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41–363 2008

LEGISLATIVE HEARING ON H.R. 2790, H.R. 3458, 

H.R. 3819, H.R. 4053, H.R. 4107, H.R. 4146, 

H.R. 4204, AND H.R. 4231 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

JANUARY 17, 2008 

Serial No. 110–63 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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COMMITTEE ON VETERANS’ AFFAIRS 

BOB FILNER, California, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

MICHAEL H. MICHAUD, Maine 

STEPHANIE HERSETH SANDLIN, South 

Dakota 

HARRY E. MITCHELL, Arizona 

JOHN J. HALL, New York 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

GINNY BROWN-WAITE, Florida 

MICHAEL R. TURNER, Ohio 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

MALCOM A. SHORTER, Staff Director 

SUBCOMMITTEE ON HEALTH 

MICHAEL H. MICHAUD, Maine, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

JEFF MILLER, Florida, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

HENRY E. BROWN, JR., South Carolina 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

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C O N T E N T S 

January 17, 2008 

Page 

Legislative Hearing on H.R. 2790, H.R. 3458, H.R. 3819, H.R. 4053, H.R. 4107, 

H.R. 4146, H.R. 4204, and H.R. 4231 ................................................................. 1 

OPENING STATEMENTS 

Chairman Michael H. Michaud .............................................................................. 1 

Prepared statement of Chairman Michaud .................................................... 32 

Hon. Jeff Miller, Ranking Republican Member ..................................................... 9 

Prepared statement of Congressman Miller ................................................... 32 

Hon. Jerry Moran .................................................................................................... 1 

Hon. Ginny Brown-Waite ........................................................................................ 6 

WITNESSES 

U.S. Department of Veterans Affairs, Gerald M. Cross, M.D., FAAFP, Principal Deputy Under Secretary for Health, Veterans Health Administration .. 23 

Prepared statement of Dr. Cross ..................................................................... 53 

American Legion, Joseph L. Wilson, Deputy Director, Veterans Affairs and 

Rehabilitation Division ........................................................................................ 14 

Prepared statement of Mr. Wilson .................................................................. 35 

Boswell, Hon. Leonard L., a Representative in Congress from the State of 

Iowa ....................................................................................................................... 8 

Prepared statement of Congressman Boswell ................................................ 34 

Capito, Hon. Shelley Moore, a Representative in Congress from the State 

of West Virginia ................................................................................................... 7 

Prepared statement of Congresswoman Capito ............................................. 33 

Disabled American Veterans, Joy J. Ilem, Assistant National Legislative Director ..................................................................................................................... 15 

Prepared statement of Ms. Ilem ...................................................................... 38 

Hare, Hon. Phil, a Representative in Congress from the State of Illinois .......... 2 

Herseth Sandlin, Hon. Stephanie, a Representative in Congress from the 

State of South Dakota .......................................................................................... 5 

Prepared statement of Congresswoman Herseth Sandlin ............................. 33 

Honda, Hon. Michael M., a Representative in Congress from the State of 

California .............................................................................................................. 12 

Kagen, Hon. Steve, a Representative in Congress from the State of Wisconsin .. 10 

Space, Hon. Zack, a Representative in Congress from the State of Ohio ........... 4 

Veterans of Foreign Wars of the United States, Christopher Needham, Senior 

Legislative Associate, National Legislative Service .......................................... 17 

Prepared statement of Mr. Needham ............................................................. 44 

Vietnam Veterans of America, Richard F. Weidman, Executive Director for 

Policy and Government Affairs ........................................................................... 19 

Prepared statement of Mr. Weidman ............................................................. 49 

SUBMISSIONS FOR THE RECORD 

American Academy of Physician Assistants, statement ....................................... 64 

Berkley, Hon. Shelley, a Representative in Congress from the State of Nevada, statement .................................................................................................... 66 

Mental Health America, statement ........................................................................ 66 

Paralyzed Veterans of America, statement ........................................................... 69 

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MATERIAL SUBMITTED FOR THE RECORD 

Jonathan Archey, Manager, Federal Relations, Ohio Hospital Association, 

to Hon. Sherrod Brown, U.S. Senate, and Hon. Zack Space, U.S. House 

of Representatives, letter dated October 18, 2007, supporting S. 2142/ 

H.R. 3819 .............................................................................................................. 73 

Richard M. Dean, CMSgt (Ret.), Chief Executive Officer, Air Force Sergeants 

Association, to Hon. Zachary Space, U.S. House of Representatives, letter 

dated November 5, 2007, supporting H.R. 3819 ................................................ 73 

U.S. Department of Veterans Affairs, News Release, entitled ‘‘VA Vet Centers 

Coming to 39 Communities, Peake: Provide Counseling for All Combat 

Veterans,’’ dated July 9, 2008 .............................................................................. 74 

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LEGISLATIVE 

HEARING ON H.R. 2790, H.R. 3458, 

H.R. 3819, H.R. 4053, H.R. 4107, H.R. 4146, 

H.R. 4204, AND H.R. 4231 

THURSDAY, JANUARY 17, 2008 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, SUBCOMMITTEE ON HEALTH, Washington, DC. 

The Subcommittee met, pursuant to notice, at 10:01 a.m., in Room 

340, Cannon House Office Building, Hon. Michael H. Michaud 

[Chairman of the Subcommittee] presiding. 

Present: Representatives Michaud, Snyder, Hare, Miller, Moran. 

Also Present: Representative Brown-Waite. 

OPENING STATEMENT OF CHAIRMAN MICHAUD 

Mr. MICHAUD. Why don’t we get started. It is my understanding 

we have votes at 11:30, so we will try to move this along so we can 

hear everyone. 

I would like to thank everyone for coming here today. Today’s 

legislative hearing is an opportunity for Members of Congress, veterans, the U.S. Department of Veterans Affairs (VA) and other interested parties to discuss recently introduced legislation that 

comes under this Subcommittee’s jurisdiction. 

I do not necessarily agree or disagree with the bills before us 

today, but I believe that it is an important process, that we encourage a frank discussion of new ideas. We have eight bills before us 

today. I look forward to hearing the testimony on these bills. 

And I would turn it over to Mr. Moran if he has an opening 

statement. 

[The prepared statement of Chairman Michaud appears on p. 32.] 

OPENING STATEMENT OF HON. JERRY MORAN 

Mr. MORAN. Mr. Chairman, thank you very much. I am happy 

to serve as the acting Ranking Member until Mr. Miller arrives, 

and I am interested in hearing the testimony from our colleagues 

on a variety of issues affecting veterans across the country. 

And I am of the opinion that oftentimes we get some of our best 

ideas in this Committee by listening to colleagues who do not serve 

with us on the House Veterans’ Affairs Committee, and I welcome 

the two gentlemen that are with us already this morning and look 

forward to hearing what they have to say. 

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I thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you very much. 

I now would like to recognize Mr. Hare who also serves as a 

member of this Committee and a very strong advocate for our veterans. 

Mr. Hare. 

STATEMENTS OF HON. PHIL HARE, A REPRESENTATIVE IN 

CONGRESS FROM THE STATE OF ILLINOIS; HON. STEPHANIE 

HERSETH SANDLIN, A REPRESENTATIVE IN CONGRESS 

FROM THE STATE OF SOUTH DAKOTA; HON. ZACK SPACE, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF OHIO; 

AND HON. SHELLEY MOORE CAPITO, A REPRESENTATIVE IN 

CONGRESS FROM THE STATE OF WEST VIRGINIA 

STATEMENT OF HON. PHIL HARE 

Mr. HARE. Good morning. Thank you, Mr. Chairman. Thank you 

for holding this hearing today, and I am pleased to provide testimony in support of H.R. 2790, the bill I introduced to elevate the 

current Physician Assistant (PA) Advisor to the Veterans Affairs 

Under Secretary of Health to a full-time Director of PA Services in 

the VA’s Central Office. 

I would like to thank my colleague, Representative Jerry Moran, 

for his leadership with me on this bill, as well as Chairman Filner, 

and Representatives Berkley, Corrine Brown, and Doyle for joining 

us as cosponsors of the bill. 

PAs have long been a critical component in providing care in the 

Veterans Health Administration (VHA) with nearly 1,600 PAs currently employed, many of whom are Reservists, Guardsmen, and 

veterans. While the PA advisor position has been valuable in establishing guidelines for utilizing PAs, we do see unnecessary restrictions on PA use, and too many problems still exist. 

I do not believe that Congress’ original intent for a position has 

been fulfilled. Confusion still exists about the medical services PAs 

can provide from facility to facility. 

VA facilities are telling PAs that they cannot and will not hire 

PAs and, most critically, the PA advisor has been excluded from 

critical planning and policy development. 

These issues not only hinder the ability of PA advisors and PAs 

currently employed by the VA, but they also discourage PAs from 

even entering the VA system. 

Without the PA advisor being able to fully perform his or her 

role in the full-time Director position, the VHA is missing a clear 

opportunity to improve the quality of healthcare for our veterans. 

Quite simply, this is a position that needs to be made permanent 

and be based on the VA’s Central Office. 

The lack of establishing the Director position ignores a valuable 

resource in improving care, prevents improvements in the recruiting and retention of the PA workforce, and disregards utilizing a 

critical aspect of the VHA workforce. 

Considering the fact that nearly 40 percent of all VA PAs are 

projected to retire in the next 5 years, the VA is in danger of losing 

its PA workforce unless some attention is directed toward the recruitment and retention of this critical group. 

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One of the biggest challenges currently facing future PAs in the 

VA system is their exclusion from any recruitment and retention 

efforts or benefits. 

The VA designates physicians, nurses as critical occupations and 

so priority and scholarships and loan repayment programs go to 

these critical occupations. However, the PAs have not been designated as a critical occupation, so no monies are directed their way. 

This is despite the fact that the VA has determined PAs and 

Nurse Practitioners (NPs) to be functionally interchangeable and 

equal in the work that they perform. Many of these problems could 

be addressed by a Director of PA Services. 

H.R. 2790 would legitimatize and recognize the role PAs play by 

creating a permanent Director that would serve as a clear voice in 

strategic planning, policy, and staffing development initiatives, as 

well as an advocate for the physician assistants. 

The VA’s position on my bill is that the status quo is working 

just fine and that no change is necessary. I strongly disagree with 

that position. The VA prefers a field-based position and thinks that 

only 75 percent of the individual’s time is necessary to devote to 

PA patient-care issues in the VA. 

However, even though the VA opposes this legislation, VHA 

Under Secretary for Health, Dr. Kussman, said he intended to 

make the PA advisor a full-time position in the VA’s Central Office. 

There is no significant cost to elevating and relocating this individual position. This change is common sense and it promotes quality medical care for our veterans. 

This bill is supported by the American Academy of Physician Assistants (AAPA), the Veterans of Foreign Wars, the Disabled American Veterans, Vietnam Veterans of America, the Blinded Veterans 

of America, and the Veterans’ Affairs Physician Assistant Association. 

I would like to thank all the Veterans Service Organizations 

(VSOs) for their support in this legislation and particularly thank 

the AAPA for their dedication on this issue. 

I thank you, Mr. Chairman, for giving me the opportunity to be 

here this morning to testify on this critical piece of legislation. 

Mr. MICHAUD. Thank you very much, Mr. Hare. 

And we have had a request from one of the cosponsors of this legislation to speak who also sits on the Committee. So if there is no 

objection, Mr. Moran. 

Mr. MORAN. Mr. Chairman, thank you, and I am pleased to join 

my colleague, Mr. Hare, as an original cosponsor of H.R. 2790, and 

am pleased to support the testimony that he provided this morning. 

I suspect that the Department of Veterans Affairs will testify 

that this legislation is not necessary, but that is certainly not what 

I am hearing from my Kansas physician assistants, and very much 

hope that we can see this bill’s passage. 

I represent one of the most rural congressional districts in the 

country and I know in healthcare that our physician assistants are 

some of our most valuable resources in trying to meet the healthcare needs of Kansans who live in those rural communities. 

And I know that that can be equally as true in the VA, and I 

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ics (CBOCs) and our physician assistants who are providing tremendous services to veterans through the outpatient clinics. 

I also know that medical institutions like Cleveland Clinic, Mayo 

Clinic, M.D. Anderson Cancer Clinic at the University of Texas, 

and others have Directors of PA Services to make sure that they 

employ the PAs in an integrated way into their healthcare delivery 

system. And I believe that the VA can utilize the same technique 

to provide a stronger voice for our PAs in making healthcare policy. 

It makes sense to me to give the PAs a stronger voice and invite 

their participation among the healthcare professions that have fulltime Directors or consultants within the VA already at the Central 

Office, our social work, nursing, pharmacy, psychology, dentists, 

and dietitians. This just makes a lot of sense to allow the physician 

assistants the same kind of opportunity. 

And I thank Mr. Hare for his leadership on this issue, and thank 

the Committee for allowing me to speak. 

Mr. MICHAUD. Thank you very much, Mr. Moran. 

I now would like to ask unanimous consent that Ms. BrownWaite be invited to sit at the dais for this Subcommittee hearing. 

Ms. BROWN-WAITE. Thank you, Mr. Chairman. 

Mr. MICHAUD. Hearing no objections. It is so ordered. 

I would now like to recognize Zack Space who is also another 

strong advocate for our veterans in this Nation. I want to thank 

you for presenting your legislation and look forward to your testimony. 

Mr. Space. 

STATEMENT OF HON. ZACK SPACE 

Mr. SPACE. Thank you, Chairman Michaud, Ranking Member 

Miller, and Members of the Subcommittee, for holding today’s hearing and including H.R. 3819, the ‘‘Veterans Emergency Care Fairness Act.’’ I am grateful for the opportunity to discuss this bill. 

In March, I received a letter from Terry Carson who is Chief Executive Officer (CEO) of Harrison Community Hospital in Cadiz, 

Ohio, a small critical care facility in rural Harrison County. Mr. 

Carson wrote to me about a problem he was experiencing at his 

small hospital when providing emergency care for veterans. 

In late May, Senator Sherrod Brown of Ohio and I held a joint 

field hearing on the issues facing rural veterans, and Mr. Carson 

participated as a witness to share his experiences. 

Mr. Carson explained that currently the VA reimburses non-VA 

hospitals for emergency care provided to veterans up to the point 

of stabilization. Once the patient is deemed stable enough to transfer, he or she is moved to a VA hospital. Oftentimes that is several 

hundred miles away from hospitals in rural areas of our country. 

The problem Mr. Carson brought to my attention is that oftentimes veterans experience a waiting period for a bed in a VA hospital. During this limbo, the VA is not required to reimburse the 

private hospital for care. Meanwhile, people like Mr. Carson feel 

morally obligated to continue care despite the fact that they cannot 

count on reimbursement. 

And it should be emphasized that many of the small hospitals, 

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ating on very, very narrow profit margins. So it is an economic burden as well. 

The ‘‘Veterans Emergency Care Fairness Act’’ closes this loophole 

by requiring the VA to cover the cost of care while a transfer to 

a VA hospital is pending and if the private hospital can document 

attempts to transfer the patient. 

Senator Brown introduced an identical companion bill on the 

Senate side and that has already advanced out of the full Committee. Senator Brown and I believe this legislation is a reasonable 

solution for the VA, private hospitals, and most importantly our 

Nation’s veterans. 

I have received support for this legislation from people all across 

the country who have found either themselves or a loved one 

caught in this hospital limbo. Additionally, the Ohio Hospital Association and the Air Force Sergeants Association have written letters of support which I can submit for the record today. 

This bill is a very good example of how our system of representational democracy is supposed to work. The constituent contacts his 

member of Congress. The member listens, and a legislative fix is 

found. 

I am proud to have had a chance to advocate for Mr. Carson, and 

I hope you will join me in recognizing his efforts and the efforts of 

those veterans that his hospital cares for by supporting H.R. 3819. 

And, again, I thank you for the opportunity. 

[The letters from the Ohio Hospital Association and the Air Force 

Sergeants Association appear on p. 73.] 

Mr. MICHAUD. Thank you very much, Mr. Space. 

And now I would like to recognize Mrs. Herseth Sandlin for her 

piece of legislation. I want to also thank her for her long-time support for our veterans’ issues and for being a long-time member of 

this Committee. 

STATEMENT OF HON. STEPHANIE HERSETH SANDLIN 

Ms. HERSETH SANDLIN. Thank you, Mr. Chairman. Good morning 

to you and to the Ranking Member and other Members of the Subcommittee. I want to thank you for having today’s hearing and I 

appreciate the opportunity to be here to discuss with you the 

‘‘Women Veterans Healthcare Improvement Act.’’ 

This bill, H.R. 4107, which I introduced last fall along with 

Congresswoman Brown-Waite of Florida, will expand and improve 

Department of Veterans Affairs healthcare services for women veterans, particularly those who have served in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). 

I would like to thank the Disabled American Veterans (DAV) for 

their support in helping craft this important bill. And I would also 

like to thank the Veterans of Foreign Wars of the United States 

of America (VFW) for their endorsement of the legislation. 

As you know, more women are answering the call to serve and 

more women veterans need access to services that they are entitled 

to when they return from their deployments or separate from service and return to civilian life. 

With increasing numbers of women now serving in uniform, the 

challenge of providing adequate healthcare for women veterans is 

more considerable than ever. In the future, these needs likely will 

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be significantly greater with more women seeking access to care for 

a more diverse range of medical conditions. 

In fact, more than 1.7 million women nationally are military veterans. More than 177,000 brave women have served our Nation in 

Iraq and Afghanistan since September of 2001, and nearly 27,000 

are currently deployed in these wars. 

By August of 2005, 32.9 percent of women veterans who had 

served in OIF or OEF had received VA healthcare. By the end of 

the following year, that number had increased to 37 percent. And 

as the VA compiles the final data for 2007, the percent is expected 

to increase again. 

And according to the VA, the prevalence of potential post traumatic stress disorder (PTSD) among new OEF/OIF women veterans 

treated at the VA from fiscal year 2002 to 2006 has grown dramatically from approximately 1 percent in 2002 to nearly 19 percent in 

2006. 

So the trend is clear, but not surprising. More women are serving 

in our Armed Forces, including the National Guard and Reserves. 

More women are being deployed overseas and more women veterans need access to healthcare services. So clearly we must do everything we can from a public policy standpoint to meet the new 

challenge that this trend presents. 

The ‘‘Women Veterans Healthcare Improvement Act’’ calls for a 

study of healthcare for women veterans who served in OIF and 

OEF, a study of barriers to women veterans seeking healthcare at 

the VA, enhancement of VA sexual trauma programs, enhancement 

of PTSD treatment for women, expansion of family counseling programs, establishment of a pilot program for childcare services, establishment of a pilot program for counseling services in a retreat 

setting for women veterans, and the addition of recently separated 

women veterans to serve on advisory committees. 

We must ensure that the VA is positioned to provide adequate 

attention to women veterans’ programs so quality healthcare and 

specialized services are available equally for both women and men. 

I believe this bill will help the VA better meet specialized needs 

and develop new systems to better provide for the quality healthcare of women veterans, especially those who are returning from 

combat who were sexually assaulted or who need childcare services, especially in order to better access the healthcare services provided by the VA. 

So, Mr. Chairman, Ranking Member Miller, again, thank you for 

inviting me to testify, and I look forward to answering any questions that you or other Members of the Subcommittee may have. 

[The prepared statement of Congresswoman Herseth Sandlin appears on p. 33.] 

Mr. MICHAUD. Thank you very much. 

I have also had a request of one of the original cosponsors to 

speak on this bill, Ms. Brown-Waite. 

OPENING STATEMENT OF HON. GINNY BROWN-WAITE 

Ms. BROWN-WAITE. Thank you, Mr. Chairman and Mr. Ranking 

Member Miller. 

When I tour the hospitals in my district, whether it is St. Petersburg, Tampa, or Gainesville, one question I always ask when I see 

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women veterans there waiting is, how is the care. Do you think you 

are getting the same services. 

And particularly in the area of mental health, women have told 

me, no, they do not believe they are getting the same services. And 

we might ask why. 

When a woman comes back from the military, very often she has 

family at home, children, and it is the caregiver in her that she 

takes care of the children, takes care of the house, might have a 

job that she goes to. 

And the trauma of having been at war or having been perhaps 

sexually assaulted does not really come back until later because 

the female physiology is a whole lot different. 

This bill, I think, will go a long way toward making sure that 

our female veterans are receiving all of the care that they need and 

the care that is necessary and tailored to them. 

You know, the specific healthcare needs of female servicemembers and veterans are sometimes overlooked by the Department of Defense as well as Department of Veterans Affairs. This 

bill will go a long way toward making sure that we have evidencebased treatment that women need to get the help to help them recover from whether it is sexual assaults or trauma of the war. 

Thank you, Mr. Chairman, and I yield back and certainly commend Ms. Herseth Sandlin for putting together this bill. And I am 

sure you hear the same story from women veterans. And thank 

you, Mr. Chairman. 

Mr. MICHAUD. Thank you very much. 

And the last bill for the first panel is H.R. 3458, introduced by 

Ms. Moore Capito. 

Ms. CAPITO. Thank you. 

Mr. MICHAUD. Thank you for coming this morning. Appreciate it. 

Ms. CAPITO. Thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you for your interest in veterans’ issues as 

well. 

STATEMENT OF HON. SHELLEY MOORE CAPITO 

Ms. CAPITO. Thank you. Thank you for giving me the honor of 

presenting this to the full Committee. I appreciate that. I want to 

thank the Ranking Member as well. 

May I submit my full statement for the record, and I am going 

to speak very briefly because I have to be on the floor. So if you 

saw me looking panicked, that was my problem. 

My issue is rural veterans. I represent a State, West Virginia, 

which I have in my research material shows that over 14 percent 

of West Virginians are veterans living in my State. 

And I am very concerned with the traumatic brain injury (TBI) 

issues that many veterans in many rural States and across the Nation are dealing with and making sure that they are able to access 

the kind of care that they need and deserve. And I think the Chairman shares the same, I know, issue. 

My bill basically introduces five pilot projects where the Secretary would pick five States that do not have the traumatic brain 

injury centers in their States and designates a case manager for 

the TBI victims in the State that would be able to follow their 

cases through their treatment. 

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And it also opens up the possibilities of using local providers, 

whether it is a CBOC or a local provider, to help that veteran. I 

mean, you can imagine having an injury such as this and then to 

actually see the physician, you might have to travel 8 or 9 hours 

by car makes it very difficult to do it on a regular basis and certainly in some cases almost impossible. 

So this is what the bill asks for. It asks for a pilot study of five 

States. It asks for a case manager for each State to specifically deal 

with this issue. This was brought to light for me from the Office 

of Rural Health at West Virginia University who deals with rural 

healthcare in the State of West Virginia quite frequently. 

It also asks for a report back to Congress every year to see how 

the needs of rural veterans are being met who unfortunately are 

suffering from the results of traumatic brain injury. 

I thank the Chairman. I thank all the Members of the Committee. It is an important issue across the country. And as I was 

reading through my background material, I guess I did not realize 

that rural States really provide a relatively larger majority of men 

and women to our military than some of our metropolitan areas. 

And we want to see that they are able to access the care. Thank 

you. 

[The prepared statement of Congresswoman Moore Capito appears on p. 33.] 

Mr. MICHAUD. Thank you very much. 

Are there questions for any of our first group of panelists? 

[No response.] 

Okay. Hearing no questions, we will dismiss the first panel. 

I would like to ask the second panel to come forward. I would 

like to thank the second panel. We are looking forward to hearing 

your testimony. And we will start off with Mr. Boswell. 

STATEMENTS OF HON. LEONARD L. BOSWELL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF IOWA; HON. STEVE 

KAGEN, A REPRESENTATIVE IN CONGRESS FROM THE STATE 

OF WISCONSIN; AND HON. MICHAEL M. HONDA, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

STATEMENT OF HON. LEONARD L. BOSWELL 

Mr. BOSWELL. Well, thank you, Mr. Chairman, Mr. Miller, and 

all of you on the panel. Good to see you and I appreciate the hard 

work you are doing for veterans. Thank you so very, very much. 

I would just like to make a couple points here. I know you are 

very busy, but some say that suicide is an epidemic, which is 

sweeping through our veteran population. And for too long, suicide 

among veterans has been ignored. I feel that now is the time to act. 

We can no longer be afraid to look at the facts and the sad fact 

is we are missing adequate information on the number of veterans 

who commit suicide every year. 

Probably all of you, all of us could tell or make reference to how 

a person or someone in our own acquaintance had a mental health 

problem and it was not dealt with and oftentimes just kind of 

swept under the rug and looked at as a sign of weakness. And that 

time has to be gone, has to pass. 

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I was shocked as I am sure many of you were when I saw a CBS 

Evening News report focusing on veteran suicide. They found that 

in 2005, over 6,200 veterans committed suicide, 120 a week. 

The report also found that veterans were twice as likely to commit suicide as nonveterans. And these are very devastating circumstances. 

However, the data collected did not come from the Department 

of Veterans Affairs, but rather from individual States. That is why 

I introduced H.R. 4204, the ‘‘Veterans Suicide Study Act,’’ to direct 

the Secretary of Veterans Affairs to conduct a study on the rate of 

suicide among our Nation’s veterans. 

I believe it is imperative we have the facts on this terrible problem if we are to effectively treat our veterans as they return home. 

While I am pleased that the ‘‘Joshua Omvig Veterans Suicide 

Prevention Act’’ is now law, we need to continue to get all the facts 

on suicide among our veterans in order to better treat them as they 

return home. 

I implore this Committee and Congress to act swiftly on 

H.R. 4204 so we can ensure we have the data we need to treat our 

Nation’s heroes. This is an issue important to veterans and their 

families in Iowa and across our Nation. 

And I would like to thank you, Mr. Chairman, for allowing me 

this time, and I would be glad to answer any questions you might 

have. 

But a thought comes to me and I know we have talked to several 

of you about the ‘‘Suicide Prevention Act.’’ But at some point, we 

want to measure, and how are we going to measure if we do not 

have some data? You know, is it effective? Maybe we need to go 

in and adjust that as we work with it or whatever we might need 

to do. 

So I feel like we need to have this information and then we can 

make comparisons as we see whether we have been effective or not. 

We have to take care of our veterans. And I know every one of you 

are committed to that as well. Thank you very much. 

[The prepared statement of Congressman Boswell appears on 

p. 34.] 

Mr. MICHAUD. Thank you. 

OPENING STATEMENT OF HON. JEFF MILLER 

Mr. MILLER. May I make a statement real quick? 

Mr. MICHAUD. Okay. Mr. Miller. 

Mr. MILLER. Thank you, Mr. Chairman. 

Mr. Boswell, I salute you on bringing this bill, H.R. 4204, the 

‘‘Veterans Suicide Study Act,’’ forward. I am probably not going to 

be able to stay past 10:30 and I just want whoever is here from 

VA to hear this from me beforehand. 

All I hear on this particular piece of legislation H.R. 4204, is why 

we cannot do it and why it is not the right piece of legislation. I 

would like to see VA get with the sponsor. Let us see if we can fix 

the language and come out with a piece that says ‘‘we can’’ instead 

of ‘‘we cannot.’’ 

Mr. Boswell. 

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Mr. BOSWELL. Well, I am not stuck on authorship. I want something to happen. You can make it a Committee bill for all I care. 

I want something to happen. 

Mr. MILLER. This will be the Boswell bill, I am sure, but I want 

VA to let us get this thing moving forward. 

Mr. BOSWELL. Thank you. 

[The prepared statement of Congressman Miller appears on p. 32.] 

Mr. MICHAUD. Thank you, Mr. Miller. 

Mr. Kagen. 

STATEMENT OF HON. STEVE KAGEN 

Mr. KAGEN. Thank you, Mr. Chairman. I really appreciate the 

opportunity to provide these few minutes to present H.R. 4231, 

which is entitled the ‘‘Rural Veterans Mental Health Improvement 

Act.’’ 

I will review with you some of the facts you are already aware 

of. We have all become aware that mental health conditions affect 

many of our soldiers. And as a physician, I can tell you that the 

brain is still a vital organ in the human body. We ought to do everything we can to protect it and to heal it. 

There are 9 million veterans who live in rural regions in America. And only one out of three of these veterans are receiving the 

medical benefits that they have already earned. 

To say it another way, two-thirds of rural veterans when they 

come home do not get their medical benefits for reasons that are 

becoming apparent more and more every day. 

Fifteen percent of veterans who have served in Iraq and Afghanistan now suffer from PTSD, post traumatic stress disorder, but 

barely of those who have already been diagnosed receive the care 

that they require. 

When people come home from overseas and combat, they have 

higher rates of divorce and this affects not just our families but our 

communities because when our soldiers are wounded mentally, 

they are unable to perform at work. They lose their jobs, lose their 

incomes, and all of our communities lose their tax base as a result. 

It is not a surprise to anyone that an early and accurate diagnosis of any medical condition saves lives and saves human tragedy. And that is what we must accomplish by serving all of our 

veterans, especially those who live in rural areas. 

What H.R. 4231 seeks to do is to make it easier for affected patients to receive the care they have earned, first by providing an 

accurate diagnosis from a qualified mental health specialist at a 

VA medical center or clinic. Secondly, for those patients who are 

affected and diagnosed as having a mental condition, they need to 

receive care as soon as possible and as close to home as possible. 

For those patients who live more than 30 miles away from a VA 

medical center, H.R. 4231 seeks to create a voucher system where 

each affected veteran would receive a voucher, receive the care, the 

expert care they need from qualified specialists close to home. If it 

is close to home, they are going to have a higher probability of receiving the care that they need. 

We know from our common experience as Congressmen and 

women that if it is close to where we are, we are much more likely 

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to get there to that event or to that, shall we say, fundraising opportunity. 

