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39–934 PDF 2007

S. HRG. 110–374 

HEARING ON VA AND DOD COLLABORATION: 

REPORT OF THE PRESIDENT’S COMMISSION 

ON CARE FOR AMERICA’S RETURNING WOUNDED WARRIORS; REPORT OF THE VETERANS 

DISABILITY BENEFITS COMMISSION; AND 

OTHER RELATED REPORTS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED TENTH CONGRESS 

FIRST SESSION 

OCTOBER 17, 2007 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

BARACK OBAMA, Illinois 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

RICHARD M. BURR, North Carolina, Ranking 

Member 

ARLEN SPECTER, Pennsylvania 

LARRY E. CRAIG, Idaho, 

JOHNNY ISAKSON, Georgia 

LINDSEY O. GRAHAM, South Carolina 

KAY BAILEY HUTCHISON, Texas 

JOHN ENSIGN, Nevada 

WILLIAM E. BREW, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

OCTOBER 17, 2007 

SENATORS 

Page 

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

Prepared statement .......................................................................................... 3 

Burr, Hon. Richard M., Ranking Member, U.S. Senator from North Carolina .. 5 

Craig, Hon. Larry E., U.S. Senator from Idaho .................................................... 8 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 9 

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 10 

Prepared statement .......................................................................................... 11 

Brown, Hon. Sherrod, U.S. Senator from Ohio ..................................................... 11 

Hutchison, Hon. Kay Bailey, U.S. Senator from Texas ........................................ 12 

Isakson, Hon. Johnny, U.S. Senator from Georgia ............................................... 13 

Webb, Hon. Jim, U.S. Senator from Virginia ........................................................ 39 

WITNESSES 

Shalala, Hon. Donna E., Co-Chair, President’s Commission on Care for America’s Returning Wounded Warriors ..................................................................... 14 

Prepared statement .......................................................................................... 18 

Dole, Hon. Bob, Co-Chair, President’s Commission on Care for America’s 

Returning Wounded Warriors ............................................................................. 21 

Prepared statement .......................................................................................... 26 

Response to written questions submitted by Hon. Daniel K. Akaka ........... 29 

Scott, LTG James Terry, U.S. Army (Ret.), Chairman, Veterans Disability 

Benefits Commission ............................................................................................ 43 

Prepared statement .......................................................................................... 48 

Response to written questions submitted by Hon. Daniel K. Akaka ........... 66 

Dunne, RADM Patrick W., U.S. Navy (Ret.), Assistant Secretary for Policy 

and Planning, U.S. Department of Veterans Affairs ........................................ 68 

Prepared statement .......................................................................................... 70 

Response to written questions submitted by Hon. Daniel K. Akaka ........... 74 

West, Togo D., Jr., Co-Chair, Independent Review Group ................................... 74 

Prepared statement .......................................................................................... 76 

Attachment .................................................................................................... 78 

Del Negro, Ariana, wife of 1LT Charles Gatlin ..................................................... 91 

Prepared statement .......................................................................................... 92 

Duffy, Col. Peter J., U.S. Army Reserve (Ret.), Deputy Director of Legislative 

Affairs, National Guard Association of the United States ................................ 98 

Prepared statement .......................................................................................... 101 

Response to written questions submitted by Hon. Daniel K. Akaka ........... 102 

Manar, Gerald T., Deputy Director, National Veterans Service, Veterans of 

Foreign Wars of the United States, on behalf of the members of the Independent Budget .................................................................................................... 105 

Prepared statement .......................................................................................... 107 

Response to written questions submitted by Hon. Daniel K. Akaka ........... 112 

Beck, Meredith, National Policy Director, Wounded Warrior Project (WWP) .... 112 

Prepared statement .......................................................................................... 115 

Page

IV 

Strobridge, Col. Steven P., U.S. Air Force (Ret.), Director, Government Relations, Military Officers Association of America ................................................. 117 

Prepared statement .......................................................................................... 118 

Response to written questions submitted by Hon. Daniel K. Akaka ........... 124 

APPENDIX 

Obama, Hon. Barack, U.S. Senator from Illinois; prepared statement ............... 133 

(1) 

HEARING ON VA AND DOD COLLABORATION: 

REPORT OF THE PRESIDENT’S COMMISSION 

ON CARE FOR AMERICA’S RETURNING 

WOUNDED WARRIORS; REPORT OF THE 

VETERANS DISABILITY BENEFITS COMMISSION; AND OTHER RELATED REPORTS 

WEDNESDAY, OCTOBER 17, 2007 

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, D.C. 

