENATOR FROM COLORADO

Thank you, Mr. Chairman, for affording me the opportunity to present before the 

Committee an issue of great importance to the veterans of Colorado. I strongly support the replacement of the current Denver VA medical center with a new facility 

at the former Fitzsimons Army Medical Center. I have introduced S. 472 with my 

colleague, Senator Salazar, to authorize the remaining funds needed to complete 

this new facility. 

Last month, Secretary Nicholson announced the VA’s commitment to this project 

after funds were appropriated, allowing for the initial land purchase to begin. This 

announcement was a strong victory for Colorado’s veterans and full authorization 

of the hospital would demonstrate the government’s continued commitment to our 

veterans. 

The Denver VA hospital was built more than fifty years ago and medical technology has far surpassed what the builders of the Denver VA originally envisioned. 

This facility, which hosted the first liver transplant in 1963, has provided tremendous care over the years, but simply does not have the infrastructure to continue 

to provide our veterans the care they need through the 21st century. While I cannot 

say enough about the care and service our veterans receive at the current facility, 

many changes and improvements can and should be made, and a new facility is the 

only way to accomplish these goals. 

This new VA hospital to be located at the Fitzsimons campus and the former 

home of the Fitzsimons Army Medical Center will carry on a strong tradition of providing exceptional medical care for our Nation’s best and bravest citizens. The current Fitzsimons campus first began treating wounded veterans in 1918, specializing 

in assisting those that were victims of chemical weapons during World War I. The 

facility continued to grow through the 20th century and became one of the premiere 

Veterans hospitals through World War II. Fitzsimons was even unofficially deemed 

the ‘‘White House of the West’’ when President Eisenhower spent seven weeks in 

the facility while recovering from a heart condition in 1955. 

The new facility will serve as an example of successful collaboration between numerous parties and will be the culmination of years of hard work. The Denver VA, 

the University of Colorado Health Sciences Center and the University of Colorado 

Hospital already have a complex and rewarding partnership in meeting veterans’ 

healthcare needs in the region, and all are partnered together on this unique 

project. The University of Colorado, who currently owns the land for the new hospital, strongly supports the move of the existing Denver VA medical facility to the 

Fitzsimons Campus in Aurora, Colorado and looks forward to strengthening their 

partnership with the Veterans’ Administration. This project allows each entity to 

focus on its strengths. 

Of course, the biggest endorsement of this new facility comes ultimately from the 

end-users: our veterans. The United Veterans Committee of Colorado, a coalition of 

45 federally chartered veterans service organizations, strongly supports the relocation of the Denver VA medical center to the Fitzsimons campus and has worked 

closely with my office and the Colorado Congressional delegation over the years to 

ensure its success. 

In the past year, the VA reached an agreement with the Fitzsimons Redevelopment Authority, the entity that manages the land at the former Fitzsimons Army 

Medical Center, and Congress granted the needed authorization to begin site acquisition and construction of the new hospital. This was an important first step, but 

full authorization of the project is still required to assure the project’s completion. 

To that end, I have introduced S. 472, in order to meet this need. Specifically, the 

language of bill S. 472 authorizes the Secretary to carry out the entire project and 

provides authority to the VA purchase the land with current year dollars. 

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There was a time when it looked like this project was in peril. Thankfully, in 2005 

Secretary Nicholson brought a much-needed, fresh perspective to this project. He 

made it a priority and made it clear to the entire Colorado delegation that he would 

pursue every opportunity to make the project a reality. I commend his efforts and 

thank him for his support. It is also important to mention the hard work and diligence of those in Colorado who have also worked to ensure the success of this new 

hospital. Without the extraordinary efforts put forth by the Fitzsimons Redevelopment Authority and its chairman, City of Aurora Mayor Ed Tauer, an agreement 

would not have been reached on the ultimate location of the hospital. 

Again, I thank you, Chairman Akaka, for the opportunity to speak here today. I 

would also like to recognize the strong support my colleague Senator Salazar has 

shown for this project. Without a bipartisan effort we would not be this close on realizing our goal. I look forward to working with the Committee on my legislation 

and making this project a reality. 

PREPARED STATEMENT OF ANN HUSTON, EXECUTIVE DIRECTOR AND CEO,

AMERICAN THERAPEUTIC RECREATION ASSOCIATION

On behalf of the American Therapeutic Recreation Association (ATRA), I am submitting the following statement in support of ‘‘The Traumatic Brain Injury Rehabilitation Act of 2007’’ (S. 1233), including recommendations to improve the impact of 

the legislation on returning soldiers with serious injuries and rehabilitative needs. 

BACKGROUND ON ATRA

The American Therapeutic Recreation Association (ATRA) is the largest, national 

membership organization representing the interests and need of recreational therapists. Recreational therapists are health care providers using recreational therapy 

interventions for improved functioning of individuals with illness or disabling conditions. According to the U.S. Department of Labor, Bureau of Labor Statistics, in 

1996 there were approximately 38,000 recreational therapists. ‘‘Employment of recreational therapists is expected to grow faster than the average for all occupations 

through the year 2006 because of anticipated expansion in long term care, physical 

and psychiatric rehabilitation and services for people with disabilities.’’

By way of background, in 1917, the American Red Cross developed convalescent 

houses in military hospitals and in 1931 began hiring recreation hospital workers. 

The formative years of the recreational therapy profession occurred from 1945–1953 

following World War II with the development of formal undergraduate education 

programs, and the establishment of three professional organizations for hospital 

recreation workers. ATRA was formed in response to recreational therapists’ demand for an independent organization solely representing the needs of the therapeutic recreation profession within health care delivery system. 