The third thing H.R. 4231 seeks to do is to guarantee that the 

families who are also affected by the post traumatic stress disorder, 

by drug and alcohol addictions that occur in such affected veterans, 

that the family gets the counseling and care that they require to 

help keep them together. 

I am proud to say that my wife, Gayle, who was President of the 

Congressional Spouse Association for the class of 2006, has made 

a marriage between United Way and the National Military Family 

Association to create access to a telephone number that will help 

rural veterans and those in the cities to get the care and the benefits that they have already needed. 

But we have to do more. This Congress can do more. And 

H.R. 4231 seeks to do just that. It is a pilot program. It is something that we can measure and monitor to guarantee to push our 

affected veterans into the care that they really require. 

If we fail to do this, if we turn our back on the needs of our veterans now, especially those mental impairments, the wounds that 

you will never see, we will be failing to do our complete job. 

And I thank you again for the time that you have provided to 

me. I will submit my written statement to your official records, and 

I am open to any questions that you may have. 

Mr. MICHAUD. Thank you very much, Mr. Kagen. 

Are there any questions from the Committee? 

Mr. Hare. 

Mr. HARE. No questions, Mr. Chairman, except to say to my two 

friends, Mr. Boswell and Mr. Kagen, I think both bills have a tremendous amount of merit. And I know how hard you have worked 

on this issue of suicide among veterans. 

And, Mr. Boswell, I will tell you that anything I can do to assist 

you on this I will, and I am proud to be on the bill with you. 

And, Mr. Kagen, let me just say I come from a very rural area 

too, in west central Illinois with all or parts of 23 counties. I do 

not think we ought to be hung up on who they are talking to, if 

it works for them, and they can stay close to home. Their families 

can go with them. 

I have had veterans that have had to travel 21⁄2 hours by van, 

get out of the van, go in, and literally sit for 2, 21⁄2 hours waiting 

to be seen for something. And, quite frankly, they just give up and 

leave. 

And I think it is incumbent upon us and this Congress to make 

sure that any veteran, any place, just because you live in a rural 

area, you have problems too. These people have served. I think we 

have an obligation to give them the type of care and the access to 

the care that they deserve. 

So I commend you both for your pieces of legislation and hopefully down the road, we will see this become law because to do anything less, I think, really dishonors the service that these people 

have put in for this Nation. 

So I want to just thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you very much. 

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I want to thank this panel as well. And the last member of the 

panel, Mr. Honda, who is presenting H.R. 4146, thank you very 

much for joining us today and we look forward to your testimony. 

STATEMENT OF HON. MICHAEL M. HONDA 

Mr. HONDA. Thank you, Mr. Chairman, and thank you for this 

opportunity. I would like to thank the leadership of this Committee 

for holding this hearing and inviting me to testify before the Subcommittee. I really do appreciate the opportunity to share my 

thoughts on veterans’ emergency services and reimbursement. 

In the 109th Congress, I introduced legislation which would 

amend the ‘‘Millennium Healthcare Act’’ and provides that the VA 

should cover an uninsured veteran’s emergency healthcare cost before and after stabilization if no VA hospital bed is available at a 

geographically accessible VA facility. 

It is a problem that I have been facing with our constituents in 

my district since I have been on the Board of Supervisors. 

As the Subcommittee knows, I reintroduced this bill as H.R. 4146 

right before Veterans Day last year. And the need for this legislation was brought to my attention by again a constituent, Robert 

Dahlberg, who is a Vietnam-era veteran. I would like to read a detailed account of what happened to Robert and why he contacted 

me. I will be very brief. 

‘‘About 2 years ago, after my helicopter crashed while fire fighting in northern California, I went to register for my veteran’s medical benefits. And as I was signing up at the VA, I asked a lot of 

questions to understand what my obligations were in order to get 

the care. 

At one point, I heard the words, and then you will need to get 

yourself once stabilized to a VA hospital, and these words alarmed 

me. 

And after further investigation, that was it. Even if I had a heart 

attack and was stabilized at a non-VA hospital, it was my responsibility to get myself to a VA hospital. The VA requirements to get 

one’s self to a VA hospital after stabilization is at best a joke and 

could financially devastate veterans of all ages and family status, 

leaving them destitute with a huge bill from the non-VA hospital. 

And to me, this is unconscionable.’’ 

The unintended loophole created by the ‘‘Millennium Healthcare 

Act’’ can leave veterans in a financial disaster. The problem, if 

nothing is done, is likely to grow as veteran ranks swell with servicemen and women returning from the wars in Iraq and Afghanistan. 

Mr. Chairman and Committee Members, we, as legislators, must 

fix this loophole. We have a responsibility to our veterans to do so. 

We owe them a debt of gratitude for their service and it is inexcusable for us to allow this loophole to even exist. 

It is an unnecessary burden for our returning veterans, Mr. 

Chairman. This important fix will save many veterans a great deal 

of grief and we should not stand by idly as more veterans are 

served absurd inordinate hospital bills because of this situation, especially as VA hospitals reduce the number of beds they have available. 

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American Veterans (AMVETS) and the American Legion support 

this bill, along with some Members of this Committee such as 

Ms. Ginny Brown-Waite and Mr. John Hall. I appreciate the bipartisan support this bill has received and urge the Committee to fix 

this problem with the health and financial stake of our veterans in 

mind. 

Again, I thank you, Mr. Chairman, for this opportunity, and am 

willing to answer any questions. 

Mr. MICHAUD. Thank you very much, Mr. Honda. 

Are there any questions? 

[No response.] 

We are letting you off easy today. Thank you very much. We 

really appreciate your testimony. 

And as staff is preparing the table for panel three, there is one 

more piece of legislation that was introduced by Ms. Berkley. It is 

H.R. 4053. She is not able to be here, but it is my understanding 

that Mr. Hare will present that legislation. 

Mr. HARE. Thank you, Mr. Chairman. I will be very brief. And 

I thank you and I thank my friend, Mr. Moran, for allowing me to 

speak on this bill this morning. 

Unfortunately, Ms. Berkley could not be here today to talk about 

her bill. As a cosponsor of her legislation, I would just like to say 

a few words in support of it. 

Nationally, one in five veterans returning from Iraq and Afghanistan suffers from post traumatic stress disorder. Twenty-three percent of members of the Armed Forces on active duty acknowledge 

a significant problem with alcohol use. It is vital that our veterans 

receive the help that they need to deal with these conditions. 

Ms. Berkley has introduced legislation which aims to improve the 

treatment and services provided by the Department of Veterans Affairs to veterans with post traumatic stress disorder and substance 

abuse disorders by establishing national centers of excellence on 

PTSD and substance abuse disorders and expanding the assistance 

of mental health services for families of veterans, among other initiatives. 

As a cosponsor of the ‘‘Mental Health Improvements Act,’’ I feel 

this bill takes a step in the right direction in providing our veterans with the care that they have earned. 

I thank you very much, Mr. Chairman, for allowing me to read 

this into the record on behalf of Ms. Berkley. And it is my sincere 

hope that we will get bipartisan support on this vital piece of legislation from the Committee. Thank you, Mr. Chairman. 

[The prepared statement of Congresswoman Berkley appears on 

p. 66.] 

Mr. MICHAUD. Thank you very much, Mr. Hare. 

Any questions for Mr. Hare? 

[No response.] 

Thank you. 

So I would invite the third panel to come on up. And as they are 

coming up, it will be Joe Wilson who represents the American Legion, Joy Ilem who represents the Disabled American Veterans, 

Christopher Needham, the Veterans of Foreign Wars, and Richard 

Weidman who represents the Vietnam Veterans of America (VVA). 

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I would like to thank all of you for coming here this morning to 

give your testimony on the piece of the legislation that we just 

heard. And we will start with Mr. Wilson and move on down the 

table. 

Mr. Wilson. 

STATEMENTS OF JOSEPH L. WILSON, DEPUTY DIRECTOR, VETERANS AFFAIRS AND REHABILITATION DIVISION, AMERICAN LEGION; JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; CHRISTOPHER NEEDHAM, SENIOR LEGISLATIVE ASSOCIATE, NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN 

WARS OF THE UNITED STATES; AND RICHARD F. WEIDMAN, 

EXECUTIVE DIRECTOR FOR POLICY AND GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA 

STATEMENT OF JOSEPH L. WILSON 

Mr. WILSON. Good morning, Mr. Chairman and Members of the 

Subcommittee. Thank you for this opportunity to present the American Legion’s views on legislation being considered by the Subcommittee today. 

The American Legion commends the Subcommittee for holding a 

hearing to discuss these important and timely issues. 

In regards to H.R. 2790, although the American Legion has no 

specific official position on this issue, we believe VA should do everything in its power to improve access to its healthcare benefits 

to include providing adequate funding to support programs within 

the VA medical system. 

In regards to H.R. 3458, the American Legion favors the intent 

of this bill to create a pilot program that would train and assign 

specified VA case managers for veterans diagnosed with TBI, or 

traumatic brain injury, and residing in rural areas. 

However, we would encourage the implementation of this program to every venue nationwide thereby ensuring across-the-board 

quality and adequate healthcare. 

In regards to H.R. 3819 and also H.R. 4146, the American Legion 

supports provisions to allow VA to pay for emergency room care at 

non-VA facilities. We believe this would prevent any delays in 

treating life-threatening injuries or illnesses for veterans not in 

close proximity to a VA facility. 

We also support H.R. 4146 because H.R. 4146 would alleviate the 

hardship or burden of veterans paying out-of-pocket expenses unfairly incurred, which is also due to unavailable beds at VA facilities. 

In regards to H.R. 4053, according to the Diagnostic and Statistical Manual of Mental Disorders IV, post traumatic stress disorder 

always follows a traumatic event that causes intense fear and/or 

helplessness in an individual. Typically the symptoms develop 

shortly after the event, but may take years. Psychological care is 

considered the most effective means of treatment for PTSD. 

In addition to treatment for PTSD, other mental health conditions such as acute reaction to stress and abuse of drugs or alcohol 

require much attention. Due to the increasing numbers of veterans 

seeking care at VA medical facilities to include those from the Gulf 

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War era and OEF/OIF, the American Legion supports a bill to further improve treatment and services provided by the VA to our Nation’s veterans. 

In regards to H.R. 4107, the American Legion supports this bill 

to include sections 101 to 103 and sections 201 to 206. In addition, 

we support expansion and improvement of healthcare services to 

all veterans. 

And regarding H.R. 4204, the American Legion receives contact 

from actual veterans who disclose their need for immediate help 

due to their thoughts of harming themselves. As the number of 

calls to suicide prevention call centers increase, the need for more 

suicide prevention counselors throughout the VA medical centers is 

warranted. 

The American Legion supports continued studies on suicides 

among veterans. In a proactive effort, these findings must be readily communicated to suicide prevention divisions to increase the 

prevention of potential tragedies. 

In regards to H.R. 4231, according to research conducted by the 

Department of Veterans Affairs, one in five veterans nationwide 

who enroll to receive VA healthcare reside in rural areas. The 

American Legion believes no veteran should be penalized or forced 

to travel long distances to access quality healthcare because of 

where they choose to live. 

Furthermore, all care, to include pilot programs, should include 

outreach to every rural venue in which veterans reside. The American Legion favors the intent of this bill to create a pilot program 

that would accommodate veterans residing in rural areas. 

However, we would encourage the inclusion of every Veterans Integrated Service Network (VISN) across the country as well as a 

more condensed pilot program than the above mentioned. 

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 the Committee in continuing the enhancement of access to quality care for all veterans. 

[The prepared statement of Mr. Wilson appears on p. 35.] 

Mr. MICHAUD. Thank you. 

Ms. Ilem. 

STATEMENT OF JOY J. ILEM 

Ms. ILEM. Thank you, Mr. Chairman and Members of the Subcommittee. We appreciate being invited to testify at this legislative 

hearing today. 

The first measure under consideration, H.R. 2790, would establish the position of Director of Physician Assistant Services as a 

full-time position within the VA Central Office. We believe PAs are 

a critical component of VA healthcare and urge the Subcommittee’s 

approval of this measure. 

H.R. 3458 would require VA to establish a rural pilot program 

of VA case-managed traumatic brain injury care. The bill would require the pilot program be conducted in consultation with the VA 

Office of Rural Health and includes protections to ensure rural veterans with TBI receive sufficient care from competent, trained providers. 

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This measure is consistent with recommendations of The Independent Budget related to VA care coordination of fee-basis and 

contract care, rural healthcare services, and TBI. Therefore, we 

have no objection to its enactment. 

H.R. 3819 would require the VA to reimburse for emergency 

treatment provided in a non-VA facility until an eligible veteran is 

transferred to VA. In accordance with the mandate from our membership, DAV supports this bill to improve reimbursement policies 

for non-VA emergency healthcare services. 

We believe H.R. 4146 is intended to achieve the same purpose as 

the bill just mentioned. However, based on our analysis, we recommend the Subcommittee to proaction on this measure and instead favorably report H.R. 3819. 

DAV supports H.R. 4053, a bill to establish new and enhanced 

treatment programs for post traumatic stress disorder and substance abuse disorder with a special regard for the treatment of 

veterans who suffer from these co-morbid conditions. 

It would also provide VA new authority to treat OEF/OIF veterans and their families for combat readjustment problems. 

We appreciate the emphasis in section 201 of the bill which includes provisions for peer counseling and outreach, requires VA 

referral and coordination with the Office of Rural Health, while ensuring that private providers are properly trained and compliant 

with VA standards. 

However, we continue to have concerns about contracting with 

non-VA providers for specialized PTSD treatment and other combat 

readjustment issues. 

H.R. 4107 is a comprehensive measure aimed at evaluating the 

unique needs of women veterans including those who served in Operations Iraqi and Enduring Freedom and improving VA’s healthcare and mental health services for women veterans. 

This legislation is consistent with recommendations from the research, experts in women’s health, The Independent Budget. And, 

therefore, we support this measure and urge the Subcommittee to 

recommend its enactment. 

H.R. 4204 would require VA to conduct a study on the number 

of veterans’ suicides since 1997. DAV supports this bill, but recommends including other relevant measures in the legislation that 

could help reduce veterans’ suicide as outlined in our written statement. 

H.R. 4231 would establish a 5-year mental health services pilot 

program in seven specific VA networks in which veterans would be 

issued vouchers for private mental health services at VA expense 

for up to 1 year. 

We have a number of concerns about this measure, specifically 

that it lacks contract care coordination features that we believe are 

essential to the protection of veterans’ health and the long-term 

maintenance of veterans’ health services. 

Additionally, under this measure, a veteran who receives care in 

the community without connection to VA loses the many safeguards built into the system for their protection including VA’s 

electronic medical record, evidence-based medicine, patient safety 

programs, and most importantly VA’s expertise in combat-related 

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mental health readjustment services. For these reasons, we cannot 

support this measure. 

As a community, all of us are concerned about rural veterans’ access to care including mental health and readjustment services, especially for our newest generation of war veterans. 

However, DAV wants to ensure that veterans receiving contract 

care through VA are treated in accordance with VA’s internal 

standards of care. 

VA has developed a national mental health strategic plan to deploy new mental health programs, ramp up existing specialized 

services for PTSD and substance abuse treatment, and hire new 

staff. 

Additionally, last year, Congress mandated VA, through its Office of Rural Health, to take specific steps to improve rural veterans’ access to care including assessing fee-basis programs and developing a plan to improve access and quality, meeting mental 

health needs, and conducting an extensive rural outreach program 

to OEF/OIF veterans and their families. 

Implementation of VA’s mental health strategic plan in conjunction with the mandate to the Office of Rural Health should create 

greater access to mental health services for all rural veterans. 

Prior to final consideration of this bill, we urge the Subcommittee 

to request the mandated reports from VA’s Office of Rural Health 

to see what progress has been made thus far. In our opinion, these 

reports should provide essential information on how to best develop 

a comprehensive solution and meet rural veterans’ mental health 

and other healthcare needs. 

Mr. Chairman, that completes my statement, and we thank you 

for the opportunity to testify. 

[The prepared statement of Ms. Ilem appears on p. 38.] 

STATEMENT OF CHRISTOPHER NEEDHAM 

Mr. NEEDHAM. Mr. Chairman and Members of the Subcommittee, the VFW thanks you for the opportunity to testify today. 

There is a wide range of healthcare legislation before us and the 

common theme through most of them is access. VA provides firstrate, high-quality healthcare to thousands of veterans every day, 

but barriers to care remain, whether that is for a veteran living in 

the country far from a VA clinic, for a woman veteran unsure of 

her entitlement to healthcare, or for a wounded warrior suffering 

from TBI who is finding that VA is not yet providing the range of 

treatment he or she needs. 

Today’s hearing addresses some of those barriers and we are generally supportive of all of the bills. Because of time considerations, 

I will limit my remarks to a few of them. Our full comments can 

be found in our written statement. 

The first two bills concern a number of our members. H.R. 3819 

and 4146 would close the loophole that is costing a number of our 

veterans thousands of dollars out of their own pocket for emergency 

care. This especially affects veterans who live in rural areas far 

away from VA clinics. 

Under current law, VA can pay for emergency treatment for a 

veteran who goes to a non-VA facility under certain circumstances 

and must be an enrolled veteran who uses the system and who 

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does not have any other form of insurance. It is a safety net for 

those who otherwise would have no emergency care. 

The wrinkle occurs in that once the veteran is stabilized, he or 

she must be transferred to a VA facility. There have been cases, 

though, where VA is unable to accept the veteran. Maybe VA cannot provide the type of care that the veteran needs or maybe there 

are not any beds available. 

Whatever the reason, when VA refuses to accept a patient, they 

also refuse to pay for the care. This is wrong and defeats the purpose of that safety net. 

We strongly urge the Committee to close this loophole to ensure 

that veterans are not penalized for VA’s inability to adequately 

care for them. 

The VFW urges passage of H.R. 4107, the ‘‘Veterans Emergency 

Care Fairness Act.’’ This comprehensive bill would authorize a 

number of important studies on the healthcare needs of women veterans, especially those returning from Iraq and Afghanistan. 

The current conflict is one of a true front line, exposing all to the 

hazards of combat. The study in section 101 would look at the 

healthcare needs of returning female servicemembers not just for 

the short term but also the long term. With the new type of conflict 

they are facing, it is essential that we stay on top of any potential 

health problems that may arise. 

We also welcome the assessment from section 102 of that bill, 

which would require VA to study barriers to care that may prevent 

women veterans from receiving healthcare on par with what men 

receive. It may be a matter of not enough outreach or substandard 

gender-specific care. Regardless, it is important to find these reasons out so that VA can correct them, especially as the number of 

women veterans continues to rise dramatically. 

Another bill we support is H.R. 2790, which would create a fulltime Director of Physician Assistants at VA’s Central Office. VA is 

the largest employer of PAs in the country with around 1,600 of 

them providing essential care to veterans. Around one-quarter of 

all primary care patients are seen by PAs making them a critical 

component of the healthcare delivery system. 

Because of this, they should have a voice in the process and a 

full-time Director would allow PAs to take part in VA’s strategic 

planning committees. 

Finally, I would make a note on the contracting provisions on a 

few of the bills, notably H.R. 4231 and H.R. 3458. 

It is our goal that VA develops the in-house expertise to provide 

the full range of treatment and recovery for all veterans, especially 

our wounded warriors. These brave men and women are likely 

going to be with the VA for the rest of their lives and the system 

must adapt to their needs. 

VA has made great strides to improve their services, but they are 

not all the way there yet. These men and women cannot afford to 

wait for VA to develop these in-house systems. They need treatment now. 

For that reason, we support the proposals of these bills to contract for care. As always, we would urge strong oversight of these 

programs to ensure that they really are meeting the needs of our 

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veterans and that they are complying with VA’s clinical, safety, 

and privacy protocols. 

Mr. Chairman, this concludes my statement. I would be happy 

to answer any questions you or the Members may have. 

[The prepared statement of Mr. Needham appears on p. 44.] 

STATEMENT OF RICHARD F. WEIDMAN 

Mr. WEIDMAN. Mr. Chairman, thank you for the opportunity to 

appear here today. There are a number of bills, so I will try to 

move very quickly. 

H.R. 2790 addresses a problem that should have been solved by 

VA several years ago. We have great hope that Secretary Peake 

and the new General Counsel are going to change the attitude regarding some laws that they do not like as just cute ideas advanced 

by the Congress and actually follow through in congressional intent 

on statutes put in place that are passed by the Congress and enacted by the President’s signature. 

To make the PA advisor a full-time position in Central Office and 

as part of the strategic planning committees only makes sense. 

One of the places where VA is falling down now and even by 

their own admission is rural healthcare. We know that a great 

number of those serving today come from areas that are not in 

proximity to one of the VA hospitals which generally are located in 

major population centers. 

PAs came about as a profession largely to serve rural areas and 

other underserved communities. And this ought to be exploding as 

opposed to being diminished. 

There are a number of things that we would recommend in addition to early passage of this legislation. First is to end what is often 

a hostile work environment toward PAs not just at the national 

level, but at the local level and ensuring that they are on the VA 

committees and on par with nurse practitioners. 

Secondly, that their scope of practice be no less than that which 

is accorded in the United States Army and the other military services. In many cases, it is more narrow at the VA. 

And the third thing is to create a scholarship program for returning Navy corpsmen and Army medics to become PAs in the VA system. It is akin to the nursing scholarships. It needs to be done. It 

needs to be done now with a nationwide effort in order to utilize 

these extraordinary experiences of these men and women who have 

served in combat and served well. 

VVA strongly supports the bill as written, but urges that you 

take some additional steps here, Mr. Chairman. 

H.R. 3458 is the pilot program for the provision of traumatic 

brain injury care. Something has to be done in order to serve these 

rural vets when it comes to TBI. But I would join the DAV and my 

colleagues at the table in making sure that we do not contract out 

and then that is it, that these people are competent, that they 

know how to deal with veterans and other problems. It is not uncommon for people who have TBI to have PTSD at the same time, 

which may or may not be diagnosed. 

In terms of the numbers of people, last May, there was a survey 

done out at Fort Carson and they found 19 percent of OIF/OEF returnees had undiagnosed TBI. These were not people in med halls 

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or in the hospital. These were just troops in the Garrison. So it is 

a huge problem and we do need to follow through with it. 

We would, however, suggest that you make a number of changes 

to require frequent substantive input by the veterans service organizations as part of the legislation, frequent reporting to this Committee and other accountability mechanisms to ensure that this 

does not go awry. 

Often good ideas get twisted and we would bring to your attention Project Hero having to do with the effort to rationalize the contracting out of care. 

H.R. 3819, the ‘‘Veterans Emergent Care,’’ just makes great 

sense and we are very much in favor of ending what is often an 

ugly, protracted, and unsuccessful effort on the part of veterans 

who have to use emergency service not in VA in order to get reimbursed or face financial ruin. 

H.R. 4053, the ‘‘Mental Health Improvement Act,’’ we are very 

much in favor of. A lot of the problems at VA, however, we would 

point out have been, in mental health in particular, have been because they do not have the organizational capacity and the resources in order to do what is done and, therefore, cause distortion 

in the system. 

The distortions in the system and the reduction of 10,000 physicians post 1996, during the flat-line period 1996 to 1999, caused 

great distortions in the system and nowhere more than in substance abuse. And in substance abuse, some VISNs, it was practically wiped out. And whatever resources they had were shifted 

into primary care for mental class vets. This needs to be restored. 

It is a resource problem in addition to a focus problem. 

And, once again, for any of the legislation that you pass, we encourage you strongly to build in more accountability mechanisms, 

et cetera. 

For H.R. 4107, we are very much in favor of this. We have been 

talking about the need for VA to gear up for women veterans since 

the beginning of the war. We would suggest you make it clear in 

that there has to be a full-time women’s coordinator at each one 

of the VA medical centers across the country. More cases than not, 

it is an ancillary duty. 

Further, there should be expansion at the major medical centers 

who see a good number of women into a free-standing women’s 

clinic. And that will help solve the problem having to do with 

women seeking help for Military Sexual Trauma (MST). Nobody 

knows why anybody goes to the women’s health clinic at Washington, D.C., and that should be the model. And I would encourage 

the Committee Members to visit it. 

The last is H.R. 4146. VVA supports this bill. Excuse me. It is 

not the last. And H.R. 4204. There is a suicide study that VVA has 

informed staff has been done at VA, but it has not been released. 

It is in peer review for publication now, but there is no reason why 

the staff cannot get a confidential briefing and certainly the Members get a confidential briefing on the results of this study done by 

VA. 

In regard to suicide among all veterans or certainly among 

Vietnam veterans, National Vietnam Veterans Longitudinal Study 

(NVVLS) is currently still not done even though it was supposed 

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to be delivered to the Congress 21⁄2 years ago. And we would encourage following through on that because one of the things that 

will show up is the suicide rate of the last generation, major generation of combat veterans and, therefore, give us some sense about 

what is likely to happen in the future with OIF/OEF veterans. 

Our best defense against suicide is a vet center system that is 

more robust than it is today. It is a great system. The Vet Centers 

work, but there is just flat not enough staff. These are our forward 

aid stations and that is where a veteran and/or her family, his or 

her family is more likely to go than to a VA hospital because it is 

in the community. We need to expand the vet center system number of staff. 

There was $17 million provided and a supplemental passed, enacted on March 7th. It did not reach the readjustment counseling 

service until mid-August when it was too late to get anybody onboard much less spend the $17 million, so they spent it on other 

services. 

This is the kind of decision on the part of VA that is simply 

short-sighted and needs to be, if it requires specific legislation to 

require them to come up to a certain Full Time Equivalent (FTE) 

level and readjustment counseling service, then we encourage you 

to do so if, in fact, it will not be reasonable. 

Thank you very much, and I appreciate your indulgence for going 

over time on my summary, sir. 

[The prepared statement of Mr. Weidman appears on p. 49.] 

Mr. MICHAUD. Thank you very much, each of you, for your testimony today. 

As you know, we have been focusing a lot on mental health 

issues, and TBI, and rightfully so. We have several pieces of legislation before us today. 

So I would like to ask each of you what type of legislation would 

you like to see come before the Subcommittee that is not included 

in what we saw today. Is there anything that we are missing? I 

will start with Mr. Wilson. 

Mr. WILSON. Nothing I see at this time, Mr. Chairman. 

Ms. ILEM. I think the measures that are before the Committee 

are some of the most very important things that we are hearing 

about today. And I think it is a good start. I cannot think of anything right offhand that could be added additionally at this time. 

Mr. NEEDHAM. I think I would agree with what Mr. Weidman 

had to say concerning sort of the Vet Centers. I agree with him 

that they do seem to sort of be a really effective tool in terms of 

dealing with mental health. Particularly, I know from reading VA’s 

prepared statements, they were concerned about some of the family 

provisions in some of the bills before us today in discussing how 

they overlap with what Vet Centers are doing. 

We are particularly concerned about some of the effects of mental 

health problems on the families. And so if Vet Centers are the way 

to go, then it would definitely be something we would need to take 

a little closer look at. 

Mr. WEIDMAN. We ask that you specifically require that the Special Committee on PTSD have VSO access to attend their meetings 

and constituent input on some kind of a basis, and further that you 

follow through on requiring VA to set here to sunshine good govsmartinez on PROD1PC64 with HEARING

22 

ernment standards with the seriously mentally ill advisory committee and that that also, the entire thing, be open. 

Dr. Kussman, his response when we have requested that is that 

they cannot carry on candid discussions with anybody there from 

the outside. Our response back to that is that just means you are 

saying things that you cannot stand in the light of day. 

And, frankly, he should not be saying those things if they cannot 

stand up in the light of day. And so we would request that you take 

those two steps. 

The other thing is something that we have discussed before, sir, 

and that has to do with taking a military history as part of the 

computerized patient treatment record. We have empty promises 

for years upon years and different Under Secretaries and different 

Directors of Clinical Care. 

And in point of fact, the new system that they are designing does 

not have in there the taking of a military history, branch of service, 

when did you serve, where did you serve, what was your Military 

Occupational Specialty (MOS), and what actually happened to you 

and utilization of that through clinical reminders in the diagnosis 

and treatment process. 

If they will not do it on their own within the next very short period of time, then we ask that the Committee pass legislation, 

which incidentally was passed by the House in 2000, that requires 

them to do so. The Senate did not pass it at that time. We have 

talked to the Senate and believe they would be amenable to passing such a provision today. It only makes good sense. 

When you ask any of your constituents, or tell any of your constituents, that when people go to a VA hospital, they do not ask 

completely what did you do in the war, dad, what did you do in 

the war, mom, and use that in the diagnosis and treatment modalities, people look at you blankly and say, but is that not what we 

are paying for. And the answer is yes, that is what we are paying 

for. 

And that is the whole purpose of having a specialized VA system. 

But if you do not take the military history, then you are going to 

miss things like, for instance, TBI, post traumatic stress disorder, 

tropical parasites, and endemic diseases whether it is southwest 

Asia or southeast Asia or Korea, or wherever it might be. 

The point is that the primary purpose of having a separate VA 

hospital is to have a veterans’ healthcare system, not a general 

healthcare system that happens to be for veterans. It is both in the 

long run cost effective, but it is also cost efficient in the long run 

because you will have better diagnoses and treat people. 

Ms. ILEM. Mr. Chairman? 

Mr. MICHAUD. Very good point. Yes. 

Ms. ILEM. If I may, I did think of a couple of things as the discussion continued. One would be touching on the family issues, the 

caregiver issues related. 

I do not think that that is something that has been completely 

fully discussed within the Subcommittee as yet and those that are 

really caring for our most seriously wounded and perhaps some additional services for them and benefits. 