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

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

Present: Senators Akaka, Murray, Brown, Tester, Webb, Burr, 

Craig, Isakson, and Hutchison. 

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

U.S. SENATOR FROM HAWAII 

Chairman AKAKA. The oversight hearing on DOD–VA Collaboration and Cooperation will come to order. 

With a big smile, I want to say aloha and welcome. Welcome to 

all of you to the Committee’s hearing on issues relating to the findings of the President’s Commission on Care for America’s Returning Wounded Warriors, known as the Dole-Shalala Commission for 

its two distinguished Co-Chairs, the Veterans Disability Benefits 

Commission, and other groups that have recently examined matters regarding coordination and collaboration between the Departments of Defense and Veterans Affairs in the care and treatment 

of veterans from Operations Enduring Freedom and Iraqi Freedom. 

Today’s hearing is the latest in a series of hearings we have held 

this year that focus on the issue of coordination and collaboration 

between the two departments. Since our first hearing last January 

on this subject, the problems that gained public attention involving 

Walter Reed Army Medical Center brought more energy to this 

issue. Our committee and the Armed Services Committee have 

worked together toward achieving the goal of wounded warriors receiving optimal care and experiencing a truly seamless transition 

from DOD to VA, but there is much more that needs to be done. 

The problems at Walter Reed led to the creation of the DoleShalala Commission, the Task Force on Returning Global War on 

Terror Heroes, and DOD’s Independent Review Group, each of 

which we will hear from today. We will also hear from the VetVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
2 

erans Disability Benefits Commission, which had been in existence 

for some time when the stories about Walter Reed first broke. I 

note that the Commission earlier this month issued a comprehensive report on the overall Disability Compensation System. The 

Committee will hold a subsequent hearing to take testimony on 

that report. 

General Scott, the Chair of the Commission, has been invited 

here today to provide the views of the Commission on the recommendations of the Dole-Shalala Commission and to discuss 

areas of overlap between the Disability Benefits Commission and 

other entities which were created in response to the stories about 

Walter Reed. 

It is important to recall that the problems identified at Walter 

Reed were not about the quality of health care provided by DOD, 

but more about a process that created confusion and inequities in 

the delivery of disability benefits to wounded warriors. The stories 

about Walter Reed also highlighted existing problems in the organization of medical holdover detachments and in the hand-off between the military services and VA for wounded or seriously injured or ill servicemembers. 

The good news is that since this spring, much hard work has 

been done by DOD, VA, and the military services in seeking to resolve these problems. However, lately DOD and VA may have been 

recognizing the significant problems of adapting the departments to 

the stresses of the current conflicts, I am satisfied that real work 

is now underway. 

I am particularly impressed by the work of the Joint VA and 

DOD Senior Oversight Committee, co-chaired by VA’s Deputy Secretary Gordon Mansfield, and DOD’s Deputy Secretary Gordon 

England, that meets every Tuesday to work on a wide range of ongoing transition issues. This, as you know, is an unprecedented 

level of attention to the issue of DOD–VA cooperation and collaboration. 

Today’s hearing gives us an important opportunity to review the 

recommendations of the Dole-Shalala Commission, the Disability 

Benefits Commission, and other reports that impact the interaction 

between DOD and VA, especially in those areas which still need 

improvement and where there is overlap or potential disagreement. 

I hope to gain a better understanding of the relationship among all 

the various recommendations with a particular focus on how the 

recommendations may relate to legislation developed by the White 

House and the response to the Dole-Shalala Commission. Senator 

Burr and I, along with the Chairman and Ranking Member of the 

Armed Services Committee, were briefed on this draft legislation 

earlier this month and I have many questions and concerns about 

it. 

I thank Senator Dole and Secretary Shalala and our other distinguished witnesses for joining us today. Their testimony will allow 

us to better understand the many recommendations and help identify areas where Congressional action is required. 

At our first hearing in January, I spoke about the stress that a 

new veteran with a life-altering wound or injury endures when 

faced with the challenge of applying for benefits and transitioning 

from one health care system to another while still in the process 

3 

of recovery and rehabilitation. With the input of the many recommendations that we will hear about today, I believe that we can 

continue to make progress toward achieving the goal of a truly 

smooth and seamless transition. 

I have a longer statement that I will place in the record, which 

is available at the press table. 