The Practice of Recreational Therapy 

Recreational therapy plays a critical role in the comprehensive rehabilitation of 

individuals with disabling conditions by contributing to the broad spectrum of 

health care through delivery of treatment services and through the provision of 

physical and recreational activities—each of which is instrumental in improving and 

maintaining physical and psycho-social functioning, preventing secondary health 

conditions, enhancing independent living skills and overall quality of life. 

Recreational Therapy services utilize various methods to promote the independent 

physical, cognitive, emotional and social functioning of persons requiring rehabilitation as a result of trauma or disease, by enhancing current skills and facilitating 

the establishment of new skills for daily living and community functioning. Recreational therapy is particularly important in terms of community reintegration 

once a disabling condition has been incurred. 

Recreational therapy also includes components that enable individuals to become 

more informed and active partners in their health care. Prescribed activity assists 

individuals in coping with the stress of illness and disability and prepares them for 

managing their disability so they may achieve and maintain optimal levels of independence, productivity, and well being. Quality services include the provision of recreational opportunity and physical activity (e.g. wheelchair sports, exercise and 

swimming programs) which allow individuals with functional deficits to prevent declines in physical, cognitive, social, and emotional health status, and therefore, reduce the need for medical services.

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With an academic degree in recreational therapy, a qualified provider may work 

in a variety of organizations and settings such as VA polytrauma centers as well 

as free-standing rehabilitation hospitals, rehabilitation units in general hospitals, 

psychiatric hospitals, long-term care or skilled nursing facilities, home health care 

agencies, amongst many others. 

Recreational therapists are standard treatment team members in psychiatric rehabilitation, substance abuse treatment, physical rehabilitation and long term care 

services in both in-patient and out-patient settings. The Centers for Medicare and 

Medicaid Services (CMS) includes recreational therapy in the mix of treatment and 

rehabilitation services used to determine compliance with the Federal Government’s 

commitment to quality care in rehabilitation, skilled nursing and long term care facilities. 

Recreational Therapy as a Viable Option 

The therapeutic recreation profession is in support of cost-effective health care 

services for individuals with disabilities. The number of Americans requiring health 

and rehabilitation services continues to increase due to an aging population, disabling conditions, improved treatment services, and greater survival rates. Therefore, the need to access a broad range of available services is crucial. 

The provision of quality services that lead to expected outcomes while reducing 

overall health care costs is the bottom line in therapeutic recreation services. Recreational therapy should be included as a viable option to meet the needs of consumers with disabilities. Ultimately, the ability to choose the most appropriate mix 

of health care options will afford the provider the most cost-effective approach to 

meet the unique needs of individuals with illnesses and disabilities. Reducing the 

length of stay and hospital or system recidivism, promoting independent community 

living, and maximizing individual productivity in society are all positive outcomes 

of recreational therapy services. 

SUPPORT FOR S. 1233

ATRA is enthusiastic about the introduction of S. 1233, the ‘‘Traumatic Brain Injury Rehabilitation Act of 2007,’’ and thanks the sponsors for ensuring that veterans 

have access to quality rehabilitative care in the most appropriate setting. 

The VA is the largest employer of recreational therapists in the Nation and ATRA 

has gained from the VA’s involvement in the professional association. ATRA has had 

VA employees serve as team leaders, task force chairs, committee members and 

ATRA board members. Two VA employees currently serve as board members to 

ATRA. 

In the four VA Polytrauma Centers (Minneapolis, Palo Alto, Tampa, Richmond), 

recreational therapists are identified as ‘‘core staff.’’ Each Polytrauma Center is required to have at least one recreational therapist as a core team member and some 

have more recreational therapists based on bed census, each providing services to 

veterans returning from the Iraq war. This ‘‘team involvement’’ is an integral part 

of rehabilitation for these patients. In addition, ATRA hosts the national VA Institute at the ATRA Annual Conference each year, coordinated by the VA Recreation 

Therapy Central Office staff. 

One of the key components that RT adds for these patients is community reintegration or transitional living skills. These skills are introduced and the basics 

taught at the Polytrauma Centers but the skills need to be fine-tuned and customized at the local VA facilities when the patient returns to his local community. 

Some of the Polytrauma Centers have recognized this need and added more recreational therapists. 

Comprehensive Team and Rehabilitation Plan 

ATRA is particularly pleased to see that S. 1233 would provide each veteran with 

traumatic brain injury (TBI) a comprehensive and flexible rehabilitation team and 

plan to include neurologists, physiatrists, physical therapists, occupational therapists, recreational therapists and other rehabilitation providers with a goal of regaining and then maintaining the veteran’s maximum level of independent function. 

ATRA believes that ‘‘team involvement’’ is an integral part of the rehabilitation 

treatment plan for these patients. 

In addition, it is a customary practice of rehabilitation care plans to require an 

individual rehabilitation plan, as the bill does, upon discharge from inpatient rehabilitation care. Such plans focus on optimal function for the individual in the community and specify functional progress. They also often rely on numerous providers 

and community support. Therefore, ATRA strongly supports this type of plan requirement, recognizing the difficulty of continuing such plans for the long term 

needs of TBI survivors. 

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Private Partnerships 

Very importantly, S. 1233 also provides each veteran with TBI access to the best, 

most appropriate and most accessible care, whether through the VA or through an 

outside provider. 

The VA has an excellent history of providing quality care to its wounded warriors 

and, as stated before, ATRA knows that the VA’s four TBI Lead Centers and regional referral centers are no exception. Additionally, we recognize current VA efforts to create residential facilities and community-based long term rehabilitation 

care with nearly 21 polytrauma rehab networks being put into place. 

However, it is important to acknowledge that gaps in coverage and care still exist. 