Also, on the mental health side, substance abuse disorder from 

talking to so many OEF/OIF veterans, we believe that is really 

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going to be a critical issue. We would like to hear more from VA 

about, through its mental health strategic plan, number one, what 

is the implementation phase of that plan and how quickly is it 

moving in terms of the substance abuse programs that they have 

promised that they are putting online and ramping up. 

And one last thing was the mild TBI issue. Although there is, 

you know, much care and discussion about the severe TBI and lots 

of bills that have been introduced regarding that issue, the mild 

TBI issue from mental health providers and physiatrists within the 

VA, I believe that that is going to be such a critical piece of the 

undiagnosed milder TBI that is still coming out within mental 

health problems. 

So we would like to see about, you know, what VA is doing in 

terms of its treatment plan, its strategic plan for those veterans 

and to really be able to catch them. Thank you. 

Mr. WILSON. Mr. Chairman, I cannot help but speak on this critical issue as it is progressing very rapidly. On behalf of the American Legion, my concern involves the connection between research 

and the critical divisions within the VA medical center. 

During the American Legion’s 2007 site visits to polytrauma centers, the staff inquired about research being conducted in the area 

of traumatic brain injury. The researcher had no response to the 

question. To be more specific, in one of the main polytrauma centers visited, was a brain research chamber. The researcher was 

asked how their research served the clinic side of the VA medical 

center, still, no response. In conclusion, there should be an inquiry 

to assess whether or not there is complete communication and 

interaction between research and clinical divisions throughout the 

VA medical center system. 

Mr. MICHAUD. Thank you very much. 

Mr. Hare. 

Mr. HARE. Thank you. Nothing, Mr. Chairman. 

Mr. MICHAUD. Okay. Well, once again, I would like to thank each 

of you for your testimony today and look forward to working with 

you as we move forward with these pieces of legislation. 

Mr. WEIDMAN. Thank you, Mr. Chairman. 

Mr. MICHAUD. The last panel today is Dr. Cross who is the Principal Deputy Under Secretary for Health, and he is accompanied by 

Walter Hall who is the Assistant General Counsel. 

I want to thank you, Dr. Cross, for coming here today. I look forward to hearing your comments and to you answering the Committee’s questions. So without any further ado, I will turn it over to 

you, Dr. Cross. 

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

DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS; ACCOMPANIED BY WALTER A. HALL, ASSISTANT 

GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Dr. CROSS. Good morning, Mr. Chairman and Members of the 

Subcommittee, and thank you for inviting me here to present the 

Administration’s views on several bills that would affect the Department of Veterans Affairs. 

smartinez on PROD1PC64 with HEARING

24 

And, of course, joining me today is Walt Hall, Assistant General 

Counsel. 

And I would like to request that my written statement be submitted for the record. 

Mr. MICHAUD. Without objection. 

Dr. CROSS. Given the breadth of issues covered in these bills, I 

will simply highlight a few key issues. We would welcome the opportunity to brief the Committee and provide technical assistance 

on any of the issues that we discuss today including our PTSD, suicide, and outreach programs among others. 

Mr. Chairman, VA strongly supports H.R. 3819. Effective reimbursement or payment of emergency treatment has been an issue 

of longstanding concern to the Department. H.R. 3819 more appropriately resolves important billing issues than does H.R. 4146 and 

properly places the financial onus on the Department. 

VA believes H.R. 4204, H.R. 3458, and sections of H.R. 4107 are 

unnecessary given VA’s current efforts which I would be delighted 

to discuss with the staff. 

Specifically we do not believe the study required in H.R. 4204 on 

veterans’ suicide rates would generate the information that would 

further our understanding of how to effectively screen and treat 

veterans who may be at risk of suicide. In fact, certain requirements mandated by the bill make its implementation unfeasible. 

Similarly, H.R. 3458 is unnecessary as VA has developed and implemented a number of recent traumatic brain injury initiatives 

including programs addressing case management. This bill would 

potentially fragment care for veterans in the greatest need of receiving healthcare in a well-coordinated, continuous manner. 

And since the bill was introduced, each VA facility has established an OIF/OEF case management program for severely injured 

OIF/OEF members. 

VA also created the Care Management and Social Work Service 

to ensure that each VA facility has an appropriate treatment team 

caring for these veterans. 

Mr. Chairman, VA believes the studies recommended in sections 

101 through 103 and sections 201 through 203 of H.R. 4107 would 

prove costly and duplicate current efforts. Regarding Title 1, VA’s 

strategic healthcare group for women veterans already studies and 

uses available data to assess the needs of women veterans and has 

developed a variety of mechanisms already to improve their care. 

For example, VA funds Drs. Donna Washington and Elizabeth 

Yano who were examining access for women veterans and how 

staffing issues impact quality. 

In response to Title 2, VA prepares our clinicians through multiple venues in identifying and treating military sexual trauma, 

utilizing evidence-based psychotherapies for mental health conditions and counseling women veterans in our Vet Centers. 

VA generally opposes H.R. 4053 and H.R. 4231. H.R. 4053 is the 

companion bill to Senate bill 2162, which the Department discussed with your Senate colleagues in October. 

While we appreciate the intent of the bill, we cannot support its 

approach of mandating forms of treatment, treatment settings, and 

composition of treatment teams. 

smartinez on PROD1PC64 with HEARING

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VA does not support the Title 4 of H.R. 4053 because it is unclear how these readjustment and transition assistance services are 

intended to differ from or interact with the readjustment counseling services and related mental health services already available 

to our veterans and their families through our Vet Centers. 

This provision would not effectively enhance current activities 

and has serious potential to create confusion and disruption for 

both VA and for our beneficiaries. 

We strongly oppose H.R. 4231 as presently drafted without exception. A recommendation for a veteran’s receipt of mental health 

counseling services by a non-VA provider should be made only by 

appropriate departmental mental health professionals. This ensures a continuum of care for the veteran, reduces the potential for 

self-referrals or conflicts of interest by participating providers, and 

supports appropriate coordination and oversight of all medical services furnished to the veteran. 

Mr. Chairman, this concludes my prepared statement, and Mr. 

Hall and I are prepared to answer your questions. 

[The prepared statement of Dr. Cross appears on p. 53.] 

Mr. MICHAUD. Thank you very much. 

You heard the testimony of the previous panels and some of the 

discussion about how the VA has done their own suicide study. 

Is that something you are willing to share with the Committee? 

Dr. CROSS. Yes, sir. 

Mr. MICHAUD. And is that complete now or is it—— 

Dr. CROSS. I understand it is being submitted for publication. 

Mr. MICHAUD. Okay. 

Dr. CROSS. But, you know, we can brief you on it. 

Mr. MICHAUD. Okay. Also, Mr. Weidman mentioned the Special 

Committee on PTSD and having VSOs be more involved in the 

process and he talked about the Deputy Secretary as well. 

Why is the VA reluctant to get more involvement and have open 

discussions with the VSOs? 

Dr. CROSS. To tell you the truth, Mr. Chairman, that is a new 

issue for me and I need to go check on it and find out what the 

background is on that. 

But I do want to say this. We meet with our VSO colleagues frequently in small groups, in large groups. We share information. We 

share papers. We have excellent personal relationships in terms of 

the mission that we have to carry out. 

And it is my intent and I believe it is all of our intent to share 

whatever information, to coordinate with them as closely as possible and to do so more than perhaps ever done before. 

Mr. MICHAUD. We also heard, and I agree with the comment, 

about Vet Centers. They do an outstanding job in a lot of the rural 

areas and they deal with a lot of issues of mental health. 

One of the issues that we have heard from VSOs, and a lot of 

the bills that are referred to us are introduced because veterans in 

rural areas are still not getting the healthcare that they need. And 

I think part of it is underfunding of the VA which hopefully the 

last budget will—I know that it definitely will help out. 

What are you doing to make sure that the Vet Centers get the 

resources as quickly as they can to take care of the veterans in the 

rural areas? 

smartinez on PROD1PC64 with HEARING

26 

Dr. CROSS. Here is what we are doing. We are expanding them. 

And I was surprised at the testimony earlier because we are opening more and more Vet Centers, expanding them into other areas. 

We are adding staff to our Vet Centers. 

And by the way, I have a representative from the Vet Centers 

here with me today. And I would recommend that, you know, if 

anyone wants to talk afterwards or at some other time, we can arrange a definitive briefing on that. 

Mr. MICHAUD. I would like to know where you are beefing up the 

Vet Centers with additional staff, what are the vacancies, or if all 

the current positions are filled, as well as the new Vet Centers that 

you are planning to open. A lot of the bills we are seeing, directly 

go back to that particular area. 

Dr. CROSS. Mr. Chairman, we would be absolutely happy to provide you with that. And I would like to highlight that we are adding staff. We are making sure that we have an environment in our 

Vet Centers as welcoming to women veterans. We are adding more 

female staff specifically to our Vet Centers to support that. 

We are changing the very way we construct our Vet Centers to 

make sure that that environment is conducive to both males and 

females. We want them to feel like this is their home and that they 

are welcome there. 

We are expanding. We will get you that list, show you where 

they are at, show you what our plans are. 

[The list of Vet Centers was included in a News Release from the 

Department of Veterans Affairs, dated July 9, 2008, which appears 

on p. 74.] 

Mr. MICHAUD. Great. And it was mentioned this morning when 

you look at the Office of Rural Health and that, as you well know, 

has been a big issue with a lot of us on this Committee, that office 

getting up and running. 

And have they made any reports or any recommendations on 

how we should be moving forward in rural health areas and when 

will those be available for the Committee? 

Dr. CROSS. We are keeping them busy as bees. They are wonderfully motivated. It is a young staff who are very engaged, who consider this their passion, their mission. They are working on papers. 

They are working on proposals. 

What they are doing is very interesting. I wanted to tell you 

their strategic direction. It is not so much to create entirely new 

programs, but what they wanted to do, and this is brilliant on their 

part, is to go look at all the programs that the VA already has and 

to reconfigure some of those programs, to readjust them to better 

serve veterans in the rural environment. So not just start from 

zero, but to take what we have already gotten built from that and 

adjust that to make it more effective for our rural veterans. 

Mr. MICHAUD. And have they come up with any recommendations so far? 

Dr. CROSS. Absolutely. They have drafted plans. They have already been to my office. 

Mr. MICHAUD. And since they have been in your office, have you 

acted upon the plans? 

Dr. CROSS. We are working on acting on the plans, giving them 

money to move those initiatives forward in substantial amounts. 

smartinez on PROD1PC64 with HEARING

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Mr. MICHAUD. I would like to also see exactly what they are recommending if it would be possible. 

Dr. CROSS. Mr. Chairman, we would love to brief you on that. 

Mr. MICHAUD. Because I think that that is a very important 

issue, and a lot of the concerns that we hear as Members of Congress deal with a lack of service or access to that care in rural 

areas. So I think it is very important that we get as much information as possible and that the VA acts upon it, but also one of the 

problems that we see is lack of communication a lot of times that 

causes a lot of problems. And it is important for not only elected 

officials, but also the VSOs, to be involved in the process and that 

they know what is happening out there so we can move forward. 

My last question deals with Mr. Hare’s bill. How can this be effectively accomplished if a Director of Physician Assistant Services 

is not located at the VA’s Central Office? 

Dr. CROSS. We have a PA advisor. He works in a very similar 

manner to our other advisors, for instance, for infectious disease, 

cardiology, podiatry, orthopedic surgery, and so forth. 

We are field based. That was the way it was originally designed 

because we thought it added credibility to the position, that they 

are still engaged in the practice and advise us. 

We did increase his percentage of time that he works with the 

Central Office from half time to three-quarters which is typical for 

what we do with others as well, in the ones I just mentioned. 

Having said that, we are flexible. I would rather that you did not 

mandate this for the following reason: When the current advisor 

who I work with very closely leaves at some point in the distant 

future, we will be recruiting for another advisor. I would like to recruit nationwide and for the best one I can find. 

Quite frankly, sometimes getting people to come and move to 

Washington is a challenge for us. And if I restrict it to those who 

can only come to Washington, we have had people in the past for 

many different positions, not just PAs, say thank you, but no. 

And so I am willing to show flexibility on that, and I understand 

the concern. I understand the concern from the PA group. And I 

met with them personally and I am willing to show some accommodation. 

Mr. MICHAUD. Okay. Thank you. 

Mr. Hare. 

Mr. HARE. Thank you, Mr. Chairman. 

Thank you, Doctor, for coming this morning. I just have four 

questions for you, two regarding H.R. 2790 and then two on 

H.R. 4053. 

What will the cost estimate be for the Director of PA Services if 

you were to include the offset that would come from eliminating 

the PA advisor role? 

Dr. CROSS. It is a relatively small amount. I do not know the 

number offhand. 

Mr. HARE. So it would not be a significant amount of—— 

Dr. CROSS. The money is not an issue. 

Mr. HARE. There are a large number, as you know, of VAemployed PAs that are veterans, some estimates are as high as 32 

percent. And many are active members in the Guard and Reserve 

units and with important military medical experience. 

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I am wondering what is being done about recruitment and retention of this occupation in terms of getting people to come in and 

to do this. 

Dr. CROSS. Let me say right from the start we tremendously 

value our physician assistants. They are part of the team. And our 

current advisor has been in so many meetings, it would be hard to 

count in terms of our policy and particularly those policies relevant 

to what they do and what we all do. 

You noted something earlier. I think you listed the number of 

PAs at 1,600 plus. When I came in, it was upper 1,400 or 1,500. 

We have increased the numbers. I heard somebody say that the 

number had gone down. It is actually going in the other direction 

as I understand it. 

So they are part of the team. We are increasing their numbers 

as we are increasing the numbers for others as well. 

Mr. HARE. Well, maybe if you could just spend a second or two 

talking about how you do the recruitment, I mean in terms of getting people to come in and do these. 

Dr. CROSS. We go out to events. We advertise. We have a group 

in New Orleans, an office there that puts out our announcements. 

Mr. HARE. Just a couple questions on H.R. 4053. A lot of us, I 

mean, you have heard I know a lot of discussion about rural districts and I have a very rural district in west central Illinois. I 

have all or part of 23 counties. 

Could you explain what the VA does when veterans who live in 

rural areas and they have this lack of access to mental health services through the VA, is there something in place to try to be able 

to bring those veterans in and to get the treatment that they need, 

because to be honest with you, I hear that all the time? 

I had instances where veterans were telling me that they have 

to get into a van, and not just for mental health services, but in 

general. Even for a chest x-ray, we have veterans that are going 

21⁄2 hours in a van to get a chest x-ray and having to wait when 

they get there for tremendous periods of time and they just, quite 

frankly, Doctor, give up and say ‘‘I am not doing this again,’’ you 

know, ‘‘I can’t do this.’’ 

So I am wondering if you would maybe be able to tell me, particularly in the mental health area, but also generally how we address this in your opinion. 

Dr. CROSS. I agree with what you said and the premise of your 

statement, I think, is correct. It is a challenge in the rural environment to provide all the medical services that might be needed in 

that environment. 

So here is what we are doing. We have taken rather dramatic action and have much more planned. First of all, you have heard 

about the Office of Rural Health that is helping to organize this. 

But here are some of the things that we have done, and I want you 

to be proud of this because it is an aggressive effort. Lots of time, 

money, people are devoted to this. 

In the past about a year and a half, 2 years, we have added over 

3,700 mental health staff in the VA. I think that is absolutely phenomenal. That includes 147 addiction therapists, 343 psychiatrists, 

720 psychologists, 1,024 social workers. And we are distributing 

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those across the Nation including where we can into the rural environments. 

We are opening more community-based outpatient clinics, and I 

think you are all well aware of those and when we opened them 

because it is quite a big deal. 

But going beyond that, sometimes our community-based outpatient clinics can create satellite sites where they can operate out 

of and we are doing that more and more, part-time places where 

they can get into the smaller communities and address the needs 

of our veterans. 

But two other things I wanted to tell you about particularly. We 

do not want the patient to have to come to the big medical center 

unless they really have to. And one of the things they have to come 

to us most often for is medicine. And so we have arranged to send 

it to their home and we have arranged through the computer process or the phone process so that they can call up and get their refills through that mechanism. 

And we are doing one other thing, which is absolutely wonderfully innovative, secure messaging. We have a pilot project starting 

now and this was really directed at the rural environment, but to 

others as well, but particularly the rural environment, how to get 

a question asked, that information, that personal touch from your 

doctor, your PA, nurse practitioner. 

And we were concerned that e-mail was not secure enough. Secure messaging will allow us to do that. We are starting the pilot 

project. They can submit the question and we will help them get 

the answer back. Better than a phone system because when you 

call up, you have to go through the phone system. The doc might 

not be available right at that time. The doc might call them back 

later. The patient might not be home at that time. 

This will work much better, I think. And so many more of our 

people, our veterans now have some form of computer access, either 

in the home or in a library nearby where they might be able to use 

this. 

There are so many things that we can do for the rural environment. I think we should be excited about this. We should see this 

as an opportunity and grab hold of it. And we have lots of ideas 

that we can talk to you about on this. 

Mr. HARE. Thank you, Doctor. 

Thank you, Mr. Chairman. 

Mr. MICHAUD. Dr. Snyder. 

Mr. SNYDER. Thank you. I am sorry I was late. The Armed Services Committee was having a hearing going on at the same time. 

But I just had one general question as I have flipped the material. It seems like we have several instances here in your discussion of some of these bills’ proposals in which you feel that the 

veterans healthcare system is already providing the services. 

Do you think that we have a gap in the awareness that Committee Members have or are we aware of gaps in our own particular areas that generally you do not see across the country or 

are we not spending enough time just trying to understand everything that you all have going on in this dynamic situation? We are 

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stan with, you know, the number of wounded and folks we are 

treating, counseling. 

Where do you think the gap is as you see members, good faith 

members, good members coming forward with bills that you do not 

think that there is a need for? Where do you all see the gap? 

Dr. CROSS. I really appreciate that question because that is exactly how I feel and many of us because Congress has been good 

to us, and the Administration has been good to us, in terms of getting us more resources and doing more things in the past several 

years. 

Let me give you an example, and this is why I am so anxious 

to volunteer, that we and my staff gathered here today have times 

outside the hearing to meet with your staff to explain some of this 

in great detail because we are doing many things that often we do 

not have time to really express in the hearing environment. 

On the Women’s Health Act, for instance, so many of these 

things we think are great ideas and really support them except we 

are already doing them. I’ll give you an example. 

The proposal for a long-term study on health. Well, we started 

it in 2007. It is a VA initiated, 10-year longitudinal epidemiological 

surveillance on the mortality and morbidity of OIF/OEF veterans, 

including women veterans. With the interest of Congress, we are 

quite willing to also expand the sampling that we do in regard to 

women veterans. And they said that we should go out and look 

at some of the gaps or services that we provide to women veterans. 

Well, we agree and we are already doing it. The VA contracted 

for a national survey of women veterans in fiscal year 2007, a 

structured survey based on a pilot survey originally conducted in 

VISN 21. We will examine the barriers to care and the access to 

care and we will include women of all areas of service and include 

veterans who never even utilize VA care. 

Just two examples. When I read through these proposals, I 

thought, well, many of these are good ideas except, and particularly 

in the TBI, we are already there. In some cases, the proposal here 

was to do things, which is actually less than we are anticipating 

doing on our own. 

One of the proposals was in regard to a $50 million expenditure 

related to PTSD. Our mental health enhancement fund last year, 

which was heavily for PTSD and heavily for substance abuse and 

similar things, was $307 million. 

So I would really appreciate the opportunity to show what we 

have done recently because some of these things may not have 

caught up with general knowledge as to what we are doing. And 

I think that we should be proud of that. 

Mr. SNYDER. Thank you. 

Thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you very much. 

Just a couple of quick questions. I know you are going to provide 

the position counts, what have you, for the Vet Centers. But for the 

Office of Rural Health, are all those positions filled in that particular office? 

Dr. CROSS. I think there is a GS14 coming in 2 weeks that we 

are waiting for. 

Mr. MICHAUD. Okay. Now, then they will be completely filled? 

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Dr. CROSS. Well, we just started the office in, you know, really 

September officially, although we were working on it before. I expect the office will change and expand. 

Mr. MICHAUD. You mentioned a longitudinal study, and I know 

we have heard quite a bit from the Vietnam Veterans of America 

as far as their longitudinal study that has never been completed. 

Do you know where that is in the process? Does the VA plan to 

move forward with that study? 

Dr. CROSS. Truthfully, Mr. Chairman, I am not an expert on 

that. I would rather get my experts together and give you a detailed briefing rather than try and wing it in this environment. 

Mr. MICHAUD. I appreciate that because I am sure we will be 

hearing more about that study again. So I would like to know and 

try to move it forward if at all possible. 

So, once again, I would like to thank you very much, Dr. Cross, 

for coming in today, Mr. Hall. I look forward to the followup answers to our questions. Look forward to working with you as we 

move forward in making sure that our veterans of this great Nation of ours are taken care of in a timely and an appropriate manner. So, once again, thank you for your testimony. 

The hearing is adjourned. 

[Whereupon, at 11:32 a.m., the Subcommittee was adjourned.] 

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A P P E N D I X 

Prepared Statement of Hon. Michael H. Michaud, 

Chairman, Subcommittee on Health 

I would like to thank everyone for coming today. 

Today’s legislative hearing is an opportunity for Members of Congress, veterans, 

the VA and other interested parties to discuss recently introduced legislation within 

the Subcommittee’s jurisdiction in a clear and orderly process. 

I do not necessarily agree or disagree with the bills before us today, but I believe 

that this is an important process that will encourage frank discussions and new 

ideas. 

We have eight bills before us today. 

I look forward to hearing the views of our witnesses on these bills before us. 

I also look forward to working with everyone here to improve the quality of care 

available to our veterans. 

f 

Prepared Statement of Hon. Jeff Miller, 

Ranking Republican Member, Subcommittee on Health 

Thank you, Mr. Chairman. 

I appreciate your holding this legislative hearing to start the New Year. 

Currently we have over 265,000 servicemembers deployed overseas in the Global 

War on Terror. These men and women and their families expect and should know 

that when they return home their service and sacrifice will be honored and supported with benefits and health care services tailored to meet their needs. 

Today we will look at eight different bills that have been introduced to improve 

the way we deliver health care to our Nation’s veterans. 

I want to thank my colleagues who have brought forth these legislative proposals 

and for joining us to provide testimony on their respective bills. 

The first bill on the agenda, H.R. 2790, would elevate the Physician Assistant Advisor position Congress established seven years ago to a full-time Director of Physician Assistant Services. It was introduced in a bipartisan manner by Phil Hare and 

Jerry Moran. The Physician Assistant profession has a strong relationship with the 

military, as it originated with medical corpsmen who wanted to transform their 

military medical training into the civilian health care field. And, it is important that 

we encourage VA to foster the recruitment and retention of these important health 

care providers. 

Two bills we will consider, H.R. 3819 and H.R. 4146, would amend current law 

to clarify VA requirements for the reimbursement and payment of emergency medical care for veterans in a non-VA medical facility. A veteran enrolled in VA health 

care should never be subject to post-emergency treatment costs for any emergency 

health related situation and I strongly support a legislative change to correct any 

ambiguities that exist in current law. 

We will also consider a number of bills that seek to create new authorities for 

new programs, research and studies for veteran patients with a traumatic brain injury; mental health concerns, including PTSD and substance use disorder; and to 

meet the specialized needs of women veterans. The Fiscal Year 2008 Consolidated 

Appropriations Act provided VA with significant new funds targeted to addressing 

the provision of care for these emergent needs. As we examine these measures, it 

is important that we keep in mind the importance of developing solutions that are 

principle centered, patient centered and complement rather than replicate existing 

authorities and ongoing efforts. 

I look forward to a very productive discussion on legislation that would ensure 

our wounded warriors receive the best and most advanced medical care that is 

available. 

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Again, I thank all of our witnesses and those in the audience who have chosen 

to participate in today’s hearing. 

Thank you, Mr. Chairman, I yield back my time. 

f 

Prepared Statement of Hon. Stephanie Herseth Sandlin, 

a Representative in Congress from the State of South Dakota 

Good morning, Chairman Michaud and Ranking Member Miller. Thank you for 

holding today’s hearing. I appreciate having the opportunity to be here to discuss 

the Women Veterans Health Care Improvement Act. 

The Women Veterans Health Care Improvement Act (H.R. 4107), which I introduced on November 7, 2007, along with Rep. Brown-Waite, will expand and improve 

Department of Veterans Affairs health care services for women veterans, particularly those who served in Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF). 

I would like to thank the DAV for their support in helping craft this important 

legislation. I would also like to thank the VFW for their endorsement of the bill. 

As you know, more women are answering the call to serve, and more women veterans need access to services that they are entitled to when they return. With increasing numbers of women now serving in uniform, the challenge of providing adequate health care services for women veterans is overwhelming. In the future, these 

needs will likely be significantly greater with more women seeking access to care 

and a more diverse range of medical conditions. 

In fact, more than 1.7 million women nationally are military veterans. More than 

177,000 brave women have served our Nation in Iraq and Afghanistan since September 2001 and nearly 27,000 are currently deployed in these wars. 

By August of 2005, 32.9% of women veterans who had served in OEF/OIF had 

received VA health care. By the end of the following year (2006) that number had 

increased to 37%. As the VA compiles the final data for 2007—the percent is expected to have increased again. 

And according to the VA, the prevalence of potential PTSD among new OEF/OIF 

women veterans treated at VA from fiscal year 2002–2006 has grown dramatically 

from approximately one percent in 2002 to nearly 19 percent in 2006. 

So the trend is clear, but not surprising: More women are answering the call to 

serve . . . and more women veterans need access to services that they are entitled 

to. Clearly, we must do everything we can from a public policy standpoint to meet 

this new challenge of women veterans. 

The Women Veterans Health Care Improvement Act calls for a study of health 

care for women veterans who served in OIF and OEF, a study of barriers to women 

veterans seeking health care, enhancement of VA sexual trauma programs, enhancement of PTSD treatment for women, expansion of family counseling programs, 

establishment of a pilot program for child care services, establishment of a pilot 

program for counseling services in a retreat setting for women veterans, and the 

addition of recently separated women veterans to serve on advisory committees. 

The VA must ensure adequate attention is given to women veterans’ programs so 

quality health care and specialized services are available equally for both women 

and men. I believe my bill will help the VA better meet the specialized needs and 

develop new systems to better provide for the health care of women veterans— 

especially those who return from combat, who were sexually assaulted, or who need 

child care services. 

Chairman Michaud and Ranking Member Miller, thank you again for inviting me 

to testify. I look forward to answering any questions you may have. 

f 

Prepared Statement of Hon. Shelley Moore Capito, 

a Representative in Congress from the State of West Virginia 

Good day, Chairman Michaud and Ranking Member Miller and the members of 

the Subcommittee. I want to first take this opportunity to thank you sincerely for 

holding this hearing on this Veteran’s TBI pilot program bill. In doing so you are 

demonstrating to our brave men and women in the Armed Services your commitment and concern for their well-being. You are also demonstrating to the American 

people, and your constituents that you are sincere about upholding the promise 

made to these young men and women by their country. 

As the Subcommittee is already aware Traumatic Brain Injury has become one 

of the signature injuries of the Middle Eastern theatre of the War on Terror. TBI 

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is a multifaceted injury with a wide range of severity and a wide spectrum of symptoms. Many sufferers require in-home care and extensive treatment and rehabilitation. 

Symptoms of mild cases of TBI include persistent headaches, ringing in the ears, 

sleep disturbances, and chronic dizziness. In the more severe cases symptoms of TBI 

include loss of consciousness, personality changes, seizures, slurred speech, debilitating weakness or numbness in the extremities, loss of coordination, increased confusion, restlessness, and/or agitation. Many returning veterans also suffer from 

PTSD which commonly accompanies TBI. These symptoms can compound duress, 

and will also complicate recovery. 

You may recall the story of a Sergeant David Emme, of the U.S. Army. Sergeant 

Emme’s convoy came under an IED attack. Emme suffered a textbook case of TBI. 

Although he was conscious on and off for 10 days after the attack he could not recall 

what happened until he woke up at Walter Reed after having been transferred from 

Iraq. What Emme suffered could be likened to the recovery of a stroke victim. He 

had to relearn names, and redevelop cognitive abilities like talking. Emme noted 

being horribly confused and disoriented during the first few days of his recovery in 

which he confused nurses and doctors for CIA agents. 

According to the Defense and Veterans Brain Injury Center, in just 2003 TBI comprised up to 20% of all surviving casualties. I will remind you 2003 saw the fewest 

U.S. military deaths in Iraq (486 deaths) and saw little over half the deaths of the 

next most violent year (822 deaths in 2006). We can only conclude that this percentage has increased with the prominence of IED attacks as the preferred method of 

attack of insurgents. 

As of January 5th, according to the Department of Defense, 28,870 members of 

the Armed Services have been wounded in Iraq. Twenty percent of that number is 

5,774, therefore at an absolute minimum almost 6,000 returning veterans suffer 

from some form of TBI. 

Currently the VA only has four treatment centers that specialize in treatment for 

battle related TBI: Richmond, VA, Tampa, FL, Minneapolis, MN, and Palo Alto, CA. 

In June of 2006 the National Rural Health Association gave testimony on the need 

for intensive treatment for geographically isolated veterans suffering from TBI. The 

testimony also emphasized the importance of Community Based Outreach Centers 

and local care facilities in providing the intensive treatment needed to overcome 

TBI. 

What my bill proposes is a five year pilot program run by the Secretary of the 

VA with the Office of Rural Health. The program will be run in five States selected 

by the Secretary. For the VA hospitals in these five States case managers will be 

assigned to any recovering TBI sufferer receiving treatment at a VA facility. In carrying out the pilot program, the Secretary is directed to provide training at Department of Veterans Affairs medical facilities located in the selected States for the case 

managers who are assigned to individuals diagnosed with TBI. 