[The prepared statement of Chairman Akaka follows:] 

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

U.S. SENATOR FROM HAWAII

Aloha and welcome to the Committee’s hearing on issues relating to the findings 

of the President’s Commission on Care for America’s Returning Wounded Warriors, 

known as the Dole-Shalala Commission for its two distinguished co-chairs; the Veterans’ Disability Benefits Commission; and other groups that have recently examined matters regarding coordination and collaboration between the Departments of 

Defense and Veterans Affairs in the care and treatment of veterans from Operations 

Enduring Freedom and Iraqi Freedom. 

Today’s hearing is the latest in a series of hearings we have held this year that 

focus on the issue of coordination and collaboration between the two Departments. 

That series began with this Committee’s first hearing of the 110th Congress on January 23. Later, when stories broke about conditions at the Walter Reed Army Medical Center, this issue became more energized, and, since that time, our Committee 

has worked in close collaboration with the Senate Armed Services Committee to find 

appropriate legislative solutions for the many problems that have been identified. 

On March 2, 2007, Chairman Levin and I visited Walter Reed to gain a first-hand 

understanding of the problems. Our visit highlighted matters involving overlapping 

jurisdiction and a real need for our Committees to work closely together. 

On April 12, the two Committees held an unprecedented joint hearing to review 

and explore issues and problems relating to how those returning from combat in 

Iraq and Afghanistan were receiving care and services. That hearing set the foundation for the development of the Senate’s proposed Wounded Warrior legislation 

which is currently in conference with the House as part of the 2008 National Defense Authorization bill. 

I could not be more pleased with the cooperative manner in which the staffs of 

the two Committees worked to develop this extremely important and comprehensive 

legislative package that addresses health care, benefits, and transition issues involving both DOD and VA. In crafting this legislation, the staffs met on a regular basis, 

received briefings from Army and VA leadership, visited Walter Reed to meet with 

Army and VA representatives, and were briefed on the findings of groups created 

by the Administration to look into the Walter Reed problems. 

It is important to remember that the problems identified at Walter Reed were not 

about the quality of health care provided by DOD, but about an overall process that 

created confusion and inequities in the delivery of disability benefits to wounded 

warriors. The stories about Walter Reed also highlighted existing problems in the 

organization of medical hold/medical holdover detachments and in the hand-off between the military services and VA of wounded or seriously injured or ill servicemembers. 

The good news is that, since this spring, much hard work has been done by DOD, 

VA, and the military services in seeking ways to resolve the problems which were 

identified. However late DOD and VA may have been in recognizing the significant 

problems of adapting their Departments to the stresses of the current conflicts, I 

am satisfied that real work is now underway. I am particularly impressed by the 

work of the joint VA and DOD Senior Oversight Committee, co-chaired by VA’s Deputy Secretary Gordon Mansfield and DOD’s Deputy Secretary Gordon England, that 

meets weekly to work on a wide range of ongoing transition issues. This is an unprecedented level of attention to the issue of DOD–VA cooperation and collaboration. 

Nevertheless, it is clear that much hard work lies ahead and that the problems 

faced by individual veterans and their families continue to demand attention and 

solutions. Today’s hearing gives our Committee the opportunity to continue our 

work in this area. 

The problems highlighted by the situation at Walter Reed led to the creation of 

a number of entities—the Dole-Shalala Commission, which was established by the 

President on March 6, 2007, and presented its report on July 30, 2007; the Task 

Force on Returning Global War on Terror Heroes, also established by the President 

on March 6, 2007, which issued its report on April 19, 2007; and DOD’s Independent 

4 

Review Group, established by Secretary Gates on February 23, 2007, and which 

completed its report on April 19, 2007. The Committee will be hearing from each 

of these groups today. 

The Committee will also be hearing today from the Veterans’ Disability Benefits 

Commission (VDBC), which was established by Congress in 2004, and which, on October 3, issued its report. The VDBC report provides an in-depth analysis of the benefits and services available to veterans, servicemembers, their survivors, and their 

families to compensate and provide assistance for the effects of disabilities and 

deaths attributable to military service. The VDBC was invited today to present its 

views on the recommendations of the Dole-Shalala Commission and the other entities which were created in response to the stories about Walter Reed and to discuss 

areas of overlap between its recommendations and those of the other groups. The 

Committee will have other hearings, beginning early next year, on the VDBC’s overall report and recommendations. 