In particular, we note the VA’s capability to provide community-based care to successfully reintegrate these soldiers into society. ATRA supports the Committee’s efforts to allow more collaboration between the VA and the private sector in order to 

ensure the best and most accessible care for our veterans. Therefore, ATRA supports 

provisions allowing private facilities to provide care on an outpatient basis in the 

community where VA cannot feasibly supply the service needed. 

We also strongly support the supplementation of VA rehabilitation services in the 

community for TBI soldiers with professionals who may be utilized from the private 

sector who are not part of VA system. Examples would be recreational therapist involvement with veterans with TBI/polytrauma injuries and physical or recreational 

therapists who are familiar with brain injury and could provide local therapy when 

other providers and treatment is unavailable. 

Rehabilitation Research 

Additionally, while we are supportive of the bill’s provisions on research of intense 

rehabilitation needs of TBI soldiers, we would suggest broader language authorizing 

research on therapies, cognitive and physical, to determine the most efficacious 

therapies for TBI soldiers. 

The problem of physical and cognitive disability in America is substantial as 

noted in the 1997 IOM Report, Enabling America. The need to enhance medical rehabilitation research to attack the problem is paramount and was a key conclusion 

of the IOM Report. Between 25 and 30 million individuals have impairments which 

limit substantially their ability to perform activities of daily living (ADLs) and 7 

percent of all individuals age 65 to 75 (24 percent of those over age 85) have disabilities limiting their ADL function. 

There are civilian agencies with well-established TBI research programs with 

which the VA should collaborate. The mission of the National Center for Medical 

Rehabilitation Research (NCMRR) within the National Institutes of Health is to 

plan, coordinate and stimulate rehabilitation research within NIH and across other 

Federal agencies. As such, we think NCMRR would enhance the VA’s ability to 

identify the most efficacious therapies for TBI soldiers and suggest that this program be carried on in conjunction with NCMRR’s TBI clinical trials network. In addition, the TBI centers and TBI model systems, funded by the National Institute 

of Disability and Rehabilitation Reseach (NIDRR) within the Department of Education has significant and valuable capacity with which the VA should seek to coordinate their TBI efforts. 

Assisted Living 

Finally, recreational therapists support the inclusion of the pilot program to assess the effectiveness of providing assisted living services to veterans. The provision 

will give veterans who might otherwise be forced into institutional long-term care 

an opportunity to live in group homes or under other arrangements. For veterans 

with TBI, such a provision will maximize rehabilitation, independence, quality of 

life, and community reintegration of veterans with TBI who are unable to manage 

routine activities of daily living. The effect of such a pilot program will only be enhanced by the other provisions of this bill that buildupon the rehabilitation plan and 

focus on community reintegration to maximize the independence of these returning 

veterans.

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CONCLUSION

In conclusion, ATRA strongly supports the Traumatic Brain Injury Rehabilitation 

Act of 2007 (S. 1233) and applauds the Committee’s commitment to improving access to and quality of care for veterans with traumatic brain injury. ATRA thanks 

Chairman Akaka and Ranking Member Craig, the sponsors of S. 1233, for ensuring 

that veterans have access to quality rehabilitative care in the most appropriate setting and we stand ready to assist the sponsors and the Committee in passing this 

much needed legislation. 

ATRA thanks the Veterans’ Affairs Committee for the opportunity to submit comments. 

PREPARED STATEMENT OF THE AMERICAN ACADEMY OF

PHYSICAL MEDICINE AND REHABILITATION

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) submits the following statement in support of ‘‘The Traumatic Brain Injury Rehabilitation Act of 2007’’ (S. 1233). Additionally, we would like to offer recommendations 

to improve the impact of the legislation on returning soldiers with serious injuries 

and rehabilitative needs. 

BACKGROUND ON AAPM&R

AAPM&R is the national medical society representing approximately 7,800 

physiatrists, physicians who are specialists in the field of physical medicine and rehabilitation. Physiatrists treat adults and children with acute and chronic pain, persons who have experienced catastrophic events resulting in paraplegia, quadriplegia, 

or traumatic brain injury, rheumatologic conditions, musculoskeletal injuries, and 

individuals with neuralgic disorders such as strong multiple sclerosis, polio, 

amyotrophic lateral sclerosis (ALS) or any other disease process that results in impairment and/or disability. 

During World War II, programs in rehabilitation medicine were begun by Howard 

Rusk, M.D., in a number of Army Air Force hospitals. After the War, Dr. Rusk and 

Frank Krusen, M.D., were consultants to the Department of Veterans Affairs as it 

expanded its health care programs to meet the increased demand for services from 

the War. Paul Magnuson, M.D., who founded the Rehabilitation Institute of Chicago 

in 1954, was Medical Director of the VA when its expansion of rehabilitation services took place. Rusk and Krusen established the specialty of Physical Medicine and 

Rehabilitation just after the war. 

Today, AAPM&R offers well developed expertise in rehabilitation for traumatic 

brain injury and amputations of upper or lower extremities, two of the disabilities 

afflicting soldiers returning from battle. AAPM&R members are also experts in the 

rehabilitation of spinal cord injured (SCI) patients and were involved in the creation 

of federally funded traumatic brain injury (TBI), burn and SCI model care systems 

in the 1970s and 1980s and, more recently, involved in the development and use 

of high technology in prosthetics. 

AAPM&R physicians are trained to provide the medical rehabilitation needed by 

military personnel returning with TBI, SCI, amputations, and other severe disabilities. These physicians provide a comprehensive approach to the restoration of function and return to the community. Multidisciplinary services are utilized where 

needed including physical therapy, occupational therapy, speech therapy, psychological services, vocational rehabilitation, job placement, recreational therapy and 

independent living assistance. 