The Secretary will also coordinate with non-Department medical facilities located 

in the selected States to provide the appropriate training necessary to manage the 

rehabilitation and treatment of TBI sufferers. Also the Secretary must determine an 

appropriate ratio of TBI patients to each case manager to ensure the patients receive proper and efficient treatment. 

For a State in which no Department of Veterans Affairs medical facility is easily 

accessible, the Secretary can enter into a contract with a private health care provider located in that area for which the provider will be reimbursed. The Secretary 

is responsible for reporting to those providers the most recent and up to date information on the TBI patients they are treating. 

Finally, the Secretary of Veterans Affairs shall submit to Congress an annual report on the pilot program. 

In summation I would like to express my gratitude to the committee for allowing 

my testimony today, and for the opportunity for H.R. 3458 to be considered before 

the U.S. Congress. Again, I would like to acknowledge the committee’s observation 

of the valiance and the sacrifices of the armed services. I am convinced by your actions that at heart you do have the best interests of veterans. 

f 

Prepared Statement of Hon. Leonard L. Boswell, 

a Representative in Congress from the State of Iowa 

Chairman Michaud, Ranking Member Miller and Members of the Committee, I 

would like to thank you for inviting me to speak before you today and for holding 

this hearing over many important pieces of veteran’s health legislation. 

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Some say suicide is an epidemic which is sweeping through our veteran population. For too long suicide among veterans has been ignored; now is the time to 

act. We can no longer be afraid to look at the facts and a sad fact is we are missing 

adequate information on the number of veterans who commit suicide each year. 

I was shocked, as I am sure many of you were, when I saw a CBS Evening News 

report focusing on veteran’s suicide. They found that in 2005 over 6,200 veterans 

committed suicide—120 per week! The report also found that veterans were twice 

as likely to commit suicide as non-veterans. These statistics are devastating. 

However, the data collected did not come from the Department of Veterans Affairs, but rather from individual States. That is why I introduced H.R. 4204, the 

Veterans Suicide Study Act to direct the Secretary of Veterans Affairs to conduct 

a study on the rate of suicide among our Nation’s veterans. It is imperative we have 

the facts on this terrible problem if we are to effectively treat our veterans as they 

return home. 

While I’m pleased that the Joshua Omvig Veteran Suicide Prevention Act is now 

law, we need to continue to get all the facts on suicide among our veterans in order 

to better treat them as they return home. I implore this Committee and Congress 

to act swiftly on H.R. 4204 so we can ensure we have the data we need to treat 

our Nation’s heroes. This is an issue important to veterans and their families in 

Iowa and across our great Nation. 

I would again like to thank members of this Committee for allowing me the time 

to speak and your diligence on this matter. I would be happy to answer any questions you might have. 

f 

Prepared Statement of Joseph L. Wilson, Deputy Director, 

Veterans Affairs and Rehabilitation Division, American Legion 

Mr. Chairman and Members of the Subcommittee: 

Thank you for this opportunity to present The American Legion’s views on veterans’ health care legislation being considered by the Subcommittee today. The 

American Legion commends the Subcommittee for holding a hearing to discuss 

these important and timely issues. 

H.R. 2790, a bill to elevate the Physician Assistant (PA) Advisor to the VA’s 

Under Secretary for Health to a full-time director, located in the VA’s 

central office 

P.L. 106–419 required the Department of Veterans Affairs (VA) to establish a PA 

(Physician Assistant) Advisor to advise on such PA issues as qualifications, clinical 

privileges, and scope of practice. Prior to the enactment of the law in 2000, VA had 

never had a PA advisor and the absence of a knowledgeable resource to advise on 

these issues resulted in unnecessary restrictions on PA ability to provide medical 

care to the veteran population. In the years since the PA advisor position was put 

into place, the VA PA population grew from 1,195 PAs to nearly 1,600 PAs—a 34- 

percent increase. 

The VA’s choice to implement the PA advisor provision as a part-time, field position has resulted in inconsistencies across VA medical facilities in their utilization 

of PAs. In one instance, the American Association of Physician Assistants was informed that a local facility determined that a PA could not write outpatient prescriptions, despite licensure in the State allowing prescriptive authority. Other PAs 

report that VA medical facilities will not hire PAs. 

The Senate Appropriations Committee report on the Department of Veterans Affairs has included language recommending that the position be strengthened. In the 

2002 report, the Senate expressed concern about the Veterans Health Administration’s (VHA’s) limitation of the PA advisor to a part-time position and encouraged 

the VHA to implement a full-time PA advisor in or around Washington, DC. Additionally, the Senate report urged the VHA to provide sufficient funding to support 

the PA advisor position. 

Although The American Legion has no specific official position on this issue, we 

believe VA should do everything in its power to improve access to its health care 

benefits, to include providing adequate funding to support programs within the 

VHA, as well as establishing and maintaining an immediate accessible, relative continuum between VA Central Office (VACO) and VA medical centers and its attachments throughout the VHA. 

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H.R. 3458, a bill to direct the Secretary of Veterans Affairs to carry out a 

pilot program on the provision of traumatic brain injury care in rural 

areas 

This bill directs the Secretary of Veterans Affairs to carry out a five-year pilot 

program, in five rural States, under which the Secretary trains and then assigns 

a specific VA case manager to each veteran diagnosed with traumatic brain injury 

(TBI), who is receiving care in a VA medical facility within that State. 

The American Legion favors the intent of this bill to create a pilot program that 

would train and assign specified VA case managers for veterans diagnosed with TBI 

and residing in rural areas; however, we would encourage the implementation of 

this program to every venue nationwide, thereby ensuring across-the-board quality 

and adequate healthcare. 

H.R. 3819, Veterans Emergency Care Fairness Act of 2007 

This bill would require the Secretary of Veterans Affairs to reimburse veterans 

receiving emergency treatment in non-VA medical facilities for such treatment until 

such veterans are transferred to VA medical facilities, and for other purposes. 

The American Legion supports provisions to allow VA to pay for emergency room 

care at non-VA facilities. We believe this would prevent any delays in treating lifethreatening injuries or illnesses for veterans not in close proximity to a VA facility. 

H.R. 4053, Mental Health Improvements Act of 2007 

This bill seeks to improve the treatment and services provided by the VA to veterans with post-traumatic stress disorder (PTSD) and substance use disorders, and 

for other purposes. 

Section 102 seeks to require the Secretary of VA to ensure that the following 

services be available at each VA medical center and Community-Based Outpatient 

Clinic (CBOC): short-term motivational counseling, intensive outpatient care, detoxification and stabilization, relapse prevention, ongoing aftercare, opiate substitution 

therapy, outpatient counseling, and pharmacological treatments to reduce the craving for drugs and alcohol. The American Legion believes this action would heighten 

assurance of continuous and consistent treatment to veterans nationwide. 

Section 103 would require VA to ensure concurrent treatment for a veteran’s substance use disorder and co-morbid mental health disorder by professionals proficient 

in treating substance use and mental health disorders. The American Legion has 

always held the position that veterans who succumb to alcohol or drug abuse caused 

by their service-connected disability are entitled to a level of compensation that reflects all aspects of their disability. 

Section 104 seeks to mandate Vet Centers as an avenue to house peer outreach 

programs to re-engage veterans of Operation Enduring Freedom/Operation Iraqi 

Freedom (OEF/OIF) who aren’t able to attend appointments for PTSD or substance 

use disorder. In this effort, The American Legion urges the Congress to authorize 

sufficient funding for programs, such as the aforementioned to adequately treat veterans suffering from PTSD and the effects of substance abuse. 

Section 105 would require the VA to establish no less than six national centers 

of excellence on PTSD and substance use disorders, to provide comprehensive inpatient treatment and recovery services to veterans newly diagnosed with these disorders. While The American Legion applauds results that would be invoked by section 105, we also request that these centers of excellence be adequately placed to 

ensure veterans residing in rural areas of the country have access to treatment as 

well. 

Section 106 seeks to require the VA to review all of its residential mental health 

care facilities, to include domiciliaries. This section includes an assessment of the 

aforesaid facilities, along with supervision and support provided throughout the 

entire Veterans Integrated Services Network (VISN); an assessment of the appropriateness of rules and procedures for the prescription and administration of medications to patients in such residential mental health care facilities; the ratio of staff 

members at each residential mental health care facility to patients at such facility; 

a description of the protocols at each residential mental health care facility for handling missed appointments; and recommendations by the VA for improvements as 

well. 

The American Legion supports this section’s request to provide up-to-standard inhabitable facilities, as well as adequate staff to ensure continuous and quality care 

for veterans. 

Section 107 would provide for Title 1 of this bill to be enacted in tribute to Justin 

Bailey, an OIF veteran who died while under VA treatment for PTSD and a substance use disorder. According to the Diagnostic and Statistical Manual of Mental 

Disorders (DSM) IV, PTSD always follows a traumatic event that causes intense 

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fear and/or helplessness in an individual. Typically, the symptoms develop shortly 

after the event, but may take years. Psychological care is considered the most effective means of treatment for PTSD. In addition to treatment for PTSD, other mental 

health conditions, such as acute reaction to stress and abuse of drugs or alcohol, 

require much attention. 

Due to the increasing numbers of veterans seeking care at VA medical facilities, 

to include those from the Gulf War era and OIF/OEF, The American Legion supports a bill such as H.R. 4053 to further improve treatment and services provided 

by the VA to our Nation’s veterans. The American Legion also supports quality 

treatment and adequate supervision, to include that which would prevent such tragedies as Justin Bailey’s. 

H.R. 4107, Women Veterans Health Care Improvement Act 

This bill seeks to amend title 38, United States Code, to expand and improve 

health care services available to women veterans, especially those serving in OIF/ 

OEF, from the VA, and for other purposes. Section 101 discusses long-term study 

on health of women serving in OIF/OEF. This section would also require VA to adjoin with War-Related Injury and Illness Centers (WRIICs) and contract with outside organizations to conduct an epidemiologic study on the health effects of women 

who served in OIF/OEF. The American Legion concurs with the intent of this section due to the course of action in ascertaining the results of the study, which include collaborating with the Department of Defense (DoD) in acquiring relevant 

health care data, such as pre-deployment health and health risk assessments in conjunction with VA access to the cohort while they are serving in the Armed Forces. 

Section 102 discusses study of barriers for women veterans to health care from 

the VA. The current Global War on Terror illustrates a few deficiencies in services 

provided for women veterans. Participation in OIF/OEF has obligated them to expand their military roles to ensure their own survival, as well as the survival of 

their units. They sustain the same types of injuries as their male counterparts. The 

American Legion supports studies to identify and alleviate barriers that hinder 

quality health care for all veterans, including women. 

Section 103 discusses comprehensive assessment of VA’s women’s health care programs. The American Legion supports assessment of such programs as disease prevention, primary care, women’s gender-specific health care, acute medical/surgical, 

and mental health treatment, domiciliary, rehabilitation and long-term care to ensure ongoing delivery of quality and adequate care to women veterans. 

Section 201 discusses improvement of sexual trauma care programs of the VA. 

The American Legion supports improvement of VA’s sexual trauma care programs, 

to include a comfortable atmosphere, which may encourage full disclosure of the veteran’s traumatic event. 

Section 202 discusses dissemination of information on effective treatment, including evidence-based treatments, for women veterans with PTSD. The American Legion supports the dissemination of information disclosing effective means of treatment for women and all veterans. 

Section 203 discusses ensuring adequate provision of services for women veterans 

at VA Vet Centers. The American Legion supports adequate provision of services for 

women and all veterans at VA Vet Centers. This also includes effective communication with VA medical centers to adequately provide quality treatment for veterans 

requiring more complicated and/or long-term treatment. 

Section 204 discusses a pilot program for childcare for certain women veterans receiving health care from facilities of the Department. The American Legion supports 

programs that allow flexibility for women and all veterans to obtain quality and 

adequate health care within the VHA. 

Section 205 discusses a pilot program for women veterans newly separated from 

service for counseling in retreat settings. It is essential that appropriate treatment 

be provided to veterans who require special needs treatment. 

Section 206 discusses the addition of recently separated women veterans to serve 

on advisory committees. It is essential that advisory committees represent the experiences of all veterans. 

H.R. 4146, to amend title 38, United States Code, to clarify the availability 

of emergency medical care for veterans in non-Department of Veterans 

Affairs medical facilities 

This bill seeks to amend title 38, United States Code (USC), to clarify the availability of emergency medical care for veterans in non-VA medical facilities. Currently, veterans who are diverted to non-VA medical facilities are unfortunately 

overwhelmed with hospital bills incurred from their stay at the respective facilities. 

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Section 1725 of title 38, USC, requires that non-facilities transfer the veteran to a 

VA facility following his or her stabilization. 

However, when there are no accommodations available at a VA medical facility 

and the veteran has to remain at the non-VA facility, he or she incurs the cost of 

the emergency care from that point. Incurring costs for actions out of the veteran’s 

control is inherently unconscionable. The American Legion supports provisions to 

authorize VA to cover the costs of emergency room care at non-VA medical facilities 

for veterans who are required to remain at these facilities due to unavailable space 

at VA medical facilities. 

H.R. 4204, Veterans Suicide Study Act 

This bill seeks to direct the Secretary of VA to conduct a study on suicides among 

veterans. The American Legion receives contact from actual veterans who disclose 

their need for immediate help due to their thoughts of harming themselves. As the 

number of calls to suicide prevention call centers increase, the need for more suicide 

prevention counselors throughout the VHA is warranted. 

The American Legion supports continued studies on suicides among veterans. 

With a proactive stance in mind, we ask that these findings be readily communicated to suicide prevention divisions to increase the prevention of potential tragedies. 

H.R. 4231, Rural Veterans Health Care Access Act of 2007 

This bill creates a pilot program in seven geographically diverse VISNs across the 

country to provide veterans living 30 miles from a VA medical facility staffed by a 

licensed mental health professional with vouchers that can be used as payment in 

full for mental health services at a private, VA approved facility. 

The aim of this bill is to also help veterans who require regular, long-term care 

and who live in areas that don’t allow frequent trips to a VA medical facility. This 

would be especially intended to make counseling for PTSD, drug/alcohol abuse and 

families more accessible. Because treatment for a variety of mental conditions requires regular one-on-one sessions with a professional, we determined, with the 

input of veterans groups, that 30 miles was a reasonable distance. Many veterans 

are disabled or economically disadvantaged, meaning that a weekly trip for counseling appointments would be prohibitive or impossible. Thus, many vets who 

should be in counseling choose to forgo it. 

According to research conducted by the VA, one in five veterans nationwide who 

enrolled to receive VA health care reside in rural areas. The American Legion believes no veteran should be penalized or forced to travel long distances to access 

quality health care because of where they choose to live. Furthermore, all care, to 

include pilot programs, should include outreach to every rural venue in which veterans reside. 

The American Legion favors the intent of this bill to create a pilot program that 

would accommodate veterans residing in rural areas; however, we would encourage 

the inclusion of every VISN across the country, as well as, a more condensed pilot 

program than the above mentioned. 

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 the 

Subcommittee in continuing the enhancement of access to quality health care for all 

veterans. 

f 

Prepared Statement of Joy J. Ilem, 

Assistant National Legislative Director, Disabled American Veterans 

Mr. Chairman and other Members of the Subcommittee: 

Thank you for inviting the Disabled American Veterans (DAV) to testify at this 

legislative hearing of the Subcommittee on Health. DAV is an organization of 1.3 

million service-disabled veterans, and devotes its energies to rebuilding the lives of 

disabled veterans and their families. 

You have requested testimony today on eight bills primarily focused on health 

care services for veterans under the jurisdiction of the Veterans Health Administration (VHA), Department of Veterans Affairs (VA). This statement submitted for the 

record relates our positions on the proposals before you today. Our comments are 

expressed in numerical sequence of the bills. 

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H.R. 2790—To amend title 38, United States Code, to establish the position 

of the Director of Physician Assistant Services within the Office of the 

Under Secretary of Veterans Affairs for Health 

The VA is the largest single federal employer of Physician Assistants (PA), with 

approximately 1,600 full-time equivalent employee (FTEE) PA positions. In the VA 

health care system PAs are essential primary care providers for millions of veteran 

outpatient and inpatient encounters and work in ambulatory care clinics, emergency 

medicine, and 22 other VA medical and surgical subspecialties. 

The passage of the Veterans Benefits and Health Care Improvement Act of 2000 

(P.L. 106–419) directed the VA Under Secretary for Health to appoint a PA advisor 

to that office. Since that time VHA has assigned this duty to a PA as a part-time, 

field-based collateral position, in addition to their local clinical care duties. However, 

this important clinical representative has not been appointed to VHA’s major health 

care strategic planning committees or been fully integrated into VHA policy and 

planning management and health care planning activities. Additionally, the PA advisor has not participated in establishing priorities or policies for the new Office of 

Rural Health, or been utilized for emergency management planning, even though 

36 percent of all VA PAs are veterans or currently serve in the military Reserves 

or Guard forces. These experiences and perspectives of VA’s PA workforce could 

bring vital information to a number of new initiatives for improving veterans health 

care, including services for our newest generation of war veterans returning from 

Operations Iraqi and Enduring Freedom (OIF/OEF). 

The Independent Budget veterans service organizations, including DAV, believe 

that PAs are a critical component of VA health care delivery and urge that the Subcommittee report this bill that would legislatively mandate the Advisor position as 

a full-time Director of Physician Assistant Services within the office of the Under 

Secretary for Health in Washington, D.C. 

H.R. 3458—To direct the Secretary of Veterans Affairs to carry out a pilot 

program on the provision of traumatic brain injury care in rural areas 

This bill would require the VA to establish a five-State pilot program of VA casemanaged traumatic brain injury (TBI) care in rural States, and would provide 

various protections to ensure rural veterans with TBI received sufficient care from 

competent, trained providers, whether in VA facilities or those with which VA contracted to provide necessary specialized services. VA would be required to assign a 

case manager to each TBI patient with a determination of an appropriate ratio of 

patients to each case manager. 

The bill would require the pilot program be conducted in consultation with the 

VA Office of Rural Health established under Public Law 109–461. The bill would 

also require VA to distribute best practice information on the treatment of TBI to 

the VA facilities and private providers that would participate in this pilot program. 

DAV has no objection to this bill since it is consistent with recommendations of 

The Independent Budget. 

H.R. 3819—Veterans Emergency Care Fairness Act of 2007 

This bill would amend the two existing authorities, sections 1725 and 1728 of 

title 38, United States Code, that determine the circumstances in which the Secretary may pay for expenses incurred in connection with an eligible veteran’s authorized emergency treatment in a non-VA facility. 

Under current law VA is authorized to pay for non-VA emergency treatment for 

a veteran’s service-connected disability, a nonservice-connected disability aggravating a service connected condition, any condition of veteran who is rated permanently and totally disabled, or a veteran enrolled in VA vocational rehabilitation. 

However, expenses incurred after the period of medical emergency ends but before 

the veteran can be transferred to a VA or another Federal facility may not be reimbursed. 

If enacted, this measure would require the Secretary of Veterans Affairs to reimburse a veteran for emergency treatment provided in a non-VA facility until such 

veteran is transferred to VA. In addition to applying the prudent layperson definition of ‘‘emergency treatment’’ under both sections, the bill intends to reverse the 

current VA practice of denying payment for emergency care provided to a veteran 

by a private facility for any period beyond the moment at which VA determines the 

veteran can be safely transferred. Specifically, it would amend the definition of reimbursable emergency treatment to include the time when VA or another Federal 

facility does not agree to accept a stabilized veteran who is ready for transfer from 

a non-VA facility, provided the non-VA provider has made reasonable attempts 

(with documentation) to effect such a transfer. 

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The DAV supports the intent of this bill which is in accordance with the mandate 

from our membership and consistent with the recommendations of The Independent 

Budget to improve reimbursement policies for non-VA emergency health care services for enrolled veterans. 

H.R. 4053—Mental Health Improvements Act of 2007 

This measure would establish new program requirements and new emphases on 

existing programs for treatment of post-traumatic stress disorder (PTSD) and substance use disorder—with special regard for the treatment of veterans who suffer 

from co-morbid associations of these disorders. 

Title I—Sections 102–104 of the bill would require VA to offer a complete package 

of continuous services for substance use disorders, including counseling; intensive 

outpatient care; relapse prevention services; aftercare; opiate substitution and other 

pharmaceutical therapies and treatments; detoxification and stabilization services; 

and other services the Secretary deemed necessary, at all VA medical centers and 

community-based outpatient clinics (unless specifically exempted). The measure 

would require that treatment be provided concurrently for such disorders by a team 

of providers with appropriate expertise. This section guides allocation funding to facilities for these new programs, as well as how facilities would apply for such funding. Sections 105 and 106 would require establishment of not less than six new national Centers of Excellence on Post-Traumatic Stress Disorder and Substance Use 

Disorder, that provide comprehensive inpatient treatment and recovery services for 

veterans newly diagnosed with both PTSD and a substance use disorder. The bill 

would require the Secretary to establish a process of referral to step-down rehabilitation programs at other VA locations from a center of excellence, and to conduct 

a review and report on all of VA’s residential mental health care facilities, with 

guidance on required data elements in the report. 

Title II—Section 201 of the measure seeks to make mental health accessibility enhancements. This provision would require the establishment of a pilot program of 

peer outreach, peer support, readjustment counseling and other mental health services for OIF/OEF veterans who reside in rural areas and do not have adequate access through VA. Services would be provided using community mental health centers (CMHC) (grantee organizations of the Substance Abuse and Mental Health 

Services Administration, Department of Health and Human Services), and facilities 

of the Indian Health Service, through cooperative agreements or contracts. This 

pilot program would be carried out in a minimum of two Veterans Integrated Service Networks (VISNs) for a three-year period. Provisions would require the Secretary to carry out a training program for contracted mental health personnel and 

peer counselors charged to provide these services to OIF/OEF veterans. All contractors would be required to comply with applicable protocols of the Department and 

provide, on an annual basis, specified clinical and demographic information including the number of veterans served. 

Title III—Section 301 of the bill would establish a new, targeted research program 

in comorbid PTSD and substance use disorders, and would authorize $2 million annually to carry out this program, through VA’s National Center for PTSD. Title IV— 

Sections 401 and 402 of the measure seek to clarify authority for VA to provide 

mental health services to families of veterans coping with readjustment issues. The 

bill would establish a ten-site pilot program for providing specialized transition assistance in Vet Centers to veterans and their families, and would authorize $3 million to be used for this purpose. Finally, provisions included in the measure would 

require a number of reports on these new authorities. 

Current research highlights that OIF/OEF combat veterans are at higher risk for 

PTSD and other mental health problems, including substance use disorder, as a result of their military experiences. Mr. Chairman, like you, we are concerned that 

over the past decade VA has drastically reduced its substance abuse treatment and 

related rehabilitation services, and has made little progress in restoring them—even 

in the face of increased demand from veterans returning from these current conflicts. There are multiple indications that PTSD and readjustment issues, in conjunction with the misuse of substances will continue to be a significant problem for 

our newest generation of combat veterans; therefore, we need to adapt new programs and services to meet their unique needs. We are especially pleased with the 

provisions pertaining to mental health services for family members. The families of 

these veterans are suffering too, and are the core support for veterans struggling 

to rehabilitate and overcome readjustment issues related to their military service. 

We hope at the same time that previous generations of veterans and their families 

could also benefit from these newly proposed programs and services. 

Although DAV has no approved resolution from our membership calling for a joint 

treatment program for PTSD and substance use disorders, we believe the overall 

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goals of the bill are in accord with providing high quality, comprehensive health 

care services to sick and disabled veterans. Additionally, the bill is consistent with 

recommendations in the forthcoming Independent Budget for fiscal year 2009. Thus, 

with only one exception, stated below, we believe these are very timely provisions, 

and we fully support them. 

Our concern relates to Title II section 201 of the bill. We support the peer counseling concept it would authorize, but we continue to have concerns about contracting with non-VA providers to provide specialized PTSD treatment. 

Although DAV believes that VA contract care is an essential tool in providing 

timely access to quality medical care, we feel strongly that VA should use this authority judiciously. Current law limits the use of VA purchased care to specific instances so as not to endanger the VA’s ability to maintain a full range of specialized 

services for enrolled veterans and to promote effective, high quality care for veterans, especially those disabled in military service and those with highly complex 

health problems such as blindness, amputations, spinal cord injury or chronic mental health conditions. A major concern is that in most cases where VA authorizes 

care to veterans by contract providers VA has not established a systematic approach 

to monitor that care, or consider any alternatives to its high cost, has not analyzed 

patient care outcomes, or even established patient satisfaction measures. For several years, The Independent Budget has recommended VA make major improvements in its contract and fee-basis programs, but VA has yet to make any improvement. 

DAV wants to ensure that all veterans receiving care from VA or through its fee 

basis or contract programs are treated in accordance with VA’s standards. In its 

2001 report, ‘‘Crossing the Quality Chasm: A New Health Care System for the 21st 

Century,’’ the Institute of Medicine (IOM) put forward six aims that now underpin 

the standard of care for U.S. providers. The IOM aims are that health care will be 

safe (avoiding errors and injury), effective (based on the best scientific knowledge), 

patient-centered (respectful of, and responsive to patient preferences, needs and values), timely (reduced waiting time and harmful delay), efficient (avoiding waste), 

and equitable (unvarying, based on race, ethnicity, gender, geography, or socioeconomic status). VA embraces the IOM aims and therefore should manage rural 

veterans’ health care issues in a way that addresses all of the aims collectively. 

VA also lacks an integrated approach to address the unique health care challenges of rural veterans, including OEF/OIF veterans living in rural areas. To remedy the gaps, VA should identify an effective and creative approach to make health 

care—including mental health care—available to our newest generation of wartime 

veterans irrespective of their locations of residence. VA should develop performance 

measures and quality standards to assess the care that is provided through contract 

or fee-basis arrangements. DAV believes that reform in rural, remote and frontier 

VA care can be achieved with the same overarching principles that have accompanied the transformation of the Veterans Health Administration (VHA) over the 

past decade. Necessary actions to achieve this reform would include: 

• Issuance of clear VHA policy that local facilities and Networks, through their 

mental health leadership, are responsible for creating a VHA-sponsored system 

that provides a stipulated array of services reasonably accessible to as many 

rural veterans, including OEF/OIF veterans as possible who need these services. 

• Provision of direct services wherever VHA has a large enough concentration of 

veterans needing such services, and has an existing VHA site of care. This 

would require VA to upgrade access to marital counseling and develop brief 

interventions for substance abuse—services that VHA does not make easily accessible in even some of its largest facilities. 

• Contracting for care where there is not a large enough concentration of veterans 

needing readjustment counseling services, after local and Network leadership 

assess the availability and quality of alternative service providers (e.g. Vet Centers, State veterans services), including the availability and quality of services 

which could be purchased in the community, and assuring that a full array of 

services is made readily available. 

• Oversight by Congress of this policy, with evidence that it is coordinated with 

the VHA Office of Mental Health Services and the newly established Office of 

Rural Health. 

Mr. Chairman, VA has received significant new funds targeted to providing better 

access to mental health services to all enrolled veterans. VA has developed a national Mental Health Strategic Plan to deploy several new mental health programs, 

ramp-up existing specialized mental health services and hire new staff. VA should 

rapidly deploy those plans then determine the degree of unmet need in rural areas. 

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In that connection, in Public Law 109–461, sections 212 and 213, Congress mandated VA to take specific steps to develop innovative and successful programs to improve care and services for veterans who reside in rural areas; assess its fee-basis 

health care programs; and, develop a plan by September 30, 2007 to improve access 

and quality of care, including measures for meeting the mental health needs of veterans residing in rural areas. VA was also required by that Act to report to Congress not later than March 30, 2007 on the VA community-based outpatient clinics 

(CBOC) and other access points identified by the Capital Asset Realignment for Enhanced Services (CARES) May 2004 decision document, and to coordinate that report through the Office of Rural Health. Finally, VA must conduct an extensive outreach program to OIF/OEF veterans who reside in rural communities in order to 

enroll those veterans in VA health care during the existing two-year enrollment period after their release from active duty. In carrying out the program the Secretary 

is required to work with State agencies, community health centers, and rural health 

clinics, to increase awareness of veterans and their families about the availability 

of health care services provided by VA. 

Again, we recognize and appreciate the emphasis placed on peer counseling, outreach and ensuring that non-VA providers are properly trained and compliant with 

VA standards, and coordination with VA’s Office of Rural Health in this provision. 

As a community everyone is very concerned about rural veterans access to health 

care—including mental health and readjustment services, especially for our newest 

generation of OEF/OIF veterans. We ask the Subcommittee to request the above 

noted reports from the Office of Rural Health to see what progress VA has made 

in addressing the needs of rural veterans. This information will provide essential 

information on how to best develop a comprehensive solution and meet the health 

care and mental health needs of this population. 

H.R. 4107—Women Veterans Health Care Improvement Act 

Mr. Chairman, women veterans are a small but dramatically growing segment of 

the veteran population. The current number of women serving in active military 

service and its reserve and Guard components has never been larger and this phenomenon predicts that the percentage of future women veterans who will enroll in 

VA health care and use other VA benefits will continue to grow proportionately. 

Also, women are serving today in military occupational specialties that take them 

into combat theaters and expose them to some of the harshest environments imaginable, including service in the military police, artillery, medic and corpsman, truckdriver, fixed and rotary wing aircraft pilots and crew, and other hazardous duty assignments. VA must prepare to receive a significant new population of women veterans in future years, who will present needs that VA has likely not seen before 

in this population. 