Among the issues that the Committee will focus on today are those relating to 

the existing DOD and VA systems for providing compensation and other benefits to 

servicemembers injured during their service. This is a key area of overlap between 

the Dole-Shalala Commission and the VDBC. 

The Dole-Shalala Commission, on the basis of its work over a relatively short period of time—their first public meeting was in mid-April and they issued their report in late July—recommended a complete restructuring of the DOD and VA disability systems, as one element of its report that includes six recommendations focused primarily on collaboration between DOD and VA and on the needs of newly 

injured servicemembers. It is not clear from the Commission’s report what outside 

expertise the Commission relied on to reach this conclusion. The only suggestion we 

have received thus far on how this comprehensive revision might be carried out 

came in the form of draft legislation on which Senator Burr and I, along with our 

counterparts on the Armed Services Committee, were briefed last week. This draft 

legislation, apparently developed by the White House, would have the Congress cede 

the responsibility for the proposed comprehensive retooling of VA’s compensation 

system to the Secretary of Veterans Affairs and require the Secretary to accomplish 

this monumental task over a very few months. 

The VDBC, in contrast, took a more systematic approach, carried out over a period of two and a half years, that focused exclusively on the complex and often inefficient service-connected disability structure. The VDBC conducted 26 public meetings, carried out extensive research, and received significant input from outside entities, including the CNA Corporation and the Institute of Medicine. 

As part of its effort, the VDBC articulated eight principles that it believes should 

guide the development and delivery of future benefits for veterans and their families. It structured its analysis by developing 31 research questions. The Commission’s staff drafted 11 white papers that analyzed 16 of those questions and presented options to the Commission for their deliberation. Attorneys conducted legal 

analyses of several of these issues and gave the Commission a historical context for 

much of the legislation that sets forth the benefits available to disabled veterans, 

their families, and survivors. 

On the basis of its analysis and considerations, the VDBC made 113 recommendations designed to improve VA’s disability compensation program for the 21st century. These recommendations collectively address the appropriateness and purpose 

of benefits, the benefit levels and payment rates, and the processes and procedures 

used to determine eligibility for benefits. 

Many significant recommendations made by the VDBC are not contemplated in 

the Dole-Shalala report and warrant further review before any action is taken on 

the Dole-Shalala recommendation related to the overall disability benefits system 

and on how the Dole-Shalala recommendation may relate to the legislation developed by the White House that I mentioned earlier. 

With respect to that draft White House legislation, I have many questions and 

concerns about it, but wish to make two general points about it. First, whatever legislation is finally submitted by the White House will not have my support as a replacement for the Wounded Warrior legislation that is now pending in the NDAA 

conference. Our Committee and the Armed Services Committee, and our counterparts in the House, have worked diligently on the Wounded Warriors legislation and 

I see no basis to scrap that effort this late in the Session. The second point I wish 

to make about the draft legislation is this: As Chairman of the Veterans’ Affairs 

Committee, I will unequivocally oppose any proposal that would abdicate the role 

and responsibility of the Congress for dealing with the VA compensation system by 

giving that task to the VA Secretary. On that point, it is worth noting that there 

is no confirmed Secretary of Veterans Affairs at present. It is inconceivable to me 

5 

that there would be any significant support for giving such a monumental task to 

VA, especially when there is no leadership in place. 

There are a number of other recommendations from the Dole-Shalala Commission 

that I hope to learn more about today, including those relating to care coordination, 

treatment for PTSD, providing support for family members who have to take time 

off from their jobs to be with their wounded family members, and recommendations 

relating to VA’s vocational rehabilitation program. 

With regard to coordination of care, I am pleased by the Dole-Shalala Commission’s recommendation that each seriously injured servicemember be provided with 

a ‘‘Recovery Coordinator’’ to serve as the patient and family’s primary point of contact throughout their treatment and to ensure that the servicemember is getting the 

care he or she needs. This is a concept the Committee has already embraced in our 

health care omnibus legislation, S. 1233, which is currently pending passage by the 

full Senate. It is clear that the need exists for care coordinators to assist patients 

in navigating through the two systems. However, I believe that if every servicemember is to be provided with a Recovery Coordinator, we must also ensure that 

their efforts are managed efficiently. Basic questions such as which agencies will 

hire and train them must be answered. 