Today many specialists in PM&R provide services in the VA health care system 

and many residents train in VA affiliated PM&R residency training programs. For 

example, the AAPM&R President-elect, David Cifu, M.D., is Chairman of the Medical College of Virginia Department of Physical Medicine and Rehabilitation and is 

a VA physician and head of the polytrauma rehabilitation center at Richmond, Virginia. Additionally, one of our members, Barbara Sigford, M.D., works at the Minneapolis VA Polytrauma Center, where she is chief of Physical Medicine and Rehabilitation Services for the Veterans Health Administration. 

SUPPORT FOR S. 1233

AAPM&R supports the ‘‘Traumatic Brain Injury Rehabilitation Act of 2007’’ (S. 

1233) and thanks the cosponsors for their commitment to ensuring that veterans 

with TBI have access to quality rehabilitative care. The bill focuses on the needs 

of TBI victims for outpatient services to enable reintegration in the community. The 

bill establishes a number of programs to facilitate this optimum rehabilitation inVerDate 0ct 09 2002 12:00 Oct 30, 2007 Jkt 000000 PO 00000 Frm 00123 Fmt 6601 Sfmt 6621 H:\RD41451\DOCS\37463.TXT SENVETS PsN: ROWENA
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cluding a comprehensive assessment and plan for rehabilitation, the use of private 

sector resources when the VA system has insufficient capacity to serve TBI victims 

or when the VA program available is too remote to be feasible for the patient 

Since approximately 20 percent of soldiers wounded in Iraq or Afghanistan have 

TBI, amputations or spinal cord injury, and TBI is the most prevalent of the three, 

focusing a special effort on TBI victims is good policy. Despite the expansion of 

polytrauma rehabilitation centers, networks and clinical teams for outpatient care, 

the system is likely to have gaps in the outpatient service system given the numbers 

of victims, the duration of their disabling condition and the paucity of TBI experts. 

Focusing on these gaps is essential. 

We suggest some areas however, in which we believe the bill might be strengthened to better achieve its goals. 

REHABILITATION PLAN

S. 1233 would provide each veteran with TBI a comprehensive assessment by a 

rehabilitation team (including neurologists, physiatrists, social workers, mental 

health specialists, occupational therapists, physical therapists, vocational rehabilitation specialists and rehabilitation nurses) and a plan with the goal of regaining, and 

then maintaining, the veteran’s maximum level of independent function in the community. 

The legislation’s requirement of an individual rehabilitation plan upon discharge 

from inpatient rehabilitation care is the customary practice of physical medicine and 

rehabilitation. These plans are intended to specify functional progress and focus on 

optimal function for the individual in the community. They often rely on numerous 

providers and supports available in the community. AAPM&R strongly supports this 

type of plan requirement, recognizing the difficulty of continuing such plans for the 

long term needs of TBI victims which may well reach 50 years. 

Private Partnerships 

S. 1233 would also provide all veterans with TBI access to the best, most appropriate care, whether through the VA or a private sector facility when the VA is unable to supply the necessary services or the VA facility is too remote from the veterans’ residence. The VA has an excellent history of providing quality care to its 

wounded warriors. Additionally, AAPM&R recognizes current VA efforts to create 

residential facilities and community-based long term rehabilitation care with nearly 

21 polytrauma rehabilitation networks being put into place. 

However, it is important to acknowledge that gaps in the capability of the VA 

health system to provide the community-based care necessary to successfully reintegrate its soldiers into society will likely exist. AAPM&R supports the bill’s efforts to allow more collaboration between the VA and the private sector in order to 

ensure that care is accessible to all TBI victims of the wars in Iraq and Afghanistan. 

The private sector involvement intended by the provision, particularly if expanded 

as we suggest below, will strengthen the ability of the VA to respond to possible 

gaps in outpatient rehabilitation care. 

We suggest an addition to the legislation which we believe would make the use 

of private sector services more effective. The legislation is limited to arrangements 

with ‘‘facilities’’ to assist the VA in delivering rehabilitation services to veterans 

with TBI on an outpatient basis. We believe there may be instances when a TBI 

victim may need a specialist in rehabilitation medicine who is not available within 

the VA system to provide outpatient care. In such instances the professional may 

not be affiliated with a rehabilitation hospital or other ‘‘facility’’. They may be in 

a professional group practice. Examples would be physical medicine and rehabilitation physicians who understand brain injury and can serve as consultants or primary physicians; neuropsychologists who may be needed for counseling; occupational or physical therapists who are familiar with brain injury and could provide 

necessary therapy services. 

OTHER COMMENTS AND SUGGESTED ADDITIONS

AAPM&R recognizes that it is appropriate for Congress to focus on traumatic 

brain injuries, as it is among the most prevalent polytrauma conditions and has a 

dramatic impact on the veteran’s long-term outcomes. Additionally, too little is 

known today about the nature of TBI, its sequelae, and the therapies to potentially 

treat it. Nearly eight years ago, the National Institutes of Health held a consensus 

conference on TBI, Chaired by Kris Ragnarsson, M.D., of Mt. Sinai Hospital, New 

York City, New York, which reported that far too little was known from research 

about therapies. We fear that little has changed in the last eight years. 

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However, we also believe that there is a need for post acute rehabilitation services, particularly on an outpatient basis, for other victims of polytrauma. AAPM&R 

would encourage the Committee to consider expanding the focus of S. 1233, or passing additional legislation, to connect veterans with other polytraumatic conditions, 

such as amputations, spinal cord injury or burns, to the necessary post acute rehabilitation services. 

Additionally, while AAPM&R is supportive of the bill’s provisions on research of 

intense rehabilitation needs of TBI soldiers, we would suggest broader language authorizing research to determine the most efficacious therapies, cognitive or physical, 

for TBI victims. We suggest that this program be carried on in conjunction with the 

TBI clinical trials network of the National Center for Medical Rehabilitation Research within the National Institutes of Health and the model systems of TBI supported by the National Institute on Disability and Rehabilitation Research in the 

Department of Education. 