Title I, sections 101–103 of the bill would authorize and mandate longitudinal 

studies by VA in coordination with the Department of Defense (DoD) to evaluate 

the needs of women who are currently serving, and women veterans who have completed service, in OIF/OEF. Also, VA would be required to study and report existing 

barriers that impede or prevent women from accessing health care and other services from VA. Thirdly, this title would require VA to make an assessment of its existing health care programs for women veterans and report those findings to the 

Congress. 

Title II, sections 201 and 202 would make improvements in VA’s ability to assess 

and treat women who have experienced military sexual trauma (MST), and would 

mandate the use of evidence-based treatment practices and methods in caring for 

women veterans who suffer from post traumatic stress disorder (PTSD) related to 

MST and/or combat exposure. The Secretary would be required to ensure appropriate training of primary care providers in screening and recognizing symptoms of 

sexual trauma and procedures for prompt referral and require qualified MST therapists for counseling. Under this authority the Secretary would also be required to 

provide Congress an annual report on the number of primary care and mental 

health professionals who received the required training, the number of full-time employees providing treatment for MST in each VA facility, and the number of women 

veterans who had received counseling, care and services associated with MST. 

Section 203 and 204 would require a study on the adequacy of care and counseling 

for women veterans in VA’s existing Readjustment Counseling Service, through its 

Vet Center programs, and would authorize a pilot program of childcare reimbursement for certain women veterans to ensure they are able to avail themselves of VA’s 

existing mental health and other specialized health care programs. Section 205 

would establish a pilot program of counseling in retreat settings for recently discharged women veterans who could benefit from VA establishing offsite counseling 

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to aid them in their repatriation with family and community after serving in war 

zones and other hazardous military duty deployments. 

Mr. Chairman, this comprehensive legislative proposal is fully consistent with a 

series of recommendations that have been made in recent years by VA researchers, 

experts in women’s health, VA’s Advisory Committee on Women Veterans, The Independent Budget, and DAV. Therefore, we support this measure and urge the Subcommittee to recommend its enactment. 

H.R. 4146—To amend title 38, United States Code, to clarify the availability 

of emergency medical care for veterans in non-Department of Veterans 

Affairs medical facilities 

Although less comprehensive, this bill is intended to achieve the same purpose as 

H.R. 3819, discussed above, to provide equity of reimbursement to veterans who receive emergency health care services through private providers under VA eligibility. 

DAV holds similar views on both bills, and therefore, supports the merit of this bill. 

While supporting the intent, we believe this bill may not offer a complete remedy 

to the conditions which prompted its introduction. Therefore, we recommend the 

Subcommittee defer action on this bill and instead favorably report H.R. 3819. 

H.R. 4204—Veterans Suicide Study Act 

This bill would require VA, in coordination with DoD, State public health offices 

and veterans agencies, and veterans service organizations, to conduct a study and 

report to Congress the number of veteran suicides that have occurred since 1997. 

Given DAV’s testimony on this topic at the full Committee’s hearing on December 

12, 2007, we support the need for a study of suicide in the veteran population; however, DAV recommends the language of the bill be amended to include other relevant measures that could help reduce veterans’ suicides, specifically—information 

about risk factors—including age and gender, combat service and co-morbid medical 

and behavioral health conditions. 

VA should also invest in translational research on how to improve clinical techniques to prevent suicidal behaviors. Another area VA should address is the impact 

on families (including parents) after a veteran or military servicemember commits 

suicide and what these families may need in terms of continued mental health counseling and care, or other VA or DoD services. Currently neither VA nor DoD knows 

very much about impact on these families post-suicide, and to our knowledge no rigorous studies have been undertaken. 

Most importantly, suicidal behavior can be controlled and monitored with readily 

available access to quality psychiatric care for those who may be at risk because 

of a variety of mental health conditions. Mental health professionals and suicidologists are well informed about techniques and treatments that can reduce suicidal 

behavior (most often a prelude to suicide attempts), including attentive primary 

health care and mental health screening, good psychological health care, early intervention in substance misuse or abuse, addressing of relationship and interpersonal 

problems, reduction in risk-taking behavior, crisis intervention, protective hospitalization, etc. 

While DAV supports the need for data on suicide in the veteran population and 

appreciates the intent of this measure, we hope the Subcommittee will consider 

making amendments to this bill to address some of these additional needs. 

H.R. 4231—Rural Veterans Health Care Access Act of 2007 

This bill would establish a five-year mental health services pilot program in seven 

specific Veterans Integrated Service Networks (VISNs), in which veterans in need 

of mental health services, but who reside at least 30 miles from a VA medical facility that employs a full-time mental health professional, would be issued vouchers 

by VA to receive private mental health services at VA expense. Vouchers would expire six months after issuance but could be renewed for an additional six months 

on request of a veteran, if deemed appropriate by the Secretary of Veterans Affairs. 

VA would be required to maintain a list of participating private providers, including 

family counseling providers and a contractor’s participation would hinge on agreement to accept VA’s vouchers as payment in full. While the program would expire 

five years after commencing, the Secretary would be required to recommend whether the program should be extended or expanded at the time. 

We have a number of concerns about this bill. The Independent Budget is clearly 

on record as opposed to vouchering, privatization and other initiatives that could endanger VA’s capabilities and lack contract care coordination aspects that we see as 

essential to the delivery of high quality care for veterans and the long-term maintenance of veterans’ health services. 

Sick and disabled veterans need a strong and vibrant VA system, one that offers 

specialized services for the kinds of serious injuries and chronic illnesses endemic 

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to that population. Congress has historically agreed with this premise and in consequence authorized VA to build and sustain its specialized programs in spinal cord 

injury, blindness, prosthetics and sensory aids, amputation care and rehabilitation, 

and, importantly in this instance, care for the seriously mentally ill and other disabled war veterans with mental health readjustment issues including PTSD. We are 

sympathetic to the plight of veterans residing in remote and rural regions, but we 

believe the type of vouchering program envisioned by this bill lacks the essential 

component of VA-managed care coordination. We believe VA’s Offices of Mental 

Health Services and Rural Health should identify unmet needs in mental health 

within the rural veteran population, then fashion programs or solutions to meet 

those needs. As stated previously in this testimony, Congress has provided VA resources to hire thousands of new mental health providers, and VA has informed us 

that over 3,500 have in fact been hired to date. These new employees, and a multiplicity of new VA mental health programs, and the mandate to the Office of Rural 

Health should create greater access to mental health services for rural veterans. We 

ask the Subcommittee to provide oversight and to request from VA its strategic plan 

to outreach and provide services to OIF/OEF veterans and other veterans living in 

rural areas. 

We also call to your attention that under the bill, the decision on whether an eligible veteran would be in need of mental health counseling would be made by a ‘‘certified mental health professional’’ with no requirement that VA make or confirm 

that determination. We believe access to care and its quality, quantity and safety, 

should be closely controlled and monitored by VA. We are also concerned about the 

intent of the provision in section 3, subsection b(4) of the bill, that states an eligible 

veteran would need to ‘‘reside[ ] at least 30 miles from a medical facility of the Department of Veterans Affairs that employs a full-time mental health professional’’ 

(emphasis added). We interpret this provision to mean that if a veteran lives within 

30 miles of a VA medical facility, and that clinic or medical center only has a parttime mental health professional, or more than 30 miles from a VA facility with a 

full-time mental health professional, the veteran would be eligible to seek care 

through the proposed voucher system without regard to whether that VA facility 

were able to provide an appointment in a timely manner. If a qualified VA provider 

is unable to provide the service a veteran needs, VA should make a determination 

that veteran’s need for care dictates the use of a contract provider. In any case, we 

believe VA should identify an appropriate contract provider and make a prompt referral. However, we believe, to ensure a veteran has access to VA’s full range of 

services, VA should always remain that veteran’s care manager. 

Mr. Chairman, DAV appreciates the opportunity to provide this written statement 

for the record and present our views on these bills. I will be pleased to respond to 

any questions you or other Subcommittee Members may have. 

f 

Prepared Statement of Christopher Needham, Senior Legislative Associate, 

National Legislative Service, Veterans of Foreign Wars of the United States 

Mr. Chairman and Members of the Subcommittee: 

On behalf of the 2.4 million men and women of the Veterans of Foreign Wars of 

the U.S. (VFW) and our Auxiliaries, I am pleased to be before you providing the 

organization’s views on an array of health care legislation. 

The majority of the bills before us today revolve around a central theme: access 

to care. Whether a rural veteran, a female veteran, or one of our heroic wounded 

warriors, there are gaps in the Department of Veterans Affairs’ (VA) ability to provide first-rate care. The bills under consideration today aim to close those gaps, ensuring that all of our veterans are adequately cared for, which is a goal that all of 

us certainly share. 

H.R. 2790 

This legislation would create a full-time Director of Physician Assistant Services 

to report to the Under Secretary of Health with respect to the training, role of, and 

optimal participation of Physician Assistants (PA). We are pleased to support it. 

Congress created a PA advisor role when it passed the Veterans Benefits and 

Health Care Improvement Act of 2000 (P.L. 106–419). The law required the appointment of a PA advisor to work with and advise the Under Secretary of Health ‘‘on 

all matters relating to the utilization and employment of physician assistants in the 

Administration.’’ Since that time, however, the Veterans Health Administration 

(VHA) has not appointed a full-time advisor, instead appointing a part-time advisor 

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who serves in the role in addition to his or her regularly scheduled duties while 

working in the field, far from where VA makes its decisions. 

The current PA advisor role is likely not what Congress envisioned when it created the role, and the PA advisor has had little voice in the VA planning process; 

VA has not appointed the PA advisor to any of the major health care strategic planning committees. 

With the role that PAs play in the VA health care process, it only makes sense 

to invite their participation and perspective. VA is the largest employer of PAs in 

the country, with approximately 1,600. They provide health care to around a quarter 

of all primary care patients, treating a wide variety of illnesses and disabilities 

under the supervision of a VA physician. Since they play such a critical role in the 

effective delivery of health care to this Nation’s veterans, they should have a voice 

in the larger process. We urge passage of this legislation and the creation of a fulltime PA Director position within the VA Central Office. 

H.R. 3458 

The VFW is certainly supportive of the intent of this legislation, which would create a pilot program to care for veterans suffering from traumatic brain injuries 

(TBI) in rural areas. 

It is clear that VA needs to do a better job caring for our wounded warriors, especially for those who transition from the polytrauma rehabilitation centers, but also 

for those who suffered, but did not stay at those specialized clinics. As we learn 

more about TBI, we are also finding that veterans can suffer from it without having 

any apparent physical injuries, meaning there are likely larger number of veterans 

suffering from mild or moderate TBI—diagnosis can come later, but only if VA properly screens the veteran. 

We have all seen the television reports and read the heart-wrenching stories 

about wounded warriors falling through the cracks. It is truly shameful that these 

brave men and women have had to suffer. We can and must do better. 

This legislation acknowledges these problems, and works to correct some of them. 

It would create, in five rural States, a pilot program that would provide trained case 

managers to veterans suffering from TBI, and allow VA to contract for care in places 

where VA is unable to meet the demand for care. All are worthy goals. 

We would ask, however, that the Committee be mindful of any potential overlap 

with the Wounded Warrior legislation that has been making its way through Congress as part of the National Defense Authorization. It is our understanding that 

the provisions, which earlier cleared both chambers of Congress, are noncontroversial and that they will likely be a part of any upcoming Defense Authorization bill. 

As always, we would hope that VA would be able to develop the in-house experience to deal with all these problems, and we believe that this should remain VA’s 

ultimate goal. In the meantime, there are hundreds of veterans with a demonstrated 

need who would benefit from the contracting care this legislation would provide. We 

cannot afford to wait; they must receive adequate care as soon as possible. 

H.R. 3620 

The VFW is pleased to support H.R. 3620, the Homecoming Enhancement Research and Oversight Act. This legislation calls for a comprehensive study on the 

physical and mental health care needs of OEF/OIF veterans, produced by DoD, VA 

and the National Academy of Sciences. 

The study, which would consist of two major phases, would look at the key issues 

and unknowns confronting those who were deployed overseas as part of OEF/OIF. 

It would include a study of the effects of multiple deployments, the scope of traumatic brain injuries and their effects on the servicemember and his or her family, 

and the long-term impact of other war-related illnesses and disabilities such as posttraumatic stress disorder. Notably, the study would also assess the physical and 

mental health care needs of women veterans. We also appreciate the emphasis this 

legislation would place on families and the effects these illnesses and disabilities appear to have on them. With the large number of citizen soldiers fighting these conflicts, it is only proper to see how all are affected, because it is clear that it is not 

just the man or woman in uniform who suffers. 

A study such as this is essential to allow VA and DoD to properly manage what 

appears to be a crisis in our returning veterans. This assessment would give the 

departments and policy managers a clear idea of what the problems are, allowing 

us to develop plans to treat the disabilities and impairments we are seeing. The 

studies that we have seen have hinted at the problem, and have shown us enough 

to make initial efforts at improving the care of these brave men and women. However, we can and must do more. 

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We must be proactive with our approach, and move forward. Proper study of the 

issues will allow VA and DoD to see if their programs are accurately meeting the 

needs of this deserving population of veterans, and will better allow us to prepare 

for their care into the future. There is plenty that we do not yet know about the 

needs of these veterans, and the more we find out, the better prepared we will be 

to fulfill this Nation’s sacred obligations to her sick and disabled veterans. 

H.R. 3819 and H.R. 4146 

The VFW is pleased to offer our support for these two pieces of legislation that 

deal with an issue important to a number of our members. These two bills would 

close a loophole in current law that causes a number of veterans each year to be 

saddled with expensive hospital bills for care related to emergency treatment. 

Section 1725 of title 38 authorizes VA to reimburse veterans for medical expenses 

related to emergency care at non-VA facilities if the veteran is enrolled and using 

the VA health care system, and if he has no other form of medical insurance. This 

is an important safety net for many veterans who have no other means to pay for 

potentially life-saving care. 

Under that same section, the definitions in (f)(1)(C) create that loophole that 

harms veterans. Current law requires that the non-VA facility transfer the veteran 

to a VA facility when the veteran is stable. However, in areas, where there is no 

suitable VA facility or when the facility is unable to accept the patient, the veteran 

is forced to stay at the non-VA facility and VA makes no payment for that emergency care. In this case, VA’s inability to adequately provide the care the veteran 

needs ends up costing the veteran thousands of dollars out of his or her own pocket, 

something that is unconscionable. Clearly, this unfair policy punishes veterans unfortunate enough to live in areas where no VA facilities are available or able to accept a veteran. The policy punishes them for something that is no fault of their own. 

Both bills amend that section and close the loophole. H.R. 3819 goes a step further. It mandates that the Secretary provide reimbursement by striking the ‘‘may 

reimburse’’ from section 1725 (a) and replacing it with ‘‘shall reimburse.’’ This would 

eliminate any potential for a weakening of the policy. H.R. 3819 also would amend 

section 1728 of title 38 to specify emergency care as a medical expense eligible for 

reimbursement to certain categories of service-connected veterans. While we support 

the concept, we would note that the Committee should carefully consider any 

externalities that could pop up from replacing ‘‘such care or services’’ with ‘‘emergency treatment,’’ especially when section 1728(a)(1) already specifies that reimbursement is for ‘‘such care or services [that] were rendered in a medical emergency.’’ 

With that in mind, we would urge the Committee to swiftly approve legislation 

that would close this loophole so that VA can properly reimburse those veterans who 

would be unfairly penalized by the current law. 

H.R. 4053 

The VFW is happy to support the Mental Health Improvements Act, comprehensive legislation that aims to improve the level of mental health services that VA provides, especially with respect to PTSD and substance abuse disorders. This legislation acknowledges and aims to improve the treatment of what is sadly a growing 

problem among veterans, especially OEF/OIF veterans. As the findings of the bill 

note, a 2005 DoD study found a 23% rate of Active Duty personnel who acknowledge 

a significant problem with alcohol use. 

Title I of the bill focuses on substance use disorders, especially in conjunction with 

PTSD and other mental health issues. It would require VA to provide treatment— 

including counseling, therapy, and detoxification services—for substance use disorders at each VA medical center and community-based outpatient clinic, although 

it gives the Secretary the authority to decide if services are not needed at a particular location. 

Additionally, it would provide funding for services to veterans suffering from 

PTSD with substance use disorders. Notably, it would allow VA to conduct these 

services in concert with peer groups, but also families. This flexibility would allow 

VA to develop a program that best works for individual veterans, adapting it to the 

veteran’s particular needs for the most effective results. 

The legislation would also create six new centers of excellence within VA to address PTSD and Substance Use disorders. These centers would provide comprehensive inpatient treatment for those veterans most in need of help with these sometimes-debilitating diseases. We are especially appreciative of the proposal to require 

the creation of a referral process for when veterans are ready to leave the centers. 

This could help to eliminate the possibility of a veteran falling through the cracks, 

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ensuring that the veteran really does receive the additional care that they would 

need to recover and return to normal life. 

The VFW also supports section 201 of the legislation, which would create a new 

pilot program of peer outreach and support to help provide readjustment counseling 

and other mental health services. With respect to the peer outreach and support, 

we believe that these types of therapies and support are often preferable to certain 

veterans. They may appear to be less formal and more casual, a style that may be 

conducive to more effective results among some veterans. We would hope that the 

results from the pilot program would lead to improvements in VA’s overall mental 

health and readjustment programs. 

Section 201 would also authorize VA to provide mental health care to veterans 

in rural areas through contracts awarded by the newly created Office of Rural 

Health. While ultimately, the VFW would like to see VA have the ability and capacity to provide the full continuum of care to all veterans within its systems, we support this measure as it fills a critical gap in service to those veterans who truly need 

it. We would urge, however, that VA and Congress provide strong oversight of these 

programs to ensure that they really are meeting the needs of our veterans, and that 

they are complying with all VA privacy and clinical protocols. 

We also support Titles III and IV of the legislation. They would require an indepth study of PTSD and substance use disorders and extend VA’s Special Committee on PTSD through the end of 2012. I would also make a note of the meaningful 

change in section 401 of the bill, which would add marriage and family counseling 

to the list of services VA should offer. As we have seen with the current conflict, 

the range of mental health services veterans suffer from do not just affect the individual, but also their families. We must do better, if not just to help those family 

members who suffer silently outside of VA’s normal range of treatment, but also to 

improve the home life of those veterans suffering, giving them stability and comfort 

in their home life. That stability is critical to the effective treatment of the veteran, 

and anything we can do to improve upon it, is something we must do. 

We thank Ms. Berkley and the members of this Subcommittee who have signed 

on to this bill for supporting it, and we would urge its approval. It could really have 

a meaningful impact upon thousands of veterans suffering from the invisible 

wounds of war. 

H.R. 4107 

The VFW is pleased to offer our strong support for this legislation, which would 

expand and improve upon the health care services provided to women veterans. Female veterans from OEF/OIF are experiencing many types of conflict that previous 

generations did not. They are involved in a conflict with no true frontline and in 

a high-stress situation with almost no relent. 

The difficulties they face, and the level of reported mental health issues that all 

OEF/OIF veterans have is itself a challenge for VA. It is essential that VA’s strategies not be a one-size-fits-all approach, but one that adapts and provides our men 

and women with tailored programs to give them every chance to return to civilian 

life fully healthy. This is especially so for our women veterans, many of whom are 

facing unprecedented levels of stress and conflict, and who, when they return, enter 

a VA that is predominantly used to caring for male veterans. 

VA has made great strides in the care provided to women veterans, but they can 

definitely do more. The Veterans Emergency Care Fairness Act would push VA even 

further along, and would address some of the most critical issues our female veterans face. 

Title I of the bill would authorize a number of studies and assessments as to VA’s 

capacity for care, but also for what the future needs of women veterans will be. Section 101 would create an essential long-term epidemiological study on the full range 

of health issues female OEF/OIF veterans face. This is critical because it is uncharted territory. With increasing numbers of women veterans in a hostile combat 

zone, there are higher rates of exposures and incidents that must be studied so that 

we know what health care issues will come up in the short- and long-term. There 

is much we do not know, and lots of essential information that is necessary to study 

to ensure that VA is meeting their full needs. 

Section 102 would require VA to study any potential barriers to care faced by 

women veterans to determine any improvements that VA must make so that women 

veterans can access the care to which they are entitled. This is especially true of 

those women veterans who choose not to use VA care. Is it because of a stigma associated with VA, a previous bad experience or other reasons? To better prepare for 

the future, VA must know the answers to these questions and we strongly support 

this study. Along those same lines, section 103 would require VA to develop an insmartinez on PROD1PC64 with HEARING

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ternal assessment of the services it provides to women veterans, as well as plans 

to improve where it finds gaps. We, too, welcome this assessment. 

We fully support the sections contained in Title II of the legislation, which deal 

with the improvement and expansion of health care programs for women veterans. 

We especially appreciate the addition of two recently separated female veterans to 

the VA Advisory Committees on Women Veterans and Minority Veterans. 

The VFW supports section 204, which would create a pilot program to provide 

childcare for women veterans receiving health care through VA. This is a terrific 

idea, which has the potential to eliminate a barrier for care, especially for single 

mothers. We note, however, that there are also a number of single fathers who 

would also benefit from the pilot program, but would be prevented from using these 

child care services under the definition of ‘‘qualified veteran’’ in section 204(a)(3). 

The VFW thanks Ms. Herseth Sandlin and Ms. Brown-Waite for the introduction 

of this important bill, and we would urge the Committee to approve it because of 

the difference it could make for our women veterans today, but also for long into 

the future. 

H.R. 4204 

The VFW supports the ‘‘Veterans Suicide Study Act,’’ legislation that would require VA to determine the number of veterans who have committed suicide over the 

last decade. 

VA has made improvements to its suicide prevention programs, improving training for VA staff and employees, and raising awareness of the seriousness and importance of this issue. VA has established a national suicide prevention hotline, and 

hired suicide prevention coordinators at its medical centers. 

Nobody knows the true number of veteran suicides, for a variety of reasons, but 

even just one loss is a tragedy. VA’s Epidemiology Service is using rates from previous conflicts to estimate the rate of suicide among OEF/OIF veterans. Although 

this may provide VA with an acceptable starting point, hard data is going to be 

much more valuable with VA’s efforts to provide truly effective mental health coverage and to improve its suicide prevention efforts. 

Recent studies have shown a demonstrable link between exposure to a combat 

zone and the risk of suicide, most notably in the November 2007 Institute of Medicine report on ‘‘Physiologic, Psychologic and Psychosocial Effects of DeploymentRelated Stress.’’ 

While this legislation would not lead to the direct treatment and care of more veterans, the numbers and information collected by this report could help VA and DoD 

get an accurate picture as to the scope of the problem, and uncover cases and examples that might otherwise go hidden. With the seriousness of this problem and the 

attention we must pay to it, more information is certainly better. The more information available to VA, DoD and Congress, the more prepared we all are to live up 

to this Nation’s responsibilities to care for her veterans. Suicide among our veterans, especially those newly returning from combat, is a tragedy, and we owe it 

to our heroes to do everything in our power to prevent it from ever occurring. 

H.R. 4231 

The VFW supports this legislation, which would create a pilot program to provide 

mental health counseling at non-VA facilities for veterans who live in rural areas. 

One of the challenges VA has faced since OEF/OIF began has been on how to best 

care for those veterans who live in more remote areas, especially with the intensive 

levels of care some of their illnesses and disabilities require. 

This is an issue with no true satisfactory answer, especially as we would prefer 

that VA be able to provide a high level of care to all eligible veterans. As we have 

seen with many veterans who live in rural areas, this is not always feasible. Veterans living far away from VA clinics or medical centers simply have a more difficult time receiving the same level of care that a veteran who lives in a town with 

a clinic receives. The Rural Veterans Health Care Access Act recognizes this and 

takes steps to improve their access to care. 

To achieve this, it creates a 5-year pilot program that allows VA to provide 6- 

month vouchers for enrolled OEF/OIF veterans who live at least 30 miles from a 

VA facility that provides full-time mental health services to receive care with private mental health counselors. We are pleased to see that the counseling services 

include family counseling, since they often suffer from the effects of the veteran’s 

mental health illness, and counseling can increase family stability, which is often 

a critical component in the rehabilitation of these complex mental health illnesses. 

While ideal circumstances would have VA providing this level of care to all eligible veterans, we understand the difficult situation today’s veterans are in. We would 

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hope that VA not rely on contract care to provide these specialized services and that 

the Department continue to make attempts to provide these services, but in the 

meantime, we cannot afford to leave these brave men and women waiting. This is 

the least we can do to make them whole, and to ease their transition back into civilian life. 

As with our support for H.R. 4053, however, we would urge vigorous oversight of 

this contract authority to determine whether veterans are truly being helped and 

that the services VA pays for live up to VA’s clinical, safety and privacy standards. 

Mr. Chairman, this concludes my testimony. I again thank you for the opportunity 

to present the VFW’s views and I would be happy to answer any questions that you 

or the members of the Subcommittee may have. 

f 

Prepared Statement of Richard F. Weidman, 

Executive Director for Policy and Government Affairs, 

Vietnam Veterans of America 

Good morning, Mr. Chairman, Ranking Member Brown-Waite, and distinguished 

members of the Subcommittee on Health. Vietnam Veterans of America (VVA) appreciates the opportunity to testify before you on the eight bills under consideration 

by the Subcommittee. I hope our comments and insights will prove of value to you. 

H.R. 2790, Amends title 38, United States Code, to establish the position of Director of Physician Assistant Services within the office of the Under Secretary of Veterans Affairs for Health. Physician assistants are an extremely valuable resource 

for veterans who use the VA health care system. To ensure that they are properly 

educated and trained, and that they are appropriately utilized in the programs and 

initiatives of the Veterans Health Administration, should be facilitated with the establishment of such a position. Veterans will be well served if the directorship is 

filled with a physician assistant with uncommon vision and competence. 

For too long the Veterans Health Administration (VHA) has essentially been allowed to thwart the clear intent of the Congress, and refuse to properly utilize physicians assistants in the mix of vitally needed health care practitioners at VHA. It 

is worth noting that the VA is the largest single federal employer of physician assistants (PAs) with the exception of the military, with approximately 1,574 full-time 

PA FTEE positions. The VA has utilized PAs since 1969, when the profession first 

started. However, since the Veterans Benefits and Health Care Improvement Act of 

2000 (P.L. 106–419) directed that the Under Secretary of Health appoint a PA advisor to his office, VHA has continued to assign this duty as a part-time field FTEE, 

as collateral administrative duties to their clinical duties. VVA has requested for the 

past six years that this be a full-time FTEE within VHA for six years. Most other 

veterans’ service organizations have made similar requests. 

All such requests have been ignored, and generally met with what can frankly 

only be characterized as condescending disdain if indeed not outright derision. VVA 

points out that this is just one of many instances where the VA ignores the clear 

will of the Congress, and even ‘‘black letter law’’ directing them to do something, 

such as complete the National Vietnam Veterans Longitudinal Study (NVVLS). 

This is the fourth Under Secretary of Health who has refused to establish this 

important FTEE as full time. This is the case despite numerous requests from members of Congress, the VSOs, and professional PA associations. The current Under 

Secretary has maintained this position as a part-time, field-based position with a 

very limited travel budget, and no discernible access to policymaking. During the 

time that the current part-time PA advisor was authorized the number of PAs have 

grown from 1,195 to approximately 1,600 today. Despite the growth, a 34% increase, 

this important clinical representative has not been appointed to any of the major 

health care VA strategic planning committees, has been ignored in the entire planning on seamless transition, polytrauma centers, traumatic brain injury planning 

and staffing, and has not been allowed to participate in rural health care or been 

utilized for emergency disaster planning. 

This is despite the facts that 36% of all VA employed PAs are veterans or currently serve in the National Guard or military reserves. These veterans who are 

also PAs could bring vital experiences with highly dangerous situations to new initiatives for improving veterans’ health care access, particularly in disaster response 

planning and execution. 

PAs in the VA health care system were vital primary care providers for millions 

of veteran encounters in each of he past few years, and PAs work in ambulatory 

care clinics, emergency medicine, and in 22 other medical and surgical subspecialties. VVA believes that PAs are a vital part of VA health care delivery. The PA Dismartinez on PROD1PC64 with HEARING

50 

rector must be included in VA Headquarters Patient Care Services, be full-time 

FTEE in Washington, DC. This needs to be just the first step toward the VHA 

changing the corporate culture that does not value PAs on a par with Nurse Practitioners. We urge Congress to enact H.R. 2790 and fund this FTEE within the VHA 

budget for FY 2009 and to ensure the position is in Washington, DC. 

Frankly, what VVA believes the Congress and the VA should do in addition to 

prompt enactment and implementation of this bill regarding physician assistants is: 

(1) Take steps to dramatically change what is often a hostile work environment for 

PAs in the VHA; and (2) Ensure that the scope of practice of PAs in the VA is at 

least as extensive as it is in the Armed Services; and (3) Create a scholarship program for returning Navy corpsmen (and women) and Army Medics to become PAs 

in the VA system, with active recruiting of the separating and demobilizing Medics, 

and with partnering agreements with affiliated institutions. The seasoned expertise 

of these returning corpsmen (women) and Medics could be vital in the future to assist VA to deliver more effective and efficient services, especially in rural areas. 

VVA strongly supports the bill as written. 

H.R. 3458, Directs the Secretary of Veterans Affairs to carry out a pilot program 

on the provision of traumatic brain injury care in rural areas. While the goal of this 

bill, which calls for a pilot program, is laudable, we believe that the best treatment 

for TBI is to be had in the VA’s polytrauma centers of excellence. Additional treatment ‘‘back home’’ ought to be done by clinicians who can communicate with their 

counterparts at these polytrauma centers. 