We must also uncover what the real impediments are to accessing treatment for 

Post Traumatic Stress Disorder that prompted the Dole-Shalala Commission to recommend improvements in this area. Is it identifying servicemembers with more severe symptoms, and getting them in the door, or is it that when they do present 

themselves at a DOD or VA facility, they are not being given proper care? The DoleShalala Commission says that Congress should enable VA to provide aggressive 

PTSD care, but it is my belief that VA already has the authority to provide the care, 

and that our role in Congress is to ensure that VA has the resources to do the job. 

In addition, the Dole-Shalala Commission recommended that the Family Medical 

Leave Act should be amended to allow up to 6 months’ leave for a family member 

of a servicemember who has a combat-related injury. Though the Commission’s recommendation as formulated does not fall within the jurisdiction of our Committee, 

other proposals addressing the need to support the families of those who are recovering from combat injuries have been made that do, so we will be looking at the 

ramifications of these approaches. 

And finally, I find the President’s Commission’s recommendations relating to VA’s 

Vocational Rehabilitation and Employment Program confusing, especially the proposal to offer individuals a monetary incentive to complete a program of rehabilitation and the subsequent effect that completion would have on an individual’s level 

of service-connected compensation. Since the Committee has an oversight hearing 

of this program scheduled for later this month, I do not intend to pursue these 

issues at today’s hearing in great depth. I will have some questions on these recommendations for the record and perhaps later on in connection with the oversight 

hearing at the end of the month. 

In closing, I note that, at the Committee’s first hearing in January, I spoke about 

the stress that a new veteran with a life altering wound or injury endures when 

faced with the challenge of applying for benefits and transitioning from one health 

care system to another, while still in the process of recovery and rehabilitation. 

With the input of the many recommendations that we will hear about today, I believe that we can continue to make progress toward achieving the goal of a truly 

smooth and seamless transition. 

Chairman AKAKA. In the interest of time and to allow others to 

speak, I will stop here and turn to the Committee’s Ranking Member, Senator Richard Burr, for his opening remarks. 

STATEMENT OF HON. RICHARD M. BURR, RANKING MEMBER, 

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Aloha, Mr. Chairman. I didn’t know it would be 

quite as challenging linguistically on this Committee as it is to 

serve with Senator Akaka, but he has challenged me to learn more 

than just what we need to do as it relates to changes in the disability system. Mr. Chairman, thank you. 

I welcome all of our distinguished panelists and I appreciate you 

being here this morning. You have all spent many hours with one 

thought in mind, and that is improving the lives of those who 

served our country in the Armed Forces. You have given us policy 

6 

suggestions that I believe can help shape how we care for our servicemen and women for decades to come. For your commitment to 

them and for your advocacy on their behalf, I am here this morning 

to say thank you to each and every one of you. 

Let me begin by making two very broad points. First, we are 

here today to review recommendations on how best to deliver 

health care, disability compensation, and rehabilitative benefits to 

those who have been injured in military service to our country. As 

we look at our strengths and our inefficiencies in getting the job 

done right, we have to keep in mind that the opportunities for today’s professional warrior are fundamentally different than in earlier generations. Today, all-volunteer forces know that injury, even 

serious injury, need not be an impediment to continuing on with 

a productive and fulfilling life. 

I am amazed when I hear over and over how some soldiers with 

very serious injuries are able to return to their units, or how they 

plan to resume fully active lives, go to school and get a job. Modern 

technology and modern attitudes about disabilities not only give 

them that hope, they appropriately give them that expectation. 

Our job, then, is to give these brave men and women the tools 

they need and to remove the stumbling blocks that are in their 

way. In fact, they demand that from their government. 

Today’s soldier chooses a military career and their expectation is 

the same as it would be for any professional working in any organization in America. If one is hurt on the job, one expects quick, effective, and relatively hassle-free physical, vocational restoration 

and supportive services from the employer. 

My second point is about our system of benefits and services for 

our veterans, servicemembers, and their families. Rather than use 

my words, I will read the Dole-Shalala Commission report where 

they said the Commission learned that, on the whole, we are a generous and giving Nation when it comes to providing for our servicemembers and veterans. Benefits include health care for veterans 

through the VA, for retirees through the Military Health System, 

and through civilian providers through TRICARE. In addition, we 

pay retirement and disability benefits and provide for education, 

adaptive equipment, employment hiring preferences, and more. 

The total cost of these benefits was well over $127 billion in 

2006. So as of last year, we had a budget of over $127 billion to 

assist veterans and servicemembers, more than double what it was 

just a decade ago. 