CONCLUSION

AAPM&R supports the ‘‘Traumatic Brain Injury Rehabilitation Act of 2007’’ (S. 

1233). We encourage the Committee to expand the scope of the legislation to allow 

VA contracting with appropriately licensed or credentialed private practice professionals with TBI expertise, broaden the research authority and cover other conditions and disabilities such as amputations, spinal cord injuries, and burns so that 

all veterans may have access to the highest quality and most appropriate rehabilitative care in order to live as independently as possible. 

We thank you for this opportunity to submit comments. 

PREPARED STATEMENT OF THE AMERICAN CONGRESS

OF REHABILITATION MEDICINE

The American Congress of Rehabilitation Medicine (ACRM) submits this written 

statement in support of S. 1233, the Traumatic Brain Injury Rehabilitation Act of 

2007. 

The mission of the American Congress of Rehabilitation Medicine (ACRM) is to 

enhance the lives of persons living with disabilities through a multidisciplinary approach to rehabilitation, and to promote rehabilitation research and its application 

in clinical practice. ACRM serves people with disabling conditions by promoting rehabilitation research and facilitating information dissemination and the transfer of 

technology. We value rehabilitation research that promotes health, independence, 

productivity, and quality of life for people with disabilities, injuries, and chronic illnesses. We are committed to research that is relevant to consumers, educates providers to deliver care through best practices, and supports advocacy efforts that ensure adequate public funding for rehabilitation and disability research priorities. 

ACRM strongly supports S. 1233, recognizing the immediate need for improved 

capacity to provide comprehensive, quality care to our Nation’s veterans with traumatic brain injury (TBI). Recent press reports have repeatedly highlighted the high 

incidence and tragic consequences of TBI both in soldiers returning from Iraq and 

Afghanistan and, by extension, in the civilian population. The Centers for Disease 

Control and Prevention (CDC) estimates that 5.3 million Americans live with the 

consequences of TBI, many of whom never seek medical help, resulting in systematic under-counting of so-called ‘‘mild’’ or ‘‘moderate’’ traumatic brain injury. 

INDIVIDUAL REHABILITATION AND REINTEGRATION PLANS

Although each person with a traumatic brain injury is unique, most people experience cognitive, behavioral, emotional and physical challenges. Cognitive limitations 

may include memory loss, impaired thinking, s slowed learning, and difficulty concentrating. Physical limitations may include spasticity, limits in walking, 

hemiparesis, speech impairments, loss of the use of one’s arms and hands, severe 

fatigue, headaches, changes in sense of smell and taste, balance problems, seizures 

and endocrine disorders. Behavioral and emotional consequences may include depression, anxiety, and impulsive behavior that may be dangerous to both the individual with brain injury and others. 

Because of the complexity of treating TBI, S. 1233 would require that all veterans 

with TBI be provided case-managed individual rehabilitation and community reintegration plans. ACRM believes these multidisciplinary, long-term plans are vital 

to the rehabilitation of individuals with TBI as the extended needs of TBI-impacted 

individuals go beyond the medical response. The needs extend into the social, psychological, physical, and vocational arenas. 

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PRIVATE PARTNERSHIPS

ACRM also applauds provisions in the legislation that would allow the VA to contract with private providers when it is not feasible for the VA to provide TBI care 

for a particular individual. It is important that veterans with TBI receive the most 

appropriate and accessible care possible, whether that care is provided through VA 

facilities or through a non-VA provider. ACRM believes this provision will open the 

door to the development and strengthening of partnerships between the VA and private rehabilitation providers that will significantly benefit our returning soldiers. 

Stronger partnerships between the VA and the private rehabilitation provider system will enable veterans with TBI to receive long term services in close proximity 

to their support network, including their families, friends and communities. 

TRAUMATIC BRAIN INJURY RESEARCH

ACRM strongly supports the provisions in S. 1233 that focus on research on traumatic brain injury. Currently, many answers are not available from research findings that address even basic questions asked by people with TBI and their families. 

The relative lack of research in this area limits the recovery of people with TBI and 

hampers clinicians trying to best treat their patients. Despite existing research efforts in both the military and civilian sectors, the pool of ‘‘solid answers’’ remains 

too small. 

Under S. 1233, in carrying out TBI-related research, the VA would be required 

to collaborate with TBI Model Systems funded by the National Institute on Disability and Rehabilitation Research (NIDRR), under the Department of Education. 

ACRM applauds the Committee for recognizing the expertise and valuable research 

available through NIDRR-funded programs. 

Currently, NIDRR funds 16 national TBI Model Systems. These Model ‘‘Systems’’ 

are essentially TBI centers that provide regional TBI treatment capacity as well as 

collect and analyze longitudinal data from people with TBI. The Model Systems also 

conduct valuable outcomes research on evidence-based TBI rehabilitation services. 

A Model System must demonstrate outstanding care to individuals with traumatic 

brain injury, from the emergency medical services, to acute care in the hospital, to 

long-term rehabilitation and community integration. 

Additionally, NIDRR currently funds several research and training centers which 

focus on improved outcomes for TBI rehabilitation services. This research helps ensure that people with TBI regain their maximum level of function and return to 

independent living. All of these civilian resources will be invaluable to the VA as 

it accelerates the development of treatment systems for returning veterans with 

TBI. If not for the collaboration required in this bill, ACRM believes that it would 

take the VA years to develop the treatment and research capacity that the NIDRRfunded Model Systems and the TBI centers currently possess. 

