```

[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]

              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

              

                     U.S. GOVERNMENT PRINTING OFFICE

41-363                     WASHINGTON DC:  2008
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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     RICHARD H. BAKER, Louisiana
Dakota                               HENRY E. BROWN, Jr., South 
HARRY E. MITCHELL, Arizona           Carolina
JOHN J. HALL, New York               JEFF MILLER, Florida
PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
PHIL HARE, Illinois                  JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania       RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada              HENRY E. BROWN, Jr., South 
JOHN T. SALAZAR, Colorado            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.

                            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

                   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

 
              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.
    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.
    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 have been an advocate for our Community-Based Outpatient 
Clinics (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 full-time 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. Brown-
Waite 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, not just in southeastern Ohio but throughout the 
country, are operating 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 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 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 evidence-based 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.
    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.
    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.
    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 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 2\1/2\ hours by 
van, get out of the van, go in, and literally sit for 2, 2\1/2\ 
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.
    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.
    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).
    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 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.
    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 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 first-rate, 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 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 
full-time 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 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 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 
to be delivered to the Congress 2\1/2\ 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 government 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 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.
    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.
    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?
    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.
    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 VA-
employed 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.
    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 2\1/2\ 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 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 treating more and more people coming 
back from Iraq and Afghanistan 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?
    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.]

                            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.

                                 
                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.
    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.

                                 
         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.

                                 
            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 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.

                                 
             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.
    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.

                                 
        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.
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 life-threatening 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 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. 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.

                                 
                   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.
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 case-managed 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.
    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 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. 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 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 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 part-time 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.

                                 
     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 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 full-time 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 post-
traumatic 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.
    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, 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 in-depth 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 internal 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 Deployment-Related 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 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.

                                 
               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 Director 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 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.
    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 Appropriations 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.

                                 
          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 prudent-layperson 
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 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 post-emergency 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 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 time-consuming 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).
    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 Sec. 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 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.
    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 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.
    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.
    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 
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 best-received 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).
    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.

                                 
         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.
    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 under-utilization 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.

                                 
                   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.

                                 
                   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 non-veterans 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 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 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 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.

                                 
               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 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 
community-based 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 experiencing 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 full-time 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.
    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.
                   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
                                         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

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.)
                                            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

                                  
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