I highlight this information to suggest that the challenges facing 

many veterans today have as much to do with confusing bureaucratic programs operated by many different offices of the government as they do with the lack of benefit programs or the lack of 

resources. I will never shy away from providing our military men 

and women and our veterans with the resources they need, but I 

expect and these citizens expect that these resources will be used 

effectively to deliver needed benefits and services. 

There is a saying that goes, if you aren’t part of the solution, 

then you must be part of the problem. So let us commit to talking 

today about meeting the challenges ahead of us. Secretary Shalala 

and Senator Dole, when you briefed us 2 weeks ago, I was pleased 

to hear that officials and staff at the Department of Veterans AfVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
7 

fairs and the Department of Defense were beginning to implement 

90 percent of your Commission’s recommendations. 

Mr. Chairman, I am committed to you, and I look forward to 

working with you, to conduct oversight of the Departments of Veterans Affairs and Defense to ensure that the best of these recommendations to improve veterans’ care are implemented without 

delay. 

Senator Dole and Secretary Shalala, you also said in our recent 

briefing that 10 percent of your Commission’s recommendations require legislative action. You called this the hard part. Of course, I 

am speaking about the recommendations to reform the Disability 

Compensation System. As you know, the Veterans Disability Benefits Commission has also spent the better part of 3 years looking 

at the hard part. I expect everyone calls it the hard part for a very 

good reason, and I think this Committee will soon find that out. I 

am fully aware that reforming the disability system will require a 

large up-front cost, but if done properly, it would also be an investment. 

Chairman Akaka, once again, I pledge to you as the Committee 

works to better the lives and well-being of those wounded in defense of the country, knowing that the character of men and 

women of our Armed Forces is an investment that comes with little 

risk and great reward. 

One final thought before I conclude my statement. Almost every 

Member of Congress has had the opportunity to visit soldiers, Marines, sailors, and airmen who are fighting in the war on terror. In 

my own conversations with them, I can’t help but be inspired by 

their love of country, their commitment to duty, their extraordinary 

optimism in the face of adversity. We have all referred to men and 

women who served with Senator Dole in the Second World War as 

‘‘The Greatest Generation,’’ and my encounters with today’s heroes 

remind me that greatness—when we talk about risking one’s life 

for the freedom of others—is of every generation. Greatness belongs 

to the few whose deeds merit that title. 

To all who have served in combat, to the families who have sacrificed so that their loved ones could serve the rest of us, and to 

all who have been injured or who have died for our freedoms, you 

have my enduring respect and gratitude. No matter when you 

served or on what continent you fought, you have made the most 

supreme sacrifice. For that, and I know I speak for everyone in this 

room, we are eternally grateful. 

Again, I thank our distinguished guests this morning for their 

willingness to share their knowledge with this Committee and I 

think I speak for the Chairman when I say that we are anxious to 

go forward and to begin this process. 

Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Burr. Using 

what we call ‘‘the early bird system,’’ I am going to call next on 

Senator Craig, and he will be followed by Senator Murray. 

Senator BURR. Mr. Chairman, could I ask my colleagues to indulge me for one additional minute? We have been joined by a very 

special person and I just want to highlight that for our audience 

today. Sarah Wade, would you stand up for a second? I just want 

you to meet a very special person. 

8 

Sarah Wade is the wife of Retired Army Sergeant Edward ‘‘Ted’’ 

Wade. Following Ted’s serious injury in Iraq on February 4, 2004, 

Sarah suspended her studies at the University of North Carolina 

at Chapel Hill to serve as an advocate for her husband and has recently become a public policy intern for the Wounded Warrior 

Project, a nonprofit organization dedicated to assisting military 

personnel injured in Iraq and Afghanistan. 

She was born and raised in Washington, D.C. Sarah currently resides in Chapel Hill, North Carolina, a constituent of mine and the 

wife of a very brave U.S. soldier. Thank you for being here, Sarah. 

[Applause.] 

Chairman AKAKA. Thank you, Senator Burr. 

Senator Craig? 

STATEMENT OF HON. LARRY E. CRAIG, 

U.S. SENATOR FROM IDAHO 

Senator CRAIG. Mr. Chairman, Richard, I will be brief, but I do 

want to welcome both Secretary Shalala and Senator Dole before 

this Committee and to reminisce only briefly. If Bob hadn’t said, 

Larry, there is work to be done on the Veterans Affairs Committee 

a good number of years ago, and you ought to go do it, I might not 

be here. And that work has continued. Thank you, Bob, for appointing me to this Committee a good number of years ago, and we have 

continued to work according to your wishes. 