THE NEED FOR ADDITIONAL TBI RESEARCH FUNDING

AND COLLABORATION

Compared to both the civilian and military need, the funding available for these 

TBI systems and centers in the past several years has been very modest and has 

not kept pace with the growing needs of the TBI survivor community. ACRM is concerned, however, that the requirement that the VA collaborate with the NIDRRfunded TBI Model Systems and TBI centers may be a hollow promise if additional 

funding is not available through the VA budget. The legislation does not authorize 

additional funding for the systems and centers and the NIDRR budget simply has 

not funded them adequately to date. In fact, NIDRR has been flat-funded for over 

4 years. In order to ensure that the VA’s partnerships with NIDRR-funded programs are as efficacious as possible, ACRM suggests that S. 1233 be modified to include authorization of an additional $19 million in Fiscal Year 2008 and in subsequent years to the TBI Model Systems and TBI centers including:

• $6 million to supplement the research efforts of the TBI Model Systems Centers; 

• $3 million to fund three additional Rehabilitation Research and Training Centers on TBI; 

• $3 million for Field-initiated Research projects on TBI; 

• $4 million for 4 centers to develop and evaluate technology to improve outcomes 

and quality of life; 

• $2 million to train diverse professional disciplines for the rehabilitation of individuals with TBI; and 

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• $1 million for a Knowledge Translation Center to evaluate and report on these 

TBI projects to Congress and ensure that clinicians incorporate the outcomes studies 

into clinical practice.

ACRM believes this additional funding for evidenced-based research and regional 

TBI treatment capacity will benefit our returning veterans with TBI, and, in-turn, 

all individuals with an acquired brain injury. This additional funding would be extremely timely and an important national investment. 

CONCLUSION

In conclusion, ACRM strongly supports S. 1233, the Traumatic Brain Injury Rehabilitation Act of 2007, and thanks Chairman Akaka, Ranking Member Craig, and 

the Committee and the bill’s cosponsors for their commitment to serving our veterans with TBI. ACRM looks forward to working with Congress toward enactment 

of this important legislation. 

Thank you for this opportunity to submit comments. 

PREPARED STATEMENT OF THE BRAIN INJURY ASSOCIATION OF AMERICA

The Brain Injury Association of America (BIAA) and its nationwide network of 

state affiliates representing survivors of traumatic brain injury (TBI), their families, 

researchers, clinicians and other professionals, believes strongly that Congress must 

facilitate greater cooperation between the military and civilian health care sectors 

to ensure returning servicemembers with TBI get the right care, right now. TBI is 

a growing public health problem in U.S. military and civilian populations. Reports 

indicate 12,274 servicemembers have sustained a TBI in Operation Iraqi Freedom 

(OIF) or Operation Enduring Freedom (OEF) as of March 24, 2007, and some projections estimate that number could ultimately grow as high as 150,000. 

The standard of care for TBI is early, intensive acute treatment and rehabilitation, followed by timely post acute rehabilitation of sufficient scope, duration and 

intensity to restore maximum function and accommodate residual disability. To optimize their independence and maintain the best possible health throughout their 

lives, individuals with brain injury need access to a full continuum of TBI care. 

The BIAA supports S. 1233, as it sets forth a pivotal mechanism for enhancing 

cooperation between the private sector and the VA health care system. Such cooperation is vitally necessary in order to provide access to, and choice within, the 

full continuum of care that returning servicemembers with TBI need and deserve. 

Efforts within the Department of Defense and the Department of Veterans Affairs 

(VA) to increase TBI research and treatment capacity in response to the influx of 

returning servicemembers with brain injuries should be recognized and applauded. 

Nevertheless, there is a broad consensus that most VA medical facilities have not 

yet attained the TBI specialty care capacity that is available from private TBI rehabilitation facilities. These civilian facilities have been developing and refining brain 

injury treatments, including cognitive rehabilitation, for more than three decades, 

and are ready on a widespread basis to stand side-by-side with the Department of 

Defense and the Department of Veterans Affairs to help provide the highest quality 

services to returning servicemembers with TBI, both now and in the long-term. 

The BIAA also strongly supports language and provisions in the bill recognizing 

that rehabilitation for individuals with TBI should be individualized, comprehensive, and multidisciplinary with the ultimate goal of maximizing independence and 

reintegration into the community. The bill’s recognition of the importance of family 

support to rehabilitation and the need for lifelong case management for veterans 

with TBI also represents a significant step forward. Further, the BIAA strongly recommends that all allied health professionals, including case managers and support 

staff, who work with servicemembers with TBI obtain brain injury specialty training 

and certification. 

Research on TBI should be intensified and accelerated on a national level, in large 

part by augmenting existing research programs of the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems. Line-item funding 

of $30 million should be allocated in Fiscal Year 2008 to continue and expand 

NIDRR’s applied research results through TBI Model Systems. The BIAA applauds 

instructions within S. 1233 for research on TBI to be pursued through collaboration 

with existing NIDRR TBI research grantees. It is extremely important, and makes 

the most sense in terms of health care quality and cost efficiency, for the VA to use 

the extensive work regarding TBI that has been done in the civilian sector and is 

ongoing in the areas of TBI research, treatment and rehabilitation services. The 

BIAA further hopes that adequate funding will be appropriated to support this collaborative research, in addition to increased funding of $30 million for TBI Model 

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Systems overall. Clearly, there is a pressing national need to increase research efforts on TBI in general, and in particular, to leverage the existing civilian TBI research and treatment capacity to improve outcomes measurement capabilities and 

augment care systems in both the military and civilian sectors. 

The Brain Injury Association of America appreciates the opportunity to comment 

on S. 1233, and stands ready to assist the Committee in all efforts to help improve 

access to the full continuum of care for returning servicemembers with traumatic 

brain injuries. 