Frankly, we need to change the current paradigm of service for TBI and other 

profoundly wounded veterans. While there were many problems with the VA care 

received by seriously wounded veterans during Vietnam, when you were in the VA 

hospital you were literally IN the VA hospital. That is no longer the case, as most 

of the health care at VA is delivered on an outpatient basis, even to those who cannot drive because of TBI or other wounds. The current model, which came out during a recent symposium with prosthetics, depends on an intact nuclear family with 

a spouse (or parent) who can take the veteran to the many medical appointments 

he or she may have in a given week. 

However, it is not always the case that there is an intact nuclear family and a 

stable home situation near to the needed medical services needed by that particular 

veteran to help shoulder this travel expense and burden with the new veteran. The 

‘‘freeze’’ and rule at VA nursing homes and domiciliary facilities leave them unable 

to adequately respond to this need. Perhaps there is need for low cost veterans 

housing units that are near VA medical centers or even constructed on their 

grounds if there is adequate land may be part of the answer. At a hearing before 

the House Committee on Financial Services last month there appeared to be some 

interest in such cooperative models by the Honorable Maxine Waters, a former 

member of this distinguished panel, in crafting legislation that would create such 

housing. Perhaps now is the time to move quickly on the possibility of such a new 

paradigm that would assist new veterans with TBI or other problems, but would 

also solve similar transport problems of other deserving veterans who are dependent 

on the ongoing treatment modalities at a VHA facility. 

We would caution about the use of outside providers of care for this increasingly 

common wound of war. While it does make sense to contract with non-VA clinicians 

in areas where no VA medical center or outpatient clinic is convenient for a patient, 

that outside provider must be certified as able to care for those with this unique 

wound. We do not believe that such clinicians are going to be easy to find. Further, 

as VA has shown with the mishandling of the inaptly named ‘‘Project HERO’’ the 

VHA must be watched like a hawk to keep them from distorting a good idea that 

makes sense. 

Having noted all of the above, VVA still favors enactment of this bill to create 

such a pilot program, but urge that you amend the bill to require frequent substantive input by the VSOs, frequent reporting to this Committee, and other accountability mechanisms to keep this good idea on track toward something that will 

strengthen the matrix of services for these deserving veterans. 

H.R. 3819, Veterans Emergency Care Fairness Act of 2007, amends title 38, 

United States Code, and requires the Secretary of Veterans Affairs to reimburse veterans receiving emergency treatment in non-Department of Veterans Affairs facilities for such treatment until such veterans are transferred to Department facilities, 

and for other purposes. VVA strongly believes that veterans who receive emergency 

treatment in non-VA facilities until they can be transferred to a VA facility should 

be reimbursed for their out-of-pocket expenses. This should not be the onerous, often 

ugly, and lengthy process that it often is today, and which usually results in the 

veteran being stuck with the bill for this emergency care. If they are not among the 

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1.8 million veterans who do not have health insurance, the VA should be able to— 

and does—bill their insurance carrier, which is right and proper. 

VVA supports the bill as written. 

H.R. 4053, the Mental Health Improvements Act of 2007, to improve the 

treatment and services provided by the Department of Veterans Affairs to veterans 

with post-traumatic stress disorder and substance use disorders, and for other purposes is one of the most important bills for your consideration. As more and more 

troops, some disturbed, others shattered by their wartime experiences come home, 

and it is patently and painfully obvious that neither the Department of Defense nor 

the VA have enough medical professionals on staff to meet their needs. The British 

Medical Journal released a study led by DoD researchers this past Tuesday that 

says that at least 1 in 9 returnees have problems with PTSD. Earlier DoD studies 

fount a higher rate. 

VVA has been pointing out the deficiencies in the number of mental health professionals at the Veterans Health Administration (VHA) for almost 10 years, and while 

there has been quite a bit of progress in the level of staffing in the past two years, 

they are still not where they should be, particularly in as to the substance abuse 

staff. Further most VAMC need more full-time mental health professionals as team 

members on the primary care teams (as distinct from the mental health clinic or 

the PTSD teams). We still hear often about veterans referred to the mental health 

clinic or the PTSD team at a VA hospital, only to be referred back to the primary 

health care team because the mental health diagnosis is not their primary diagnosis, and the mental health clinic does not have the resources to properly serve 

them. 

DoD must be taken to task for having discharged some 28,000 servicemembers for 

‘‘personality disorders’’ which allegedly pre-existed their entrance into the U.S. military. To send them off to war, and then to cut them loose because of some phantom 

‘‘preexisting condition,’’ is damnable. It violates the covenant made with these men 

and women when they pledged life and limb in defense of the Constitution of the 

United States. They need the help of health care professionals, not the disapprobation of their superiors and the termination of their enlistment and all the mental 

baggage that goes along with it. Further, the military has done really very little on 

their pledge to change the corporate culture that punishes those who admit to problems with PTSD symptoms to one that gets those soldiers (and their families) much 

needed help. 

VVA went to see Assistant Secretary of Defense for Health about three weeks before the war started to urge they do a better pre-deployment health assessment, including a mental health workup. We also urged that they move to be ready for significant PTSD problems, and that they set up nonpunitive modalities whereby war 

fighters could get help without effectively ending the their military career. Dr. 

Winkenwerder essentially was dismissive of all we had to say, and stated that they 

saw no need to change any of their policies. Unfortunately, we were prescient of 

what was to come, and the deplorable situation that still exists today. As we are 

all aware, DoD’s mistakes and nonperformance becomes the problem of the VA as 

soon as the servicemember is no longer on active duty. 

This bill needs to dovetail with mental health initiatives taken by the VA to ensure that there is no duplication of effort. More importantly, its provisions must 

have the funding needed to be effective. Anything less is unacceptable. 

VVA requests that you modify the provision that mandates the Special Committee 

on PTSD to require that this Committee meet in public, at least to the VSOs and 

other key stakeholders. Our preference would be to require that they have consumer 

representatives meet with the Committee regularly as well. The current Undersecretary refuses to allow VSOs even to attend the Special Committee on PTSD meeting, and continues to conduct their business in secrecy. When asked why his response has been that they need to be able say things they might not say in public. 

VVA’s response has been and is that then they perhaps should not be saying something that cannot stand the light of day. 

In this same vein, VVA urges the Committee to require that the Advisory Committee on (Serious) Mental Illness be public in the sense that the constituent representatives and the VSOs be allowed to attend the entire meeting, even if they are 

participants in the discussion for only a portion of the multi-day meeting. This Committee began to conduct much of their business in secrecy during the reign of Dr. 

Jonathan Perlin after he summarily fired the most senior and respected members 

of that body in what is still known in VHA as the ‘‘Friday Night Massacre.’’ We ask 

that the Congress require this Committee return to the way of business that is in 

keeping with an open and democratic government. 

With the modifications noted, VVA favors passage of this bill. 

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H.R. 4107, the Women Veterans Health Care Improvement Act, amends 

title 38, United States Code, to expand and improve health care services available 

to women veterans, especially those serving in Operation Iraqi Freedom and Operation Enduring Freedom, from the Department of Veterans Affairs, and for other 

purposes should go a long way toward enhancing the health care services offered 

to—and needed by—women veterans. Women now constitute 16–18 percent of our 

Armed Forces. They are being killed and maimed in record numbers. It is vital for 

the VA to gear up to meet their needs now and over the coming decades. 

Beginning a long-term study of the health status of women who served in Afghanistan and Iraq should be an invaluable tool in enabling the VA to assess current 

needs and anticipate future health care needs. And make no mistake: The PTSD 

that affects women is not a carbon copy of that which takes over the psyche of their 

male counterparts. There are other psychological ramifications that we are only now 

beginning to comprehend. 

One would hope that VAMC directors, seeing a spike in the numbers of women 

veterans seeking health care, would gear up to meet their needs. They should not 

have to be prodded by legislation. Several years ago, Sanford Garfunkel, who then 

was the director of the VAMC in Manhattan, saw an influx of veterans with HIV 

and full-blown AIDS. He secured the funding, necessary approvals, and established 

the first ward for veterans with these then-fatal conditions. We know there are 

bright and committed medical center directors today who react to the needs of their 

patients; we would hope that passage of this bill would be of significant assistance 

to them. 

At minimum every VA medical center facility should have a full-time women veterans coordinator who sits on the policymaking council for the hospital, and in the 

larger cities there should be a full free standing women’s clinic, such as is found 

at Washington, D.C. VAMC. 

H.R. 4146, Amends title 38, United States Code, to clarify the availability of 

emergency medical care for veterans in non-Department of Veterans Affairs medical 

facilities. This just seems to make a lot of sense. Amending section 1725(f)(1)(C) of 

title 38 by adding ‘‘. . . with the determination of whether the veteran can be so 

transferred to be based both on the condition of the veteran and on the availability 

of a bed in a Department facility that is no geographically inaccessible to the veteran’’ just makes sense. One has only to wonder why such a provision needs to be 

added into law. 

VVA supports the bill as written. 

H.R. 4204, The Veterans Suicide Study Act, directs the Secretary of Veterans 

Affairs to conduct a study on suicides among veterans is based on two unfortunate 

realities, recognized by Congress: That suicide among veterans is a serious problem; 

and that there is a lack of information on the number of veterans who commit suicide each year. 

Anecdotally, suicide by active-duty troops and recently separated troops seems to 

be surging. DoD has tended to minimize the numbers, tracking only those on active 

duty who take their lives. No one, however, is tracking veterans who, months or 

years after they have reentered the civilian world, are overcome by war-induced demons. 

We doubt very much if truly accurate numbers can ever be arrived at. But the 

VA—and DoD—really do need to try harder and not sniff that the suicide of someone six months removed from Iraq can not be attributed to his/her service over 

there. 

H.R. 4231, The Rural Veterans Health Care Access Act of 2007, directs the 

Secretary of Veterans Affairs to carry out a pilot program to provide mental health 

services to certain veterans of Operation Enduring Freedom and Operation Iraqi 

Freedom. VVA believes that this bill needs some careful treading. While it is of the 

utmost importance that mental health problems be dealt with forcefully and in a 

timely manner, handing out vouchers for mental health services to veterans who reside in rural America is not necessarily the way to go—unless there is close communication with case managers and primary care clinicians at VA clinics and medical 

centers. 

Our concern is that outsourcing a lot of this care can only lead to future difficulties if not carefully and closely monitored. And, to be quite frank, we can envision 

scenarios in which VA managers, rather than hiring the psychologists and psychiatrists they need, rather than ensuring that the Vet Centers are adequately staffed, 

outsource mental health to the detriment of veterans and their families. This must 

be guarded against. 

VA Vet Center Staffing and Suicide Prevention—VVA is very concerned that 

the VA Vet Centers, operated by the Readjustment Advisory Service, have not received additional staffing that is vitally needed. The War Supplemental Appropriasmartinez on PROD1PC64 with HEARING

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tions bill enacted early last March contained $17 million to hire an additional 250 

full-time mental health practitioners at the VA Vet Centers. These funds were not 

released to the RCS until mid-August, when it was too late to even get those staff 

on board before the end of the Fiscal Year, much less fully spend the money on additional personnel. So they bought a new computer system. 

If the Congress wants to do something about the first line of defense against suicide, then forcing the VHA to increase the staffing of the VA Vet Centers is the single most effective action you can take, as well as the most cost effective and cost 

efficient step you can take. The Vet Centers are essentially the forward Aid stations 

to go out and get the wounded and get them into the medical services and treatment 

matrix. The Vet Centers see veterans of every generation who initially would not 

go anywhere near the VA medical center with a mental health or PTSD problem, 

for a variety of societal reason. 

VVA thanks the Subcommittee for permitting us to present our views on these 

vital issues here today. I will be happy to answer any questions. 

f 

Prepared Statement of Gerald M. Cross, M.D., FAAFP, 

Principal Deputy Under Secretary for Health, 

Veterans Health Administration, U.S. Department of Veterans Affairs 

Good morning, Mr. Chairman and Members of the Subcommittee: 

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

eight bills that would affect Department of Veterans Affairs (VA) programs that provide veteran health care benefits and services. With me today is Walter Hall, Assistant General Counsel. 

H.R. 3819 Veterans Emergency Care Fairness Act of 2007 

Mr. Chairman, the first bill I will discuss is H.R. 3819. VA strongly supports this 

measure, which would amend sections 1725 and 1728 of title 38 to make mandatory, 

standardize, and enhance our authority to pay expenses incurred when a covered 

veteran receives previously unauthorized emergency treatment in a non-VA facility. 

Those sections are currently discretionary (the Secretary ‘‘may reimburse’’ as opposed to ‘‘shall reimburse’’), cover different veteran populations, and use different 

definitions of ‘‘medical emergency.’’ 

Currently, the Secretary may reimburse or directly pay the reasonable value of 

non-VA emergency treatment of a service-connected disability, a nonservice-connected disability aggravating a service-connected disability, any disability of a veteran with a permanent and total disability, or for a covered vocational rehabilitation 

purpose. When such claims are filed, VA medical professionals must determine 

whether there existed an actual emergency of such nature that delay in obtaining 

treatment would have been hazardous to life or health. Expenses incurred once the 

veteran had been stabilized and could have been transferred safely to VA or another 

Federal facility may not be reimbursed or paid. 

The Secretary may also reimburse or pay for the reasonable value of expenses incurred by a covered veteran for non-VA emergency treatment where the treatment 

is sought for a non-service connected disability. The statutory standard for determining whether the treatment was emergent is whether a prudent-layperson would 

have thought it reasonable to seek immediate medical attention. This prudentlayperson standard means that if it turns out that the veteran’s condition was not 

an actual medical emergency, VA can still reimburse or pay the expenses. This happens, for instance, when a veteran goes to the nearest emergency room believing a 

heart attack is underway but a severe case of heartburn is actually diagnosed. As 

with claims for service-connected conditions, the Secretary is only authorized to reimburse or pay for the reasonable value of the emergency treatment, and the emergency is considered ended at the point the veteran could have been transferred safely to a VA facility or other Federal facility. 

H.R. 3819 would make it mandatory for the Secretary to reimburse or pay for the 

reasonable value of treatment for any veteran who meets eligibility criteria and 

would standardize the programs by applying the prudent-layperson definition of 

‘‘emergency treatment’’ in both situations. Most importantly, it would define ‘‘emergency treatment’’ as continuing until (1) the veteran could have been transferred 

safely to a VA or other Federal facility, or (2) a VA or other Federal facility agrees 

to accept such transfer if, at the time the veteran could have been transferred safely, the non-VA provider makes and documents reasonable attempts to transfer the 

veteran to a VA facility or other Federal facility. While VA facilities work aggressively to accept the transfers once an emergency is stabilized, there have been cases 

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where VA has been unable to find a facility that had the resources needed to furnish 

the care required. In those rare cases, the veteran may ultimately be liable for postemergency costs, imposing a serious monetary hardship. The bill would appropriately foreclose this result. 

Effective reimbursement or payment of emergency treatment has been an issue 

of concern to the Department. H.R. 3819 appropriately resolves important billing 

issues, properly placing the financial onus on the Department to provide appropriate 

care either in the VA or Federal system or at a non-VA facility. 

VA determined funds were available within the FY2008 President’s Budget level 

for this expanded benefit. 

As a technical matter, I would like to clarify that if a veteran currently meets 

the eligibility criteria on which the reimbursement or direct payment claim is based, 

VA invariably pays the claim. Thus, changing the Secretary’s authority from ‘‘may’’ 

to ‘‘shall’’ for purposes of both types of claims would have no practical effect. Nevertheless, we do not object to such a change. 

H.R. 4146 Emergency Medical Care for Veterans in Non-VA Facilities 

H.R. 4146 would also amend section 1725 of title 38 to make clear that the determination as to whether a veteran can be transferred safely to a VA or other Federal 

facility is to be based both on the condition of the veteran and on the availability 

of a bed in a Department facility that is not geographically inaccessible to the veteran. We favor the approach in H.R. 3819, which would make the same definition of 

‘‘emergency treatment’’ apply to claims filed pursuant to both section 1725 and 1728. 

H.R. 4146 would amend only section 1725. As a result, a greater benefit (i.e., VA 

reimbursement or payment of non-VA emergency treatment up until the point in 

time a VA bed is available for the eligible veteran) would be provided to veterans 

with non-service connected disabilities than is available to veterans under section 

1728 for service-connected disabilities, a discrepancy that cannot be justified. We 

therefore prefer the standardization of terms, and increased consistency in application, that H.R. 3819 would provide. 

H.R. 4053 Mental Health Improvements Act of 2007 

Title I. Substance Use Disorders and Mental Health Care 

H.R. 4053 is the companion bill to S. 2162, on which the Department testified before the Senate Committee on Veterans’ Affairs this past October. While we appreciate the attention given to the critical issues addressed in this bill, we cannot support its prescriptive approach of mandating forms of treatment, treatment settings, 

and composition of treatment teams. 

Section 102 would require the Secretary to ensure that, at each VA medical center 

and community-based outpatient clinic (CBOC), available services would include, at 

minimum: short term motivational counseling, intensive outpatient care, detoxification and stabilization, relapse prevention, ongoing aftercare and outpatient counseling, opiate substitution therapy, and pharmacological treatments aimed at reducing cravings for drugs and alcohol. The Secretary could, however, exempt an 

individual medical center or CBOC from providing any of the otherwise required 

services, but the Secretary would have to report annually to Congress on the facilities receiving an exemption, including reasons for the exemption. 

Section 103 would require the Secretary to ensure concurrent VA treatment for 

a veteran’s substance use disorder and co-morbid mental health disorder by a team 

of clinicians and health professionals with expertise treating substance use and 

mental health disorders, in conjunction with other professionals as considered appropriate by the Secretary. 

Section 104 would mandate that the Secretary carry out a program to enhance 

VA’s treatment of veterans suffering from substance use disorders and PTSD 

through a competitive allocation of funds to VA facilities. Funding awarded to a 

facility would be used for purposes specified in the bill, such as peer outreach 

programs through VA’s Vet Centers to re-engage veterans of Operation Enduring 

Freedom/Operation Iraqi Freedom (OEF/OIF) who miss multiple appointments for 

post-traumatic stress disorder (PTSD) or a substance use disorder. These peer outreach programs would need to be done in tandem with efforts of CBOCs and PTSD 

and substance use disorder treatment teams in VA’s medical centers. Funds would 

also be used for collaboration between VA’s urgent care clinicians and substance use 

disorder and PTSD professionals to ensure expedited referrals and for other specified purposes. 

Section 104 would further require the Secretary to allocate $50 million from appropriated funds available for medical care for each of fiscal years 2008, 2009, and 

2010 to fund these programs; the Secretary would be required to submit a report 

to Congress within the first year regarding the program and the facilities for which 

funding had been allocated. The bill would require the total expenditure for PTSD 

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and substance use disorder programs to not be less than $50 million in excess of 

a specified baseline amount. (The bill would define the baseline as the amount of 

the total expenditures on VA’s treatment programs for PTSD and substance use disorders for the most recent fiscal year for which final expenditure amounts are 

known, as adjusted to reflect any subsequent increase in applicable costs to deliver 

those programs.) 

Section 105 would require the Secretary to establish not less than six national 

centers of excellence on PTSD and substance use disorders, to provide comprehensive inpatient treatment and recovery services to veterans newly diagnosed with 

these disorders. Candidate sites would be restricted to VA medical centers capable 

of treating concurrent PTSD and substance abuse disorders and of providing inpatient care, and located in a geographical area with a high number of veterans diagnosed with both PTSD and substance use disorders. This provision would also require the Secretary to establish a process to refer and aid the transition of veterans 

from these national centers to programs providing step down rehabilitation treatment. 

Section 106 would require the Secretary, acting through the Office of the Medical 

Inspector (OMI), to review all of VA’s residential mental health care facilities, including domiciliary facilities. The OMI report must include a description of the care 

available in residential mental health care facilities in each Veterans Integrated 

Service Network; an assessment of the supervision and support provided in the 

VHA residential mental health care facilities; the ratio of staff members at each residential mental health care facility to patients at such facility; an assessment of the 

appropriateness of rules and procedures for the prescription and administration of 

medications to patients in such residential mental health care facilities; a description of the protocols at each residential mental health care facility for handling 

missed appointments; and any recommendations the Secretary considers appropriate for improvements to residential mental health care facilities. The bill requires 

OMT to submit to Congress a detailed report with these specified findings. 

Section 107 would provide for Title I of this bill to be enacted in tribute to Justin 

Bailey, an OIF veteran who died while under VA treatment for PTSD and a substance use disorder. 

VA does not support enactment of this title. Title I is overly prescriptive and 

would attempt to mandate the type of treatments to be provided to covered veterans, the treatment settings, and the composition of treatment teams. Treatment 

decisions should be based on professional medical judgments in light of an individual patient’s needs, and experienced health care clinicians and managers are in 

the best position to decide how best to deliver needed health care services at the 

local level. It is more consistent with the principles of patient-centered medicine, as 

well as more efficient, to focus on making these services available to patients who 

require them, as opposed to requiring every VA facility to provide these services. 

We are also concerned that section 104 would require all the competitively funded 

peer outreach services to be furnished through VA’s Vet Centers. This would make 

Vet Centers reliant on the medical centers to provide funding needed to meet the 

peer outreach requirements of this program. Vet Centers generally receive their 

funding apart from the medical centers. And we do not support section 105. VA has 

previously expressed its difficulties with the concept of centers of excellence as opposed to the achievement of an overall standard of delivery of excellent care on a 

national basis; this provision is also overly restrictive and prescriptive. I refer you 

to the concerns VA has previously expressed regarding disease-specific treatment 

centers and models. Finally, section 106 would impose extremely onerous and timeconsuming requirements on the OMI, which would overwhelm that office’s capacity 

to meet its responsibility to oversee and investigate the quality of care furnished 

in all lines of service throughout the VA system—an absolutely vital function within 

the Veterans Health Administration. To meet the mandate, the Department would 

have to expand that office significantly. The OMI should be focused on its general 

mission, not on the narrowly focused duties set forth in section 106. 

Title II. Mental Health Accessibility Enhancements 

Section 201 of H.R. 4053 would require that, within six months after enactment 

of the bill, the Secretary establish a 3-year pilot program to assess the feasibility 

and advisability of providing eligible OIF/OEF veterans, particularly those from the 

National Guard or Reserve, with services including peer outreach and support, specified readjustment counseling, and other mental health services. Eligible veterans 

would include those who are enrolled in VA’s health care system and who, for purposes of the pilot program, receive a referral from a VHA health professional to a 

community mental health center or to a facility of the Indian Health Service (IHS). 

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In providing readjustment counseling services and other mental health services 

to rural veterans lacking access to comprehensive VA mental health services, section 

201 would require the Secretary, acting through the Office of Rural Health, to contract for those services with community mental health centers (as defined in 42 CFR 

§ 410.2) and/or IHS facilities. 

Sites for the pilot must include at least two Veterans Integrated Service Networks 

selected by the Secretary (VISNs). At least two of the sites would have to be located 

in rural areas that lack access to comprehensive VA mental health services. A participating community mental health center or IHS facility would be required, to the 

extent practicable, to provide readjustment counseling and other mental health services through the use of telehealth services. It would also need to utilize best practices and technologies and to meet any other requirements established by the Secretary and would have to comply with applicable VA protocols before incurring any 

liability on behalf of the Department. It would further be required to provide clinical 

information on each veteran treated, as required by the Secretary. 

The Secretary would be required to carry out a national program of training for 

(1) veterans to provide peer outreach and peer support services under the pilot program; and required training for (2) clinicians at community mental health centers 

or IHS facilities to ensure they could furnish covered services in a manner accounting for factors unique to OEF/OIF veterans’ experiences, including combat and military training experiences. This provision would also establish detailed annual reporting requirements for participating centers and facilities. 

Mr. Chairman, all of these services are already available to OEF/OIF veterans, 

including those who served in the National Guard or the Reserves. No demonstrated 

need exists for the pilot program or these additional authorities, which are duplicative of currently existing authorities. It is also unclear to us how the peer outreach 

services to be provided under section 201 relate to the peer outreach program that 

would be established by section 104. 

As to the requirement to contract with a community mental health center or IHS 

facility, VA has previously expressed a concern that imposition of such a requirement may inadvertently reduce the opportunity for a veteran to receive care from 

the most highly qualified contractor. Additionally, it is most often the case that 

when VA lacks capacity to provide mental health services in a certain rural area, 

the same situation exists for the community mental health centers and IHS facilities. IHS facilities, staff, and other resources should be focused on American Indians 

and Alaska Natives. VA and IHS have a Memorandum of Understanding (MOU) 

that provides the appropriate framework for cooperative ventures within the capacities of each of our two agencies, using that MOU and our current flexibilities to 

contract with the most appropriate provider when VA is not able to provide necessary services is the most effective way of assuring that rural veterans get the care 

they need. 

Title III. Research 

Section 301 of H.R. 4053 would require the Secretary, through the National Center for PTSD, to carry out a program of research into co-morbid PTSD and substance use disorder, including coordination of research and data collection and dissemination. The bill prescribes that the research address: co-morbid PTSD and 

substance use disorder; systematic integration of treatment for the disorders; and 

development of protocols to evaluate care of veterans with co-morbid disorders and 

to facilitate the cumulative clinical progress of such veterans. Section 301 would authorize $2 million to be appropriated for each fiscal year 2008 through 2011 to carry 

out this program and specifically require the funds be allocated to the National 

PTSD Center in addition to any other amounts made available to it under any other 

provision of law. 

Section 302 would continue the Special Committee on PTSD (which is established 

within VHA) through 2012; otherwise the Committee’s mandate would terminate 

after 2008. VA strongly supports continuing the Special Committee. 

With the exception of the extension of the Special Committee, VA does not support the provisions in title III. VA is a world-recognized leader in the care of PTSD 

and substance use disorders, particularly when these conditions co-exist. Please note 

that the recent scientific literature review by the Institute of Medicine did not find 

that VA’s treatments for PTSD other than Cognitive Processing Therapy (CP Therapy) and Prolonged Exposure Therapy (EP Therapy) were not efficacious; rather, the 

IOM concluded that the scientific literature did not show that the other therapies 

used by VA met its standard for unequivocally and conclusively demonstrating their 

efficacy in the treatment of PTSD. The activities required by title III are also redundant of VHA’s ongoing efforts, particularly of the research efforts being carried out 

by VA’s National PTSD Center. We would welcome the opportunity to brief the 

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Committee on VA’s achievements and efforts in this area, along with the role of the 

Office of Mental Health in overseeing the PTSD and substance abuse programs. 

Title IV. Assistance for Families of Veterans 

In connection with the family support services authorized in chapter 17 of 

title 38, United States Code (i.e., mental health services, consultation, professional 

counseling, and training), section 401 would amend the statutory definition of ‘‘professional counseling’’ to expressly include ‘‘marriage and family counseling.’’ This 

provision would also ease eligibility requirements for such services by authorizing 

their provision when ‘‘appropriate’’ (as opposed to ‘‘essential’’) for a veteran’s effective treatment and rehabilitation. Section 401 provides for that these services to be 

available to family members in VA medical centers, Vet Centers, CBOCs, or in other 

facilities the Secretary considers necessary. Currently, these family support services 

are restricted to care provided in inpatient care settings. 

Section 402 would require the Secretary to carry out, through a non-VA entity, 

a 3-year pilot program to assess the feasibility and advisability of providing ‘‘readjustment and transition assistance’’ to veterans and their families in cooperation 

with Vet Centers. Readjustment and transition assistance would be defined as preemptive, proactive, and principle-centered, and would include assistance and training for veterans and their families in coping with the challenges associated with 

making the transition from military to civilian life. This provision would require the 

pilot program be furnished pursuant to an agreement between the Secretary and 

any for-profit or non-profit organization the Secretary selects as having demonstrated expertise and experience providing the designated services. The pilot program would be carried out in cooperation with 10 geographically-distributed Vet 

Centers, which would be responsible for promoting awareness of the assistance 

available to veterans and their families through the Vet Centers, the entity selected 

to conduct the pilot, and other appropriate mechanisms. Section 402 would establish 

detailed reporting requirements and authorize $1 million to be appropriated for each 

of fiscal years 2008 through 2010 to carry out the pilot program. Such amounts 

would remain available until expended. 

VA does not support title IV. It is unclear how these ‘‘readjustment and transition 

assistance’’ services are intended to differ from, or interact with, the readjustment 

counseling services and related mental health services already available to veterans 

and their families through our Vet Centers. The provision conflicts in many respects 

with VA’s existing authorities to provide readjustment counseling and related mental health services and creates confusion, especially regarding client outreach, in 

what is currently a highly successful program. (Indeed, the 98-percent rate of client 

satisfaction with the Vet Centers is the highest of all VA’s programs.) 

We also do not understand the implied need for use of a non-VA organization for 

provision of these services. Vet Centers already provide marriage and counseling 

services to family members as necessary to further the veteran’s readjustment. Let 

me assure you that, when necessary, our Vet Centers readily contract with appropriate organizations and providers to ensure veterans and their families receive covered family support services. In sum, this provision would not effectively enhance 

current authorities or Vet Center activities; rather, we see that it has serious potential to create confusion and disruption for both VA and our beneficiaries. 

If the purpose of section 402 is to authorize readjustment and transition assistance services for family members that are other than those required for the veteran’s successful readjustment, we would object. In contrast to the situation with 

veterans, if during the provision of readjustment counseling services, Vet Center 

staff identify a family member’s need for more complex mental health care services 

or other medical care that is not in furtherance of the veteran’s recovery or readjustment, VA can neither refer the family member to a VA facility for such care nor 

refer that family member to a non-VA provider. Consequently, both our Vet Center 

staff and the affected family member would be placed in an untenable position. 