I want to thank all of the panelists and the Commissions who 

are before us today. The work you do is critically important to veterans, to soldiers who will become veterans soon across this Nation, 

and we thank you for it. 

Earlier this year, Mr. Chairman, I asked a Member of the staff 

here on the Veterans Affairs Committee to submit testimony before 

Secretary Shalala and Senator Dole’s Commission regarding the 

DOD–VA collaboration, especially as it relates to the overlapping 

health benefits systems. I have been very involved over the past 

few years in examining ways that DOD and VA can work together 

closely. 

We early on began to use the word ‘‘seamless,’’ but it became 

pretty obvious to me that it was a word, it was not a reality, not 

in the way we want it to be. And I would hope, Mr. Chairman, 

Richard, that as we work through this, seamless becomes a system 

and simply not a phrase, because that is exactly what is doable 

today if we can cause DOD and VA to come together in a way that 

recognizes what we want to achieve for America’s veterans. 

I have used testimony from General Omar Bradley’s Commission 

in 1956. I know Senator Dole has referred to it on occasion. I would 

hope that 51 years after today, that this Committee has not convened in a way that it is referring to the Dole-Shalala Commission 

as goals that should have been achieved but were not accomplished. 

I know government is a daunting system and sometimes very, 

very difficult to change, Mr. Chairman. We can and we must 

change it. And for the sake of America’s veterans, I hope we can. 

So to meet that challenge, Mr. Chairman and Senator Burr, I accept your challenge to do just that, to look back a few years from 

now and say that we have accomplished what we set out to do. It 

9 

is now a seamless system. When one transfers from active to veteran, it is simply the push of a button and the movement of a system. We have watched the failure too long. We have watched the 

bureaucracy be too daunting. It shouldn’t require the wife of a soldier to become an advocate simply to work their way through a system that is impossible or nearly impossible to penetrate. 

We are moving in those directions. Now our challenge from the 

Commissions is to revisit it and revisit it on an annual basis, to 

challenge it, to oversee it, and to force it to change. Thank you for 

being with us. 

Chairman AKAKA. Thank you very much, Senator Craig. 

Now we will hear from Senator Murray. 

STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Thank you very much, Chairman Akaka, Ranking Member Burr, for holding this really important hearing. 

Secretary Shalala, Senator Dole, welcome to our Committee. 

Thank you for the work you have done and for being here today 

to present the recommendations of your Commission as well as the 

other three reports that we are going to hear about today about 

how we can improve the care for our servicemembers and veterans 

as they transition from the military to the VA. 

It has been 8 months now since the Washington Post exposed the 

scandalous conditions that all of us read and were shocked by, mice 

running in walls and moldy walls and holes in ceilings and the bureaucratic maze that our men and women who fought so bravely 

for us faced when they got home. Obviously, no one should have 

to endure those kinds of conditions, but most of all, the men and 

women who fought so courageously for all of us. 

I think it is important to remember that it wasn’t just Walter 

Reed. I think, as you well know, it was many of our facilities that 

were facing very bad conditions. This was symptomatic of the entire system, and it wasn’t just infrastructure. It was a long time 

waiting to see a doctor. It was bureaucratic ineptitude. It was VA 

claims backlogs that were taking months and years that were really harming our men and women’s ability to be able to take care of 

their families when they come home. 

I think all of us know that, without hesitation, these men and 

women take on the task that this Nation has given them. They answer the call to serve in Iraq or Afghanistan or wherever we send 

them. They have left their loved ones for years. They have put 

their careers on hold. They put their lives on the line, and the least 

we can do is make sure when they come home, they get prompt, 

respective, comprehensive support for the work that they have 

done. 

I have said, Mr. Chairman, many times that no matter how divided this country may be over this current war in Iraq, this country is extremely united behind making sure that the men and 

women who have fought for us get the care that they deserve. We 

have taken that and used it this year, and the first time in the Iraq 

supplemental war bill, putting in funding for veterans, $1.8 billion 

in emergency funding, for the first time counting the care of veterans as part of the cost of war, which I think is extremely imporVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
10 

tant to do. Of course, this year’s VA military construction bill increased funding $3.6 billion over the President’s request as a recognition of the costs that we are responsible for. 