PREPARED STATEMENT OF THE COMMISSION ON ACCREDITATION

OF REHABILITATION FACILITIES

The Commission on Accreditation of Rehabilitation Facilities (‘‘CARF’’) submits 

the following statement for the record in support of S. 1233, the Traumatic Brain 

Injury Rehabilitation Act of 2007. 

BACKGROUND

CARF is a forty-one-year-old nonprofit organization that establishes standards 

and assesses conformance with these standards for the continuous improvement of 

service quality to persons with disabilities and other needs. CARF’s mission is to 

promote the quality, value, and optimal outcomes of rehabilitation and other human 

services through a consultative accreditation process that centers on enhancing the 

lives of persons served. CARF uses an independent, professional, nonprofit peer review system recognized by multiple Federal and state agencies, national and international associations, all Canadian provinces, several major insurers, advocacy 

groups, and professional organizations. 

Of great relevance at the moment is the eleven-year partnership between CARF 

and the Veterans’ Administration. In 1996, CARF and the VA initiated an agreement to promote continuous quality improvement in rehabilitation services through 

national accreditation. Since the first VA accreditations in medical rehabilitation, 

employment and community services, and behavioral health in 1997, the scope and 

number of CARF-accredited VA programs and services has grown to include both 

mandated and voluntary accreditations across the rehabilitation and human service 

continuum. 

The partnership between the VA and CARF has expanded accreditation both in 

the types of programs and the number of programs. This increase in diversity of accredited programs was in direct response to veterans’ needs and the VA and CARF 

developed new programs or new standards, respectively. However, as successful as 

the VA–CARF collaboration has been, there are many VA programs that are not 

CARF accredited, nor accredited by other organizations. CARF looks forward to continuing its work with the VA to help ensure that—through accreditation—veterans, 

including those with traumatic brain injuries (TBI) and their families, receive the 

high quality services they deserve. 

CARF SUPPORT FOR S. 1233

CARF strongly supports the Traumatic Brain Injury Rehabilitation Act of 2007 

(S. 1233) and the Committee’s efforts to ensure that veterans with TBI have access 

to the highest quality and coordinated care in the most appropriate, least restrictive 

setting. We applaud the Committee’s emphasis on comprehensive, long-term rehabilitation and community integration for TBI survivors for once the immediate medical needs of those with brain injuries are met, the physical, behavioral, cognitive 

psychosocial, vocational, and often residential needs must be addressed. 

VA and Private Partnerships 

S. 1233 would provide all veterans with TBI access to the most appropriate services, whether through VA facilities or through non-VA providers. The legislation recognizes that while the VA provides excellent medical and rehabilitative care for veterans, such care for TBI survivors is complex, long-term in nature, and not always 

accessible in the veteran’s community environment, where their support system is 

strongest. Therefore, the legislation would allow the VA to enter into agreements 

with private providers to implement a veteran’s individualized rehabilitation plan 

when VA services are not feasible or accessible. 

CARF applauds the bill’s requirement that all private partners be accredited by, 

or meet the standards of, an independent, peer-reviewed organization that accredits 

specialized rehabilitation programs for adults with traumatic brain injury. CARF 

believes that this independent accreditation requirement is vital to ensuring quality 

of care for our wounded warriors receiving services outside the VA health system. 

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The proposed requirement parallels the move to accreditation by CARF of the VA’s 

own programs serving the rehabilitation needs of veterans. 

CARF has developed a comprehensive set of standards for TBI programs, focusing 

on the unique medical, physical, cognitive, psychosocial, behavioral, vocational, educational, and recreational needs of persons with acquired brain injuries. These 

standards encompass specialty programs for persons with brain injury provided in 

a variety of settings including brain injury home- and community-based rehabilitation programs, outpatient rehabilitation programs, comprehensive integrated inpatient rehabilitation programs, residential rehabilitation programs, long-term residential services, and vocational services. Currently, CARF accredits 288 programs 

within the VA nationwide, including five comprehensive brain injury programs, multiple inpatient rehabilitation, vocational rehabilitation, and homeless veterans’ 

health care programs. 

The CARF accreditation process is a rigorous one, involving the development of 

consensus quality standards subjected to peer review. The accreditation process is 

also based on peer review with a strong focus on the person served by the program 

and the impact that those services actually have on the recipient of care. 

We are confident that CARF-accredited TBI programs meet the Department’s, the 

Committee’s, and our veterans’ high standards of quality and comprehensive care. 

Individual Rehabilitation and Community Reintegration Plans 

CARF strongly supports the legislation’s requirement of individualized rehabilitation and reintegration plans for each veteran with TBI leaving inpatient therapy. 

It is commonplace for inpatient rehabilitation programs, and required by CARFaccredited inpatient rehabilitation programs, to provide patients with reintegration 

plans that not only address the future medical needs of the individual, but his/her 

psychological, transitional residential, social, and vocational needs as well. And, because some of our returning veterans have unique injuries and complicated behavioral and psychological issues, a case management model for outpatient, community 

rehabilitation is extremely appropriate. 

Given CARF staff and surveyors’ significant expertise in the areas of social, medical, and vocational services and TBI rehabilitation, CARF would like to serve as 

a resource to the Committee and the Department as they develop and implement 

these individual rehabilitation and reintegration plans. 

Assisted Living Services 

CARF supports the Committee’s effort to examine the effectiveness of long-term 

residential services for veterans with TBI. However, CARF has concerns regarding 

the use of the term ‘‘assisted living.’’

The legislation defines assisted living services as ‘‘services of a facility in providing room, board, and personal care and supervision of residents for their health, 

safety and welfare.’’ However, CARF is concerned that the popular interpretation of 

the term ‘‘assisted living’’ commonly describes a facility that has adequate staff to 

assist the residents with very limited and often aging-related needs. 