H.R. 4231 Rural Veterans Health Care Access Act of 2007 

Mr. Chairman, VA strongly opposes H.R. 4231, which would require the Secretary 

to implement a 5-year pilot program using a voucher system to pay for mental 

health counseling at non-VA facilities for eligible OEF/OIF veterans. Those eligible 

for this benefit are veterans eligible to receive hospital care and medical services 

under section 1710 of title 38, United States Code, who also: served on active duty 

in support of a contingency operation (as defined in section 101(13) of title 10, 

United States Code); are diagnosed with a mental health condition for which a certified mental health provider recommends mental health counseling; and reside at 

least 30 miles from a VA medical facility employing a full-time mental health professional. 

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Under the pilot program, the Secretary would compile and maintain a list of mental health providers, including family counseling providers, who agree to accept a 

voucher as payment in full for counseling services furnished to the veteran bearing 

the voucher and to accept VA payment at the rates specified in the bill. Providers 

would be required to comply with all applicable VA protocols. H.R. 4231 would also 

permit an eligible veteran to use these vouchers as payment in full for visits to a 

family counseling provider (on the list) if a certified mental health provider or the 

Secretary recommends that the veteran and the veteran’s family receive family 

counseling. 

Once requested by an eligible veteran, the Secretary would be required to issue 

a 6-month supply of vouchers within 30 days. An additional 6-month supply of 

vouchers could be provided. To receive payment under a voucher, following provision 

of mental health or family counseling services, the provider would submit a voucher 

bearing the signatures of the provider and the veteran. 

Prior to the pilot program’s expiration, the Secretary would be required to conduct 

a study of its effectiveness and, based on that study, recommend whether the program should be extended or expanded. If the Secretary determines it should be extended or expanded, H.R. 4231 would authorize the Secretary to take such action. 

VA strongly objects that as now drafted the bill would permit a veteran with a 

diagnosed mental health condition to be eligible for individual and family counseling 

services under the program based on a non-VA provider’s recommendation. Without 

exception, a recommendation for a veteran’s receipt of mental health counseling 

services by a non-VA provider should be made only by the appropriate Department 

mental health professional. This is necessary to ensure a continuum of care for the 

veteran as well as appropriate coordination and oversight of all the medical services 

furnished to the veteran. This would also lessen any potential for self-referrals and 

conflicts of interest by participating providers. 

Second, this bill would result in fragmentation of care. Vouchers would be available only for some types of care (mental health counseling) but the bill does not 

address their possible need for biomedically based mental health services and 

evidence-based psychotherapy. H.R. 4231 could also lead to further barriers in 

integrating mental health services with other components of care and to the delivery 

of evidence-based interventions for mental health conditions. 

The Office of Rural Health (ORH) is currently collaborating across VHA to develop policies and practices that expand and adapt current initiatives, and to develop new models of care delivery that may be most appropriate for rural veterans. 

More importantly, ORH will leverage the VHA’s capabilities to develop partnerships with governmental and nongovernmental entities to provide the best solutions 

to the challenges that rural veterans face and enhance the delivery of care by creating greater access, engaging in research, promulgating best practices and developing sound and effective policies to support the unique needs of enrolled veterans 

residing in geographically rural areas. 

Lastly, we note the bill does not provide any criteria for determining the need or 

scope for family counseling services, whereas, it limits a veteran’s eligibility to counseling services needed to treat the diagnosed mental health condition. 

We further note the distance requirement would not limit this benefit to veterans 

residing in rural areas because those in many urban settings would likewise meet 

this requirement. 

H.R. 2790 Director of Physician Assistant Services 

H.R. 2790 would re-title the position of VHA’s ‘‘Advisor on Physician Assistants’’ 

to ‘‘Director of Physician Assistant Services.’’ This change in position title would appear to raise the incumbent and this discipline to the same level as VHA’s other 

directors and lines of service. The bill would also expand the statutory duties of the 

position to require the incumbent to report to the Under Secretary for Health on 

all matters relating to the education and training, employment, appropriate utilization, and optimal participation of physician assistants within VA programs and initiatives. Finally, it would also require the incumbent to serve full-time and be located with the VA Central Office. 

The current field-based Advisor position was established in 2000 and is successfully meeting the bill’s objectives. Nonetheless, we do not object to the change in 

position title, although we note that physician assistant services do not constitute 

an actual service line. We do object to the provision in the bill that would restrict 

the locus of the position to VA Central Office. VA derives significant benefits from 

having the flexibility to use field-based clinicians in this and similar positions. Often 

the best candidates for such positions do not wish to give up their clinical duties 

entirely and relocate to Washington. It is also valuable for us to keep this position 

as a dual, as opposed to a full-time, role to enhance the incumbent’s effectiveness 

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by maintaining a ‘‘hands-on’’ approach and frontline perspective. We estimate the 

cost of converting this position to one that is full-time would be $34,252 for fiscal 

year 2008 and $413,151 over a ten-year period. 

H.R. 4204 Veterans Suicide Study Act 

H.R. 4204 would require the Secretary to conduct a study to determine the number of veterans who have committed suicide between January 1, 1997, and the date 

of the bill’s enactment. The study would have to be carried out in coordination with 

the Secretary of Defense, Veterans Service Organizations, and State public health 

offices and veterans agencies. The bill would require the Secretary to submit a report to Congress on his findings within 180 days of the bill’s enactment. 

We do not believe the study required by this bill would generate information that 

would further our understanding of how to effectively screen and treat veterans who 

may be at risk of suicide. It would merely provide us with the rates for this cohort 

of veterans. VA has studied suicide rates for multiple cohorts of veterans and, 

through such efforts, has already identified the major clinical risk factors for suicide. (In fact, we recently completed such a study for OEF/OIF veterans that we discussed at a recent hearing before the full House Committee on Veterans’ Affairs.) 

Using the data generated from those studies, we have developed protocols and 

processes to mitigate those risk factors. For these reasons, we do not support 

section 103. 

Further, certain requirements mandated by the bill make its implementation not 

feasible. As now drafted, it would not afford VA the flexibility needed to develop a 

thorough and useful study. To design and carry out a study that is best designed 

to provide usable information to address the issue of veteran suicide rates, we believe the Secretary (not Congress) should determine the organization(s) with which 

the Department should coordinate the study. For instance, CDC currently studies 

suicide rates among the general population, while VA’s role has been to validate the 

information compiled by CDC. 

Additionally the 180-day timeframe is not realistic, as there is currently a 2-year 

time lag in the information released by CDC on suicide rates. We would be glad to 

brief the Committee on study designs we believe would be more feasible and would 

better serve its ends. We estimate the cost of this bill to be $1,580,006 in fiscal year 

2008 and $2,078,667 over a 10-year period. 

H.R. 3458 Pilot Program on Traumatic Brain Injury Care in Rural Areas 

Mr. Chairman, H.R. 3458 would require VA to carry out a 5-year pilot program 

to enhance care to veterans with traumatic brain injury (TBI) in five rural States 

(selected by the Secretary) in consultation with VA’s Office of Rural Health. VA 

would be required to assign a VA case manager to each VA patient diagnosed with 

TBI. The bill would further direct the Secretary to take specific actions in the pilot 

program States, including: 

• Providing training to the assigned case managers, including coordinating with 

non-Department medical facilities, as appropriate, for such training; 

• Determining an appropriate ratio of patients with TBI per case manager to ensure proper and efficient treatment; 

• Seeking contracts with private health care providers in any area where no VA 

medical facility is easily accessible to TBI-diagnosed residents, with the independent contractors to be reimbursed by VA; and 

• Providing updated information on the treatment of TBI to such private health 

care providers as have contracted with VA under the bill. 

We do not support H.R. 3458 because it is not necessary. A number of TBI initiatives have been developed and implemented by VA under current authorities, including programs that address the issue of case management. In determining to provide care directly or by contract, VA considers not only local capacity and staffing 

issues but also the needs of the individual veteran and his or her family. 

In our view, the bill would also establish a troubling precedent by establishing 

contract authority separate from our fee-basis contracting authority in chapter 17 

of title 38, United States Code, for the treatment of a single condition/type of injury. 

These typically are very complex medical cases involving co-morbidities. Treatment 

of TBI and TBI related conditions cannot easily be singled out from other conditions 

requiring simultaneous medical attention. That is, TBI cannot be treated in a vacuum. For that reason the bill has potential to fragment care for the veteran population that most needs to receive its VA health care in a well-coordinated manner 

with continuous monitoring and oversight. We also note the number of eligible veterans covered by the bill is potentially great, because this bill is not limited to TBI 

due to injuries sustained during service in combat operations. 

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Since the time this bill was introduced on August 4, 2007, each VA facility has 

put into place an OEF/OIF case management program for severely injured OEF/OIF 

members. In October of 2007, VA established the Care Management and Social 

Work Service to ensure that each VA facility has an appropriate treatment team 

caring for these veterans (to include a program manager, clinical case manager(s), 

transition patient advocate, and a VBA OIF/OEF liaison). All enrolled severely injured servicemembers receive screening for TBI, and any OEF/OIF veteran who requests case management services may receive them. 

H.R. 4107 Women Veterans Health Care Improvement Act 

Title I. Studies and Assessments of Department of Veterans Affairs Health 

Services for Women Veterans 

In general, Title I of H.R. 4107 would require VA to conduct a number of studies 

related to health care benefits for women veterans. More specifically, section 101 

would require VA, in collaboration with VHA’s War-Related Injury and Illness 

Study Centers, to contract with one or more qualified entities or organizations to 

conduct an epidemiologic cohort (longitudinal) study on the health consequences of 

combat service of women veterans who served in OEF/OIF. The study would need 

to include information on their general, mental, and reproductive health and 

mortality. The bill would require VA to use a sufficiently large cohort of women 

veterans and require a minimum follow-up period of ten years. The bill also would 

require VA to enter into arrangements with the Department of Defense (DoD) for 

purposes of carrying out this study. For its part, DoD would be required to provide 

VA with relevant health care data, including pre-deployment health and health risk 

assessments, and to provide VA access to the cohort while they are serving in the 

Armed Forces. 

Section 102 of the bill would require VA to contract with a qualified independent 

entity or organization to carry out a comprehensive assessment of barriers encountered by women veterans seeking comprehensive VA health care, especially for those 

who served in OEF/OIF. In carrying out this study, the bill recommends VA survey 

women veterans who seek or receive VA health care services as well as those who 

do not. Section 102 would also set forth specific elements to be researched as part 

of the study. They include the following: 

• Perceived stigma with respect to seeking mental health care services. • Driving distance or availability of alternate transportation to the nearest appropriate VA facility on access to care. • Availability of childcare. • Acceptability of integrated primary care, or with women’s health clinics, or both. • Comprehension of eligibility requirements for, and the scope of services available under, such health care. • The quality and nature of the reception by providers of such health care and 

their staff of the veteran. • The perception of personal safety and comfort of women veterans in inpatient, 

outpatient, and behavioral health facilities of the Department. • Cultural sensitivity of health care providers and staff to issues that particularly 

affect women. • Effectiveness of outreach for health care services available to women veterans. • Other significant barriers identified by the VA Secretary. 

Once the assessment is completed, the Secretary would be required to ensure the 

head of the Center for Women Veterans and the Advisory Committee on Women 

Veterans (as well as any other pertinent VA program offices) review the results of 

the study and submit their own findings with respect to it. The Secretary would 

need to include these findings in the Congressional report required under this section. 

Section 103 would require VA to conduct a comprehensive assessment of all VA 

health care services and programs for women veterans. In particular, the assessment would need to address specialized programs for women with PTSD, homeless 

women, women requiring care for substance abuse or mental illnesses, and those requiring pregnancy care. In conducting this study, VA would be required to determine whether effective health care services, including evidenced-based health care 

services, are readily available to and easily accessed by women veterans in areas 

of health promotion, disease prevention and health care. The determination would 

need to be based on the following factors: frequency with which such services are 

available and provided; demographics of the women veterans population; sites where 

such services are available and provided; and whether, and to what extent, waiting 

lists, geographic distance, and other factors obstruct the receipt of any of such services at any such site. 

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In response to the comprehensive assessment, section 103 would further require 

VA to develop a program to improve the provision of health care services to women 

veterans and to project their future health care needs (including mental health care) 

and, particularly, those of women serving in the OEF/OIF combat theaters. In so 

doing, VA would have to identify the services available under each program at each 

VA medical center and the projected resource and staffing requirements needed to 

meet the projected workload demands. 

Section 103 would also require VA to submit, not later than one year after the 

bill’s enactment, a report to the Congress on the conduct of this assessment. The 

Comptroller General of the United States would then be required to review VA’s report and to submit to Congress its own report on the Department’s findings, together with any recommendations for administrative or legislative action. 

Mr. Chairman, we do not believe section 101 is needed because a longitudinal 

study is already underway. Therefore, VA does not support this provision. For several years veterans, VA, and Congress have been concerned with identifying possible 

war-related illnesses among returning women veterans, including adverse effects on 

reproductive health. To that end, in 2007, VA initiated its own 10-year study, the 

‘‘Longitudinal Epidemiologic Surveillance on the Mortality and Morbidity of OIF/ 

OEF Veterans Including Women Veterans.’’ Several portions of the study mandated 

by section 101 are already incorporated into this project; however, to comply fully, 

we will need to increase the number of women veterans in the original longitudinal 

study. We already have a proposal before the Under Secretary for Health to adjust 

the number of study participants accordingly. 

Mr. Chairman, section 101(c) of H.R. 4107 would be objectionable because it requires the DoD to provide health data on active-duty women, as well as ‘‘access to 

the cohort of such women while serving in the Armed Forces.’’ This provision could 

require active-duty women to participate in a VA survey while still in the military. 

It also could require the DoD to provide private medical information before separation. 

Similarly we do not believe section 102 is necessary because a similar comprehensive study is already underway. VA contracted for a ‘‘National Survey of Women 

Veterans in FY 2007–2008,’’ which is a structured survey based on a pilot survey 

conducted in VISN 21. This study is examining barriers to care (including access) 

and includes women veterans of all eras of service. Additionally, it includes women 

veterans who never used VA for their care and those who no longer continue to use 

VA for their health care needs. 

Section 103 would require a very complex and costly study. While we maintain 

data on veteran populations receiving VA health care services that account for the 

types of clinical services offered by gender, we lack current resources to carry out 

such a comprehensive study within a one-year timeframe. We would therefore have 

to contract for such a study with an entity having, among other things, significant 

expertise in evaluating large health care systems. This is not to say that such a 

comprehensive assessment is not needed and we recognize there may well be gaps 

in services for women veterans, especially given that VA designed its clinics and 

services based on data when women comprised a much smaller percentage of those 

serving in the Armed Forces. (Since the fifties, the number of women veterans using 

VA services has averaged between 3–5% of all veterans. With women now representing 5% of all veterans using VA, and 38.9% of OEF/OIF returning women veterans using VA for their health care needs, it is incumbent on us to identify gaps 

in services and in availability of gender-related services.) VA’s Strategic Health 

Care Group for Women Veterans already studies and uses available data and analyses to assess and project the needs of women veterans for the Under Secretary for 

Health. The study required by section 103 would unacceptably divert significant 

funding from direct medical care. 

We estimate the costs of section 101 to be $2,327,503 in fiscal year 2008 and 

$10,857,000 over a ten-year period. We estimate no costs for section 102 because 

VA’s own comparable study is underway, with $975,000 in funding committed for 

fiscal years 2007 and 2008. Section 103 would have a cost of $4,354,000 in fiscal 

year 2008. 

Title II. Improvement and Expansion of VA Health Care Programs for 

Women Veterans 

Section 201, titled ‘‘Improvement of Sexual Trauma Care Programs of the Department of Veterans Affairs,’’ would require VA to train all mental health professionals 

who provide services to veterans under that program and to ensure such training 

is done in a consistent manner that includes principles of evidenced-based treatment. Section 201 would also require VA to train primary care providers in screening and recognizing the symptoms of Military Sexual Trauma (MST) and to ensure 

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procedures exist for prompt referral of these veterans to appropriate mental health 

professionals. The provision recommends that VA’s care and services for MST include the services of therapists who are qualified to provide counseling and who 

demonstrate an understanding of the burden experienced by former service members who experience both combat and MST. 

Section 201 would also require VA to establish staffing standards used at VA 

health care facilities for full-time equivalent employees trained to provide treatment 

for conditions related to MST. These standards would need to ensure availability of 

services, and access to MST treatment, for all veterans seeking this care. This provision would also establish detailed reporting requirements for the Department. 

We do not support the training-related requirements of section 201 because they 

are not necessary. In Fiscal Year 2007, VA funded a Military Sexual Trauma Support Team, whose mission is, in part, to enhance and expand MST-related training 

and education opportunities nationwide. VA also hosts an annual four-day long 

training session for 30 clinicians in conjunction with the National Center for PTSD, 

which focuses on treatment of the after-effects of MST. VA also conducts training 

through monthly teleconferences that attract 130 to 170 attendees each month. Recent topics included overviews of several commonly used evidence-based treatment 

protocols (e.g., protocols for CP Therapy, PE Therapy, and Acceptance and Commitment Therapy). VA has also recently unveiled the MST Resource Homepage, a Web 

page that services as a clearinghouse for MST-related resources such as patient education materials, sample power point trainings, provider educational opportunities, 

reports of MST screening rates by facility, and descriptions of VA policies and benefits related to MST. It also hosts discussion forums for providers. In addition, VA 

primary care providers screen their veteran-patients, particularly recently returning 

veterans, for MST, using a screening tool developed by the Department. We are currently revising our training program to further underscore the importance of effective screening by primary care providers who provide clinical care for MST within 

primary care settings. 

We object strongly to the provision in section 201 that would require VA to establish staffing standards for this program. Staffing-related determinations must be 

made at the local level based on the identified needs of the facility’s patient population for MST treatment and services, workload, staffing, and other capacity issues. 

Imposition of national staffing standards would be an utterly inefficient and ineffective way to manage a health care system that is dynamic and experiences continual 

changes in workload, utilization rates, etc. 

Section 202 would require VA, through its National Center for PTSD, to develop 

and implement a plan for developing and disseminating information regarding effective treatments, including evidence-based treatments, for women veterans with 

PTSD and other co-morbid conditions. The plan would need to include a proposed 

timetable for the dissemination to all VA facilities, but in no case could dissemination occur later than one year after the bill’s enactment. Section 202 would also require the plan to include any proposed additional resources needed to provide MST 

training and MST counseling and treatment. The measure would establish detailed 

reporting requirements, as well. 

VA does not support section 202 because it is duplicative of activities already underway by the Department. VA is strongly committed to making state-of-the-art, 

evidence-based psychological treatments widely available to veterans and this is a 

key component of VA’s Mental Health Strategic Plan. We are currently working to 

disseminate evidence-based psychotherapies for a variety of mental health conditions throughout our health care system. There are also two programs underway to 

provide clinical training to VA mental health staff in the delivery of certain therapies shown to be effective for PTSD, which are also recommended in the VA/DoD 

Clinical Practice Guidelines for PTSD. Each training program includes a component 

to train the professional who will train others in this area, to promote wider dissemination and sustainability over time. 

Section 203 would require VA to conduct a study of the Vet Centers’ capacity to 

provide services for women veterans and to determine their capacity to provide a 

sufficient scope and intensity of services. Once completed, the Secretary would have 

to develop a plan to ensure that adequate counseling and mental health services for 

women veterans are available at each Vet Center, taking into account their specialized needs. 

We do not support section 203 because it is not necessary and is duplicative of 

VA’s ongoing activities in this area. VA’s Vet Center program is one of VA’s bestreceived programs as it currently exists, and it already provides the services sought 

by this subsection. We would be glad to brief the Committee on all of our activities, 

particularly our extensive outreach efforts and the significant expansion now underway to increase capacity (both in terms of staff and new facilities). 

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Section 204 would require VA, not later than six months after the bill’s enactment, to carry out a two-year pilot program to furnish childcare services (directly 

or indirectly) to eligible women veterans receiving certain services through the Department. Sites for the pilot program must include at least three VISNs. Child care 

could only be provided for the period of time that the eligible veteran receives covered services at a Department facility and is required to travel to and from the facility for those services. Eligible veterans would include women veterans who are the 

primary caretaker of a child (or children) and who are receiving one or more of the 

following health care services: regular or intensive mental health care services, or 

such other types of intensive health care services for which the Secretary determines the provision of child care would improve access to those services. Moreover, 

under section 204, VA could provide the covered child care services through a variety of means, i.e., stipends offered by child care centers (directly or by voucher system), the development of partnerships with private agencies, collaboration with 

other Federal facilities or program, or the arrangement of after school care. Section 

204 would authorize $1.5 million to be appropriated for each year of the pilot and 

establish Congressional reporting requirements. 

VA does not support section 204. Although we understand that the lack of available child care services can pose a barrier to access to care for some of our veterans, 

providing child care services—either in-house or through other arrangements— 

would divert funds and resources from our primary mission of providing direct patient care. We note that private health care facilities do not generally provide these 

services. Section 204 also unjustifiably discriminates against male veterans who, but 

for their sex, would otherwise meet the eligibility criteria. We estimate the cost of 

section 204 to be $500,000 in fiscal year 2008 and $2,500,000 in fiscal year 2009. 

Section 205 would require VA to establish a two-year pilot program to evaluate 

the feasibility and advisability of providing counseling and transition adjustment assistance for newly separated women veterans that is conducted in a group retreat 

setting for as long as the Secretary deems is needed to be effective. Participation 

in the program would be voluntary and would not require a referral from any provider. Section 205 provides that the counseling services would be individually tailored to the participants’ specific needs, and they could include some or all of the 

following types of counseling: mental health, family and marital, role and relationship, substance use disorder, or other counseling services determined to be necessary to assist the veteran before final repatriation with her family. Section 205 

would also authorizes $2 million for each year of the pilot, and require VA to submit 

a detailed report to Congress within six months of the pilot’s completion. 

VA does not support section 205. We find the intent of the legislation confusing 

in that it would require that counseling be at the same time provided in a group 

setting but specifically tailored to the individual needs of each participating veteran. 

We know that counseling services provided in group therapy sessions are not appropriate or effective for all veterans and/or certain mental health conditions. Determination of the appropriate treatment milieu for each veteran should be based on 

the clinical judgment of a trained VA professional and should not be mandated— 

even as a pilot program. Likewise, we object to the precedent of permitting patients 

to self-refer for medical care. The need for these services should be made by the appropriate VA professional who can ensure they are medically appropriate and necessary. Moreover, the veterans participating in the pilot may assume in error that 

their medical and counseling problems can be completely resolved through this program with no need for future VA services. We note that VA has a number of counseling and transition adjustment programs underway to meet the needs of newly 

discharged/separated women veterans. 

Finally, section 206 would require the Department’s Advisory Committee on 

Women Veterans, created by statute, to include women veterans who are recently 

separated veterans. It would also require the Department’s Advisory Committee on 

Minority Veterans to include recently separated veterans who are minority group 

members. (It is noted that section 206 contains a typographical error, as the Advisory Committee on Minority Veterans was established by section 544 of title 38, 

United States Code, not section 542.) These requirements would apply to committee 

appointments made on or after the bill’s enactment. 

We support section 206. Given the expanded role of women and minority veterans 

serving in the Armed Forces, the Committees should address the needs of these cohorts in carrying out their reviews and making their recommendations to the Secretary. Having the perspective of those who have recently separated would enable 

the Committees to, among other things, project the future needs of these veteran 

groups. 

This concludes my prepared statement. I would be pleased to answer any questions you or any of the members of the Subcommittee may have. 

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Statement of American Academy of Physician Assistants 

On behalf of the nearly 65,000 clinically practicing physician assistants (PAs) in 

the United States, the American Academy of Physician Assistants (AAPA) is pleased 

to submit comments in support of H.R. 2790, a bill to amend title 38, United States 

Code, to establish the position of Director of Physician Assistant Services within the 

office of the Under Secretary of Veterans Affairs for Health. The AAPA is very appreciative of Representatives Phil Hare and Jerry Moran for their leadership in introducing this important legislation. The Academy also wishes to thank Chairman 

Filner and Representative Berkley for cosponsoring H.R. 2790. 

AAPA believes that enactment of H.R. 2790 is essential to improving patient care 

for our Nation’s veterans, ensuring that the 1,600 PAs employed by the VA are fully 

utilized and removing unnecessary restrictions on the ability of PAs to provide medical care in VA facilities. Additionally, the Academy believes that enactment of H.R. 

2790 is necessary to advance recruitment and retention of PAs within the Department of Veterans Affairs. 

Physician assistants are licensed health professionals, or in the case of those employed by the federal government, credentialed health professionals, who: 

• Practice medicine as a team with their supervising physicians. 

• Exercise autonomy in medical decisionmaking. 

• Provide a comprehensive range of diagnostic and therapeutic services, including 

performing physical exams, taking patient histories, ordering and interpreting 

laboratory tests, diagnosing and treating illnesses, suturing lacerations, assisting in surgery, writing prescriptions, and providing patient education and counseling. 

• May also work in educational, research, and administrative settings. 

Physician assistants’ educational preparation is based on the medical model. PAs 

practice medicine as delegated by and with the supervision of a physician. Physicians may delegate to PAs those medical duties that are within the physician’s scope 

of practice and the PA’s training and experience, and are allowed by law. A physician assistant provides health care services that were traditionally only performed 

by a physician. All States, the District of Columbia, and Guam authorize physicians 

to delegate prescriptive privileges to the PAs they supervise. AAPA estimates that 

in 2007, approximately 245 million patient visits were made to PAs and approximately 303 million medications were prescribed or recommended by PAs. 

The PA profession has a unique relationship with veterans. The first physician 

assistants to graduate from PA educational programs were veterans, former medical 

corpsmen who had served in Vietnam and wanted to use their medical knowledge 

and experience in civilian life. Dr. Eugene Stead of the Duke University Medical 

Center in North Carolina put together the first class of PAs in 1965, selecting Navy 

corpsmen who had considerable medical training during their military experience as 

his students. Dr. Stead based the curriculum of the PA program in part on his 

knowledge of the fast-track training of doctors during World War II. Today, there 

are 139 accredited PA educational programs across the United States. Approximately 1,600 PAs are employed by the Department of Veterans Affairs, making the 

VA the largest single employer of physician assistants. These PAs work in a wide 

variety of medical centers and outpatient clinics, providing medical care to thousands of veterans each year. Many are veterans themselves. 

Physician assistants (PAs) are fully integrated into the health care systems of the 

Armed Services and virtually all other public and private health care systems. PAs 

are on the frontline in Iraq and Afghanistan, providing immediate medical care for 

wounded men and women of the Armed Forces. PAs are covered providers in 

TRICARE. In the civilian world, PAs work in virtually every area of medicine and 

surgery and are covered providers within the overwhelming majority of public and 

private health insurance plans. PAs play a key role in providing medical care in 

medically underserved communities. In some rural communities, a PA is the only 

health care professional available. 

Why are PAs so fully integrated into most public and private health care systems? 

We believe it’s because they foster the use and inclusion of their PA workforce. Each 

branch of the Armed Services designates a PA Consultant to the Surgeon General. 

And, many major medical institutions credit their integration of PAs in the workforce to a Director of PA Services. To name just a few, the Cleveland Clinic, the 

Mayo Clinic, the University of Texas MD Anderson Cancer Center, and New Orleans’ Ochsner Clinic Foundation all have Directors of PA Services. We believe that 

what works for the Armed Services and the private sector will also work for the VA. 

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How does the lack of a Director of PA Services at the VA relate to recruitment 

and retention of the VA workforce? As far as the AAPA can tell, there are no recruitment and retention efforts aimed towards employment of physician assistants 

in the VA. The VA designates physicians and nurses as critical occupations, and so 

priority in scholarships and loan repayment programs goes to nurses, nurse practitioners, physicians, and other professions designated as critical occupations. The PA 

profession has not been determined to be a critical occupation at the VA, so moneys 

are not targeted for their recruitment and retention. PAs are not included in any 

of the VA special locality pay bands, so PA salaries are not regularly tracked and 

reported by the VA. We’ve been told that this has resulted in lower pay for PAs employed by the VA than for health care professionals who perform similar medical 

care. Why are PAs not considered a critical occupation at the VA? Is it possible they 

were overlooked, because there was no one to raise the issue? 

The outlook for PA employment at the VA does not differ from that for nurse 

practitioners and physicians. Approximately 40 percent of PAs currently employed 

by the VA are eligible for retirement in the next five years, and the VA is simply 

not competitive with the private sector for new PA graduates. The U.S. Bureau of 

Labor Statistics, U.S. News and World Report, and Money magazine all speak to the 

growth, demand, and value of the PA profession. The challenge for the VA is that 

the growth and demand for PAs is in the private sector, not the VA. 

According to the AAPA’s 2007 Census Report, PA employment in the federal government, including the VA, continues to decline. AAPA’s Annual Census Reports of 

the PA Profession from 1991 to 2007 document an overall decline in the number 

of PAs who report federal government employment. In 1991, nearly 22% of the total 

profession was employed by the federal government. This percentage dropped to 9% 

in 2007. New graduate census respondents were even less likely to be employed by 

the government (17% in 1991 down to 5% in 2007). 

Unless some attention is directed toward recruitment and retention for PAs, the 

AAPA believes that the VA is in danger of losing its PA workforce. The elevation 

of the PA advisor to a full-time Director of PA Services in the VA Central Office 

is the first step in focusing the VA’s efforts on recruitment and retention of PAs. 