However, given our experience with TBI rehabilitation, CARF recognizes the more 

extensive and specific residential needs of these individuals. We suggest that the 

Committee use the term ‘‘brain injury long-term residential services’’ If you do not 

get them to understand that these are Brain Injury programs first rather than residential programs first then I think they will still have assisted living facilities saying they can do brain injury work to describe the types of facilities which could best 

serve veterans with TBI and in which these pilot programs would take place. In this 

manner, if the VA requires accreditation of these assisted living providers, it will 

more likely engage accreditation organizations that will truly understand the residential and long-term needs of TBI survivors. 

CARF currently accredits 262 brain injury residential and 261 long-term residential brain injury programs in the private sector and would appreciate that opportunity to work with the Committee to identify the types of residential programs 

most appropriate for returning soldiers with TBI and therefore, most appropriate for 

these pilot programs. 

CONCLUSION—SUPPORTING VA FUTURE DIRECTIONS

In conclusion, CARF is vested in growing and changing with the VA as its programs and services move into the twenty-first century. To maximize the quality of 

services and amount of care the VA provides to veterans, CARF standards can be 

used to help align the VA to deliver the greatest amount of consumer benefit possible from each dollar of funding the service networks receive. CARF will continue 

to anticipate changes in the field and begin developing specific service unit standards as veterans’ needs change and service delivery progresses. 

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CARF strongly supports S. 1233 and applauds the Committee’s commitment to 

improving access to and quality of care for veterans with traumatic brain injury. We 

are pleased to see language in the bill that recognizes the value of independent accreditation as a means of ensuring quality and look forward to working with Congress toward enactment of this important legislation. 

[Note: The following is an e-mail from a Vermont resident sent to Senator Bernard Sanders on May 17, 2007.]

DEAR SENATOR SANDERS: I read in the Rutland Herald yesterday about the Veterans benefits and the veterans that fall into the catagory ‘‘8’’. My husband applied 

and he fell into that catagory because he had not signed by by 2003, he was denied 

any medical benefits. He needs to have medical care because he has diabetes and 

we are unable to afford health insurance for him. I am hoping you can do something 

about this situation for veterans. Thank you. 

EPILEPSY FOUNDATION, 

Landover, MD, May 22, 2007. 

Hon. DANIEL K. AKAKA, 

Chairman, Committee on Veterans’ Affairs, 

412 Russell Senate Office Building, 

Washington, DC. 

DEAR CHAIRMAN AKAKA: On behalf of the over 3 million Americans with epilepsy, 

the Epilepsy Foundation is pleased to support S. 1233, The Veterans Traumatic 

Brain Injury Rehabilitation Act of 2007. The Foundation is deeply concerned with 

the high incidence of epilepsy that results from traumatic brain injury. Although we 

do not have data on post-traumatic epilepsy from the current wars, the statistics 

from the Vietnam era are alarming. VA-funded research conducted in collaboration 

with the Department of Defense found that 53 percent of veterans who suffered a 

penetrating TBI in Vietnam developed epilepsy within 15 years. For these serviceconnected veterans, the relative risk for developing epilepsy more than 10 to 15 

years after their injury was 25 times higher than their age-related civilian cohorts. 

Indeed, 15 percent did not manifest epilepsy until five or more years after their 

combat injury. 

Because of these alarming statistics from the Vietnam War, the Epilepsy Foundation is thankful that S. 1233 addresses the periodic assessment of the rehabilitation 

plan. The consequences of a TBI may change over time and new symptoms may develop. For example, individuals with TBI may develop post-traumatic seizures 

months or years after the injury. Because epilepsy requires regular monitoring and, 

for many patients, frequent changes in their anti-seizure medications, this periodic 

assessment is crucial. The Foundation strongly supports the ‘‘team approach’’ laid 

out in section 3 of S. 1233. Each veteran who suffers a TBI should receive ongoing 

individualized, comprehensive and multidisciplinary rehabilitation after inpatient 

services. Rehabilitation plans that are based upon a comprehensive assessment of 

the veteran’s physical, cognitive, vocational, and psychosocial impairments, using a 

multidisciplinary team that includes neurologists (as required by S. 1233), are essential to rehabilitative success. Additionally, we support the provision in section 3 

which requires involving the family and veteran in the development and review of 

the rehabilitation plan. TBI is a devastating and life-altering event which affects the 

veteran and his or her family. Families of veterans with TBI need support and education, and should be part of the rehabilitative team to the greatest extent possible. 

Perhaps the most important aspect of S. 1233 is the recognition of seizure disorders as a common outcome of TBI (Sec. 8). We know that post-traumatic epilepsy 

is going to be a significant long-term consequence of TBI, and this language will 

help create awareness of the growing problem. 

Given this high rate of post-traumatic epilepsy that veterans with TBI are likely 

to endure, the Epilepsy Foundation believes that Congress should also authorize, 

and the VA must establish a strong national epilepsy program with research, education and clinical-care components, to include Epilepsy Centers of Excellence. We 

are concerned that the VA lacks a national program for epilepsy with clear guidelines on when to refer patients for further assessment and treatment of epilepsy. 

VA Centers of Excellence have been the model of innovation in the delivery of highly 

specialized health care and research for other disabling and chronic diseases in the 

veteran population. VA has infrastructure to address many of the other common 

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consequences of TBI, such as psychosocial changes, vision problems and movement 

disorders but not post-traumatic epilepsy. 

I personally look forward to working with you on moving this legislation forward. 

Please feel free to contact me or Donna Meltzer, Senior Director of Government Affairs at 301–918–3764 or dmeltzer@efa.org. Thank you again for your leadership and 

commitment to our Nation’s veterans. 

Sincerely, 

TONY COELHO, 

Immediate Past Chair, 

Epilepsy Foundation Board of Directors.

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