The current position of Physician Assistant (PA) Advisor to the Under Secretary 

for Health was authorized through section 206 of P.L. 106–419 and has been filled 

as a part-time, field position. Prior to that time, the VA had never had a representative within the Veterans Health Administration with sufficient knowledge of the PA 

profession to advise the Administration on the optimal utilization of PAs. This lack 

of knowledge resulted in an inconsistent approach toward PA practice, unnecessary 

restrictions on the ability of VA physicians to effectively utilize PAs, and an underutilization of PA skills and abilities. The PA profession’s scope of practice was not 

uniformly understood in all VA medical facilities and clinics, and unnecessary confusion existed regarding such issues as privileging, supervision, and physician 

countersignature. 

Although the PAs who have served as the VA’s part-time, field-based PA advisor 

have made progress on the utilization of PAs within the agency, there continues to 

be inconsistency in the way that local medical facilities use PAs. In one case, a local 

facility decided that a PA could not write outpatient prescriptions, despite licensure 

in the State allowing prescriptive authority. In other facilities, PAs are told that the 

VA facility can not use PAs and will not hire PAs. These restrictions hinder PA employment within the VA, as well as deprive veterans of the skills and medical care 

PAs have to offer. 

The Academy also believes that the elevation of the PA advisor to a full-time Director of Physician Assistant Services, located in the VA central office, is necessary 

to increase veterans’ access to quality medical care by ensuring efficient utilization 

of the VA’s PA workforce in the Veterans Health Administration’s patient care programs and initiatives. PAs are key members of the Armed Services’ medical teams 

but are an underutilized resource in the transition from active duty to veterans’ 

health care. As health care professionals with a longstanding history of providing 

care in medically underserved communities, PAs may also provide an invaluable 

link in enabling veterans who live in underserved communities to receive timely access to quality medical care. 

Thank you for the opportunity to submit a statement for the hearing record in 

support of H.R. 2790. AAPA is eager to work with the House Committee on Veterans Affairs Subcommittee on Health to improve the availability and quality of 

medical care to our Nation’s veteran population. 

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Statement of Hon. Shelley Berkley, 

a Representative in Congress from the State of Nevada 

Mr. Chairman, 

Thank you for holding this hearing on the important issue of mental health legislation. 

Nationally, one in five veterans returning from Iraq and Afghanistan suffers from 

PTSD. Twenty-three percent of members of the Armed Forces on active duty acknowledge a significant problem with alcohol use. It is vital that our veterans receive the help they need to deal with these conditions. 

The effects of substance abuse are wide ranging, including significantly increased 

risk of suicide, exacerbation of mental and physical health disorders, breakdown of 

family support, and increased risk of unemployment and homelessness. Veterans 

suffering from a mental health issue are at an increased risk for developing a substance abuse disorder. 

A constituent of mine, Lance Corporal Justin Bailey, returned from Iraq with 

PTSD. He developed a substance abuse disorder and checked himself into a VA facility in West Los Angeles. After being given five medications on a self-medication 

policy, Justin overdosed and died. 

I have introduced the Mental Health Improvements Act, which aims to improve 

the treatment and services provided by the Department of Veterans Affairs to veterans with PTSD and substance use disorders by: 

• Expanding substance use disorder treatment services at the VA medical centers. • Creating a program for enhanced treatment of substance use disorders and 

PTSD in veterans. • Requiring a report on residential mental health care facilities of the Veterans 

Health Administration (VHA). • Creating a research program on co-morbid PTSD and substance use disorders. • Expanding assistance of mental health services for families of veterans. 

It is imperative that we provide adequate mental health services for those who 

have sacrificed for this great Nation and those who continue to serve. This bill takes 

a step in the right direction in providing our veterans with the care they have 

earned. I urge my colleagues to cosponsor this important piece of legislation, and 

I look forward to further action in this Committee. 

f 

Statement of Mental Health America 

Mr. Chairman, Mental Health America commends you for scheduling this hearing, 

and for your and this Committee’s ongoing concern about the mental health of our 

veterans. 

Mental Health America (MHA) is the country’s oldest and largest nonprofit organization addressing all aspects of mental health and mental illness. In partnership 

with our network of 320 State and local Mental Health Association affiliates nationwide, MHA works to improve policies, understanding, and services for individuals 

with mental illness and substance abuse disorders, as well as for all Americans. Established in 1909, the organization changed its name in 2006 from the National 

Mental Health Association to Mental Health America in order to communicate how 

fundamental mental health is to overall health and well-being. MHA is a founding 

member of the Campaign for Mental Health Reform, a partnership of 17 organizations which seek to improve mental health care in America, for veterans and nonveterans alike. 

Unique Aspects of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) 

Importantly, a number of the bills before the Subcommittee address mental health 

issues. While service-members have experienced mental health problems in every 

war, our operations in Iraq and Afghanistan differ markedly from prior combat engagements, with critically important implications for veterans’ readjustment and recovery. It is critical therefore that the Committee target legislation to most effectively address the unique circumstances of these operations. 

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

unique in their heavy reliance on the National Guard and Reserves who make up 

a large percentage of our fighting forces. Reserve forces alone have made up as 

much as 40 percent of U.S. forces in Iraq and Afghanistan, and at one point, more 

than half of all U.S. casualties in Iraq were sustained by members of the Guard 

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or Reserves. These operations are also unique in their reliance on repetitive deployments. Deploying to a combat zone is necessarily enormously stressful to a soldier 

and to his or her family; that stress increases markedly with each subsequent deployment. The impact of those deployments on service-members has been profound. 

Veterans’ Mental Health Needs 

A recently published DoD-conducted longitudinal assessment of mental health 

problems among soldiers returning from Iraq (published in the Journal of the American Medical Association, Nov. 2007) found that 42.4 percent of National Guard and 

Reserve-component soldiers screened by the Department of Defense required mental 

health treatment. The high percentages of Guard and Reservists among OIF/OEF 

veterans creates unique challenges that VA has not previously faced. First, these 

‘‘citizen-soldiers’’ often live in communities remote from VA medical facilities. Yet 

they are as likely to have readjustment issues or to experience anxiety, depression 

or PTSD as veterans who have good access to VA health care. Long-distance travel 

is a very formidable barrier to a veteran’s seeking (and continuing) needed treatment. That barrier is likely to be even higher for veterans with mental health 

needs, given the lingering stigma surrounding mental health treatment and the well 

documented reluctance of some veterans to seek VA help because of fears of disclosures that might compromise their military status. 

The high incidence of mental health problems among returning service-members 

and particularly among Guard and Reservists should be cause for alarm, especially 

in rural and frontier areas, and the many places in the country where VA lacks any 

(or sufficient) specialized mental health service capacity. To be clear, VA is both a 

facility-based system, and a largely passive system that generally puts the burden 

on the veteran to seek care. While VA reports that significant numbers of OIF/OEF 

veterans have been treated at its facilities for behavioral health problems, there are 

compelling reasons to question how many veterans are not seeking and, therefore, 

not getting needed mental health treatment. 

We should also be mindful of the expert advice of the Department’s own Special 

Committee on Post-Traumatic Stress Disorder, which in a report in February 2006 

advised that ‘‘VA needs to proceed with a broad understanding of post deployment 

mental health issues. These include Major Depression, Alcohol Abuse (often beginning as an effort to sleep), Narcotic Addiction (often beginning with pain medication 

for combat injuries), Generalized Anxiety Disorder, job loss, family dissolution, 

homelessness, violence toward self and others, and incarceration.’’ The Special Committee advised that ‘‘rather than set up an endless maze of specialty programs, each 

geared to a separate diagnosis and facility, VA needs to create a progressive system 

of engagement and care that meets veterans and their families where they live. . . . 

The emphasis should be on wellness rather than pathology; on training rather than 

treatment. The bottom line is prevention and, when necessary, recovery.’’ Importantly, the Special Committee also advised that ‘‘[b]ecause virtually all returning 

veterans and their families face readjustment problems, it makes sense to provide 

universal interventions that include education and support for veterans and their 

families coupled with screening and triage for the minority of veterans and families 

who will need further intervention.’’ 

Early treatment can help resolve post-traumatic stress disorder, depression, and 

other problems common in combat veterans. But those who do not get needed help 

too often self-medicate (using alcohol or drugs), develop chronic health problems, 

and experience interpersonal difficulties and even family breakup. As the Committee well knows, alarming numbers of returning veterans have even taken their 

lives. 

H.R. 2874: Needed Legislation 

In light of the issues outlined above, we believe this Committee, to its great 

credit, has taken a profoundly important step in developing and adopting H.R. 2874, 

the Veterans’ Health Improvements Act of 2007, which the House passed last July. 

We regret that the Senate has not yet taken action on that measure. In our view, 

section 6 of that legislation provides critical solutions for the many OIF/OEF veterans with mental health needs who are not now getting the help they need from 

the VA. As you know, the key elements of the bill would require VA to mount a 

national program to train a cohort of OIF/OEF veterans to work as peer-outreach 

and peer-support specialists. In areas of the country where veterans cannot reasonably reach VA facilities, the bill calls on VA to partner with community mental 

health centers and similar entities to provide peer outreach and support services, 

readjustment counseling and needed mental health services. As a condition of such 

arrangements, those community providers would be required to hire a trained peer 

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specialist. That individual’s role would be to help identify veterans in need of counseling or services, help overcome any reluctance to treatment, and navigate and support the veteran through the treatment process. We believe these provisions merit 

Senate adoption. 

Among the bills before the Subcommittee is H.R. 4053, a measure that seeks to 

improve VA’s behavioral health service-delivery. While a key focus of that bill is on 

improving such services at VA health care facilities, sections 201 and 402—which 

require VA to conduct modest pilot programs on peer outreach services and use of 

community mental health centers, in the case of section 201, and readjustment and 

transition assistance, in section 402—propose an approach very close to that in section 6 of H.R. 2847. Our concern is not with the program design proposed by the 

bill, but with its very limited scope. Enactment of sections 201 and 402 would, in 

our view, inadvertently shut a critical door to needed services for OIF/OEF veterans 

in rural, frontier and many areas of the country that are distant from VA facilities. 

Given the alarmingly high rate of mental health problems being experienced by returning veterans, we urge that the Committee not retreat from H.R. 2847 nor, in 

the absence of effective mechanisms to reach veterans who live at considerable distances from VA facilities, substitute limited pilot programs in lieu of a robust effort 

that offers the promise of helping all OIF/OEF veterans who are experiencing readjustment or behavioral health problems. We welcome the Committee’s consideration 

of other sections of H.R. 4053, given the importance of ensuring that VA behavioral 

health service delivery does effectively serve veterans who are able to access VA care. 

Family Services 

In that regard, it is noteworthy that H.R. 2874, as introduced, included a provision that would have directed VA to establish a program to provide support and assistance to immediate family members of OIF/OEF veterans. (That provision, which 

would have authorized VA to provide immediate family members of OIF/OEF veterans with counseling and needed mental health services for a period of up to 

3 years was not adopted in the Committee’s markup of H.R. 2874.) Importantly, 

H.R. 4053 includes a section 401, which is apparently intended to clarify VA’s authority to provide mental health services to families of veterans. It is not clear, however, that the proposed amendments in that provision in fact accomplish its admirable goal. 

Current law and practice do in fact limit VA assistance to family members, and 

warrant change. VA is an integrated health care system which offers a relatively 

full continuum of care and services for eligible veterans. Among those services is 

‘‘readjustment counseling.’’ These services are provided principally at so-called ‘‘Vet 

Centers,’’ many of which are located in population centers and are operated independently of VA medical centers and clinics. Typically provided by psychologists and 

clinical social workers, Vet Centers’ services routinely include family therapy as a 

core component. But veterans and family members who do not have reasonable access to a Vet Center and rely instead on a VA medical center or clinic would not 

typically have access to family services. Most VA medical centers and clinics focus 

exclusively on the veteran patient (rather than on the veteran as part of a family 

unit). (Indeed those facilities employ measures of ‘‘workload’’ data that provide no 

workload credit for family services.) This focus and workload system effectively discourage clinicians from providing family therapy and support services. We see no 

sound programmatic rationale for encouraging family support at one set of VA facilities (the Vet Centers) and discouraging it at others. VA’s Special Committee on 

PTSD reported in 2006 that ‘‘the strength of a war fighter’s perceived social support 

system is one of the strongest predictors of whether he/she will or will not develop 

PTSD.’’ VA health care, and particularly mental health care, would often be more 

effective if barriers to family involvement were eliminated. 

Current law does provide VA some limited authority for counseling family members (but not for any other mental health services). But even that limited authority 

is circumscribed. Under section 1782(b) of title 38, family counseling is expressly 

limited to circumstances where such counseling had been initiated during a period 

of hospitalization, and continuation is essential to hospital discharge (unless the veteran is receiving treatment for a service-connected condition). 

While H.R. 4053 suggests in the heading of section 401 that it would establish 

clarifying authority to provide ‘‘mental health services,’’ its substantive provisions 

are limited to ‘‘marriage and family counseling.’’ For a spouse who has experienced 

deep clinical depression or anxiety associated with a service-member’s multiple 

tours of combat duty and with the profound fears associated with a war that has 

claimed thousands of casualties, marriage or family ‘‘counseling’’ will not necessarily 

meet that spouse’s clinical needs. Moreover, as a technical matter, we believe any 

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effort to provide clarifying authority must address the limitations in section 1782(c) 

as well as the very practical ‘‘workload’’ disincentives. 

Mental Health America would be pleased to work with the Committee to craft language to provide VA needed authority to assist family members consistent with its 

mission of serving veterans. 

f 

Statement of Paralyzed Veterans of America 

Mr. Chairman and members of the Subcommittee, Paralyzed Veterans of America 

(PVA) would like to thank you for the opportunity to submit a statement for the 

record regarding the proposed legislation. We appreciate the continued emphasis on 

providing the best quality health care for veterans who experience mental illness 

as well as veterans who live in rural areas—two segments of the veteran population 

that present some of the most difficult challenges. 

H.R. 2790, Director of Physician Assistant Services 

PVA fully supports H.R. 2790, a bill that would establish the position of Director 

of Physician Assistant Services within the Veterans Health Administration (VHA) 

at the Department of Veterans Affairs (VA). This legislation mirrors the recommendation included in The Independent Budget for FY 2008 and that will be included in the FY 2009 edition as well. 

As explained in The Independent Budget, Physician Assistants (PA) in the VA 

health care system are the providers for millions of health care visits every year in 

primary care clinics, ambulatory care clinics, emergency medicine, and in 22 other 

medical and surgical specialties. Since the PA advisor position was authorized by 

P.L. 106–419, the ‘‘Veterans’ Benefits and Health Care Improvement Act of 2000,’’ 

the number of PA’s in the VHA have grown significantly. And yet, four Under Secretaries for Health have all refused to make this position a full-time equivalent employee position. We appreciate the fact that this legislation will finally correct this 

senseless decision. 

H.R. 3458, Pilot Program on TBI Care for Rural Veterans 

PVA has no objection to the provisions outlined in H.R. 3458. The proposed legislation would authorize the VA to conduct a pilot program in five rural States. The 

program would be coordinated with the VA’s Office of Rural Health. The goal of the 

pilot program would be to provide the best available services for veterans who have 

experienced traumatic brain injury (TBI). We appreciate the fact that the legislation 

provides some protections to ensure that properly trained professionals are caring 

for the needs of this critical segment of the veteran population. 

While we have expressed some concerns in the past with the idea of contract care 

for different groups of veterans, we understand that the VA must tap into the resources and expertise that private providers can offer. To that end, we have no objection to the provisions of the legislation that authorize contract care when necessary and appropriate. It is important that services for veterans who have incurred 

a TBI be coordinated between the VA and private providers. 

H.R. 3819, the ‘‘Veterans Emergency Care Fairness Act’’ 

PVA generally supports the provisions of H.R. 3819, the ‘‘Veterans’ Emergency 

Care Fairness Act,’’ as the legislation is in accordance with the recommendations 

of The Independent Budget for FY 2008. However, we remain concerned about some 

of the eligibility criteria that determine what veterans are eligible for this reimbursement. In accordance with The Independent Budget for FY 2008, we believe that 

the requirement that a veteran must have received care within the past 24 months 

should be eliminated. Furthermore, we believe that the VA should establish a policy 

allowing all veterans enrolled in the health care system to be eligible for emergency 

services at any medical facility, whether at a VA or private facility, when they exhibit symptoms that a reasonable person would consider a medical emergency. 

H.R. 4053, the ‘‘Mental Health Improvements Act’’ 

First, I would like to say that PVA generally supports this proposed legislation 

which improves services provided by the VA to veterans with Post-Traumatic Stress 

Disorder (PTSD) and substance use problems. Current research highlights that Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat veterans are at higher risk for PTSD and other mental health problems as a result 

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of their military experiences. In fact, the most recent research indicates that 25 percent of OIF/OEF veterans seen at a VA facility have received mental health diagnoses. We are pleased with the provisions of section 102 and 103 of the legislation. In 

fact, The Independent Budget is set to recommend that VA provide a full continuum 

of care for substance use disorders including additional screening in all its health 

care facilities and programs—especially primary care. We also believe outpatient 

counseling and pharmacotherapy should be available at all larger VA communitybased outpatient clinics. Furthermore, short-term outpatient counseling including 

motivational interventions, intensive outpatient treatment, residential care for those 

most severely disabled, detoxification services, ongoing aftercare and relapse prevention, self help groups, opiate substitution therapies and newer drugs to reduce craving, should be included in VA’s overall program for substance abuse and prevention. 

Although we support the creation of PTSD centers of excellence outlined in section 

105 of the legislation, we wonder whether this step is necessary. The VA already 

maintains a broad network of PTSD treatment centers. Furthermore, in 1989, the 

VA established the National Center for Post-Traumatic Stress Disorder as a focal 

point to promote research into the causes and diagnosis of this disorder, to train 

health care and related personnel in diagnosis and treatment, and to serve as an 

information clearinghouse for professionals. The Center offers guidance on the effects of PTSD on family and work, and notes treatment modalities and common 

therapies used to treat the condition. This Center already functions as a center of 

excellence. At the very least, it should be incorporated into this new network of centers of excellence. 

PVA has some concerns with the pilot program outlined in Title II of the bill. 

While we certainly support the emphasis placed on peer counseling and outreach, 

we maintain our concerns about contract services with community health centers. 

The VA should be able to provide the services described in the legislation through 

judicious application of its already existing fee basis authority. We do, however, appreciate the emphasis on ensuring that the non-VA facilities are compliant with VA 

standards, particularly through additional training managed specifically by the VA. 

While we also support Title III of the legislation regarding research into co-morbid 

PTSD and substance use disorder, we wonder if this is duplicative with activities 

already taking place at the National Center for PTSD. However, PVA has long supported research initiatives into various types of conditions and the treatments associated with them. 

Finally, we recognize the unique challenge associated with providing mental 

health services to families of veterans. This is an area that the VA has had little 

experience with in the past. Likewise, we see no problem with the VA examining 

the feasibility of providing readjustment and transition assistance to veterans and 

their families. It is certainly an issue that has become more apparent as more men 

and women return from conflicts abroad broken and scarred. The impact that this 

has on the veteran and his or her family cannot be overstated. 

H.R. 4107, the ‘‘Women Veterans Health Care Improvement Act’’ 

PVA supports H.R. 4107, the ‘‘Women Veterans Health Care Improvement Act.’’ 

This legislation is meant to expand and improve health care services available in 

the Department of Veterans Affairs (VA) to women veterans, particularly those who 

have served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/ 

OIF). More women are currently serving in combat theaters than at any other time 

in history. As such, it is important that the VA be properly prepared to address the 

needs of what is otherwise a unique segment of the veterans population. 

Title I of the bill would authorize a number of studies and assessments that 

would evaluate the health care needs of women veterans. Furthermore, these studies would also identify barriers and challenges that women veterans face when seeking health care from the VA. Finally, the VA would be required to assess the programs that currently exist for women veterans and report this status to Congress. 

We believe each of these studies and assessments can only lead to higher quality 

care for women veterans in the VA. They will allow the VA to dedicate resources 

in areas that it must improve upon. 

Title II of the bill would target special care needs that women veterans might 

have. Specifically, it would ensure that VA health care professionals are adequately 

trained to deal with the complex needs of women veterans who have experienced 

sexual trauma. Furthermore, it would require the VA to disseminate information on 

effective treatment, including evidence-based treatment, for women veterans dealing 

with Post-Traumatic Stress Disorder (PTSD). While many veterans returning from 

OEF/OIF are experiencing symptoms consistent with PTSD, women veterans are exsmartinez on PROD1PC64 with HEARING

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periencing unique symptoms also consistent with PTSD. It is important that the VA 

understand these potential differences and be prepared to provide care. 

PVA views this proposed legislation as necessary and critical. The degree to which 

women are now involved in combat theaters must be matched by the increased commitment of the VA, as well as the Department of Defense, to provide for their needs 

when they leave the service. We cannot allow women veterans to fall through the 

cracks simply because programs in the VA are not tailored to the specific needs that 

they might have. 

H.R. 4146, Emergency Medical Care in Non-VA Facilities 

While we support the intent of this proposed legislation, we believe that this issue 

is handled in a more comprehensive manner by H.R. 3819. Therefore, we recommend that the Subcommittee table this bill in favor of approving H.R. 3819. 

H.R. 4204, the ‘‘Veterans Suicide Study 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. Any measure that may help reduce the incidence of suicide 

among veterans is certainly a good thing. As such, PVA supports this legislation. 

This bill would require the VA to conduct a study to determine the number of veterans who have committed suicide since January 1, 1997. 

It is important to note that VA has made suicide prevention a major priority. VA 

has developed a broad program based on increasing awareness, prevention, and 

training of health care staff to recognize suicide risk. A national suicide prevention 

hotline has been established and suicide prevention coordinators have been hired in 

each VA medical center. Research into the risk factors associated with suicide in 

veterans and prevention strategies is underway. 

However, it is equally important to point out that suicide prevention is something 

that can be addressed early on in the mental health process. With access to quality 

psychiatric care and other mental health professionals, many of the symptoms experienced early on can be addressed in order to reduce the risk of suicide down the 

road. This extends to proper screening and treatment for veterans who deal with 

substance abuse problems as well. 

H.R. 4231, the ‘‘Rural Veterans Health Care Access Act’’ 

PVA opposes this proposed legislation. H.R. 4231 would establish a pilot program 

that would require the VA to provide vouchers to veterans who served in OEF/OIF 

who need mental health services, and who reside at least 30 miles from a VA facility 

that employs a full-time mental health professional. These vouchers could then be 

used to purchase mental health services with private providers. PVA finds it difficult to comprehend the rationale for establishing a precedent for veterans to seek 

services outside of the VA health care system, as this proposed legislation would do. 

First, let me say that we are absolutely opposed to any suggestion that veterans 

be given a voucher to seek health care services outside of the VA. This step amounts 

to nothing more than privatization of the VA, turning the VA health care system 

into an insurer of care instead of a provider of care. Likewise, The Independent 

Budget has also taken a position against vouchering in the past. Veterans who 

would seek care in the private sector 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. 

We are also very concerned about the seemingly arbitrary nature with which a 

veteran’s eligibility for this voucher is established. The legislation states that if a 

veteran resides 30 miles or more from a VA medical facility that does not employ 

a full-time mental health professional, then that veteran is eligible for a voucher. 

Given the fact that the definition of rural is very subjective, I would suggest that 

30 miles from a facility does not qualify as rural. 

Furthermore, we believe that it is patently unfair to suggest that the VA cannot 

meet the need if the mental health professional in that local facility is not a fulltime employee. If a VA facility is able to provide a mental health appointment in 

a timely manner, regardless of the employment status of the mental health professional, then it is unnecessary to allow a veteran to go into the private sector with 

a voucher. Otherwise, this represents mandating private care for the sake of convenience and not for the sake of demonstrated need. 

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Ultimately, we cannot support vouchering of any health care services in the VA 

because we believe it will only diminish the quality of care in the VA health care 

system. Furthermore, we believe that this pilot program would set a dangerous 

precedent, encouraging those who would like to see the VA privatized. Privatization 

is ultimately a means for the federal government to shift its responsibility of caring 

for the men and women who served. 

We look forward to working with the Subcommittee to develop workable solutions 

that will allow veterans to get the best quality care available. We would like to 

thank you again for allowing us to submit a statement for record on these important 

measures. We would be happy to answer any questions that you might have. 

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MATERIAL SUBMITTED FOR THE RECORD 

Ohio Hospital Association 

Columbus, Ohio 

October 18, 2007 

The Honorable Sherrod Brown 

United States Senate 

455 Russell Senate Office Building 

Washington, DC 20510 

The Honorable Zack Space 

United States House of Representatives 

315 Cannon House Office Building 

Washington, DC 20511 

Dear Senator Brown and Congressman Space: 

On behalf of the Ohio Hospital Association (OHA) and our more than 170 hospitals and health systems, we appreciate your recent introduction of the Veterans 

Emergency Care Fairness Act of 2007 (S. 2142/H.R. 3819). The legislation will address a significant concern regarding the reimbursement of medical care provided 

to America’s veterans. 

Currently, veterans who present at a community hospital for emergency treatment are stabilized and then transferred to a regional Veterans’ Affairs (VA) hospital. The Chief of the Health Administration Service authorizes reimbursement be 

made from the U.S. Department of Veterans’ Affairs to the community hospital and 

the patient for necessary stabilization services and transfer costs. 

Unfortunately, especially in rural areas, the VA hospital is unable or unwilling 

to admit the patient for a period of time until transportation arrangements can be 

made or until an inpatient bed is available at the VA. In these circumstances, a 

community hospital must care for the patient for an extended period prior to transfer. Current law is unclear on whether the patient, the community hospital, or the 

Department of Veterans’ Affairs is responsible for the cost of this care. Title 38 USC 

1725 states that the Department may reimburse for such treatment. 

Your legislation clarifies this issue by requiring the Department to provide reimbursement to the veteran patient or directly to the hospital for care provided during 

the post-stabilization ‘‘waiting’’ period, provided the hospital documents reasonable 

attempts to transfer the patient to a VA. Hospitals already must document such 

transfer attempts, so we do not believe this provision would add an administrative 

burden to the community hospital. 

Again, thank you for championing this important clarification in veterans’ health 

policy. We look forward to working with you during the 110th Congress to ensure 

enactment of the bill. 

Sincerely, Jonathan Archey 

f 

Manager, Federal Relations 

Air Force Sergeants Association 

Temple Hills, MD 

November 5, 2007 

The Honorable Zachary Space 

315 Cannon House Office Building 

Washington, D.C. 20515 

Dear Congressman Space, 

On behalf of the members of the Air Force Sergeants Association, we offer our 

support for H.R. 3819, the ‘‘Veterans Emergency Care Fairness Act of 2007.’’ Your 

bill would provide reimbursement for emergency care when veterans obtain immediate care at nearby medical facilities. AFSA’s 130,000 members represent the quality-of-life interests of current and past enlisted members of all components of the 

Air Force and their family members. Your bill is important to many of our members. 

Many veterans do not live near a VA medical facility. Accordingly, one of the 

great challenges is how to obtain emergency care until the veteran can be transported to the nearest VA facility and how to pay for it. Under current law this presents a financial hardship to many. Your legislation would help rectify such unfortunate situations. 

Mr. Space, we support your effort in this regard and I offer AFSA’s assistance in 

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advancing this important legislation. Please let me know if we can assist you on this 

and other matters of mutual concern. 

Respectfully, Richard M. Dean, CMSgt (Ret.) 

f 

Chief Executive Officer 

DEPARTMENT OF VETERANS AFFAIRS 

News Release 

FOR IMMEDIATE RELEASE 

July 9, 2008 

VA Vet Centers Coming to 39 Communities 

Peake: Provide Counseling for All Combat Veterans 

WASHINGTON—Combat veterans will receive readjustment counseling and other 

assistance in 39 additional communities across the country where the Department 

of Veterans Affairs (VA) will develop Vet Centers by fall 2009. 

‘‘Community-based Vet Centers—already in all 50 States—are a key component 

of VA’s mental health program,’’ said Dr. James B. Peake, Secretary of Veterans Affairs. ‘‘I’m pleased we can expand access to bring services closer to even more veterans, including screening and counseling for post-traumatic stress disorder.’’ 

The existing 232 centers conduct community outreach to offer counseling on employment, family issues and education to combat veterans and family members, as 

well as bereavement counseling for families of service members killed on active duty 

and counseling for veterans who were sexually harassed on active duty. 

Vet Center services are available at no cost to veterans who experienced combat 

during any war era. They are staffed by small teams of counselors, outreach workers and other specialists, many of whom are combat veterans. The Vet Center program was established in 1979 by Congress, recognizing that many Vietnam veterans 

were still having readjustment problems. 

The centers have hired 100 combat veterans who served in Iraq and Afghanistan 

as outreach specialists, often placing them near military processing stations, to brief 

servicemen and women leaving the military about VA benefits. 

VA’s 2009 budget proposal seeks $20 million more than this year’s budget for Vet 

Centers, to include operating and leasing space for the new centers. Eighteen of the 

counties that will have new centers already have one or more; the other 21 do not. 

A list of the new Vet Center locations is attached. 

Vet Centers 2/2/2 

Communities Receiving New VA Vet Centers 

Alabama—Madison 

Arizona—Maricopa 

California—Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, 

San Diego 

Connecticut—Fairfield 

Florida—Broward, Palm Beach, Pasco, Pinellas, Polk, Volusia 

Georgia—Cobb 

Illinois—Cook, DuPage 

Maryland—Anne Arundel, Baltimore, Prince George’s 

Michigan—Macomb, Oakland 

Minnesota—Hennepin 

Missouri—Greene 

North Carolina—Onslow 

New Jersey—Ocean 

Nevada—Clark 

Oklahoma—Comanche 

Pennsylvania—Bucks, Montgomery 

Texas—Bexar, Dallas, Harris, Tarrant 

Virginia—Virginia Beach 

Washington—King 

Wisconsin—Brown 

Æ 

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