But I do think this environment that the country is in today, 

where we are all so supportive of these men and women, gives us 

a chance today to do these fundamental reforms to the VA and 

DOD that are so badly needed, and we need to really strike while 

the iron is hot. 

The Senate has already done that. We passed the Dignified 

Treatment of Wounded Warriors Act, which deals with the seamless transition process. That bill is now being worked out with the 

House and hopefully will be enacted soon so we can begin to provide some real solutions. I am interested today in how the Commission report ties in with that and how we can make sure we are 

doing that correctly together. 

But I am especially pleased that we are now actually looking at 

all of this and we are seeing studies and commission reports and 

recommendations by a number of different groups who are going to 

be in front of us today and I look forward to hearing from all of 

our witnesses and having a chance for us to really do the best with 

the best information we have. 

Senator Dole, Secretary Shalala, I am especially looking forward 

to your thoughts on the administration’s proposed legislation to 

carry out your recommendations and I am very glad to see the 

President come to the table on this issue and to work with us, I 

hope, as part of moving forward the Dignified Treatment of Wounded Warriors Act, as well. 

So, Mr. Chairman, this is a very important hearing. The country 

is waiting. They want to know what we are doing and how we are 

moving forward and it is incumbent upon all of us to act well, so 

thank you very much. 

Chairman AKAKA. Thank you very much, Senator Murray. 

Senator Tester? 

STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Mr. Chairman and Ranking Member Burr. I really, really appreciate the fact that you are having 

this hearing. I think it is long overdue to really take a look at what 

families and veterans have gone through to navigate through the 

bureaucracy of the DOD and the VA. 

I also want to thank everybody who is on these panels here 

today. It truly is an all-star cast of expert witnesses and I want to 

tell you I appreciate Senator Dole, Secretary Shalala coming today 

and I look forward to your testimony, as I am sure we all do. 

I would ask, Mr. Chairman, that my entire statement be put in 

the record, but I do want to talk about a few things. 

Over the last 10 months, I have held ten listening sessions with 

veterans throughout the State of Montana. The last one was last 

weekend in Mile City, Montana. At these listening sessions, I have 

heard about good things that have happened with the VA and I 

have heard about some things that have been, quite honestly, unacceptable with the VA. 

11 

As we go forth in what we are doing here in this Committee, I 

think it is critically important that we take all the necessary steps. 

I have heard just this morning issues or words like complex, impenetrable, bureaucratic, ineptitude. I think we all know that there 

is room for improvement and I think that the people who fought 

for this country and put their lives on the line and protected us in 

times of war and even not deserve it and we owe it to them. 

Just yesterday, a fellow by the name of Dan Gallagher from Missoula, head of the VFW in Missoula—in fact, he is here in the audience today—stepped into my office and said it is just a matter of 

course that when people first apply for benefits, they get turned 

down, right out of the chute. It is just the way things are done. 

That is a bad way to do business and we cannot accept that kind 

of work ethic, quite honestly. It is almost like the VA is working 

against the veterans instead of working for the veterans. So, we 

need to make sure that good health care and good benefits that 

happen for some of our veterans, occur for all of our veterans. 

With that, I very much look forward to your testimony, Senator 

Dole, Secretary Shalala. And thank you, Mr. Chairman and Ranking Member Burr. 

[The prepared statement of Senator Tester follows:] 

PREPARED STATEMENT OF HON. JON TESTER, U.S. SENATOR FROM MONTANA

Thank you, Mr. Chairman. I am glad that we are having this hearing—it is long 

overdue for us to take a look at what families are going through when it comes to 

navigating the DOD and VA bureaucracies. 

We’ve all heard the stories about the current system being complicated for injured 

servicemembers to navigate and stretched beyond the capabilities of the doctors and 

claims processors. 

I met yesterday with the head of the American Legion Post in Missoula—Dan 

Gallagher. Dan has spent his entire adult life helping Montana veterans get the 

care and the benefits that they’re entitled to. 

He brought me a letter and in it, he said this: 

‘‘Our veterans and our returning warriors have a right to the care their service 

has earned them. We cannot let the yellow ribbons to, once again, become red tape.’’ 

My friend, Dan Gallagher, has it exactly right. But that is exactly what is happening to a number of vets. Not just the catastrophically injured vets that we’ve all 

read so much about at Walter Reed and other places, but all throughout the DOD 

and the VA. 

I want to thank the witnesses for being here, because I think they all share a 

real desire for change in the system. We’ve got to simplify where we can, and make 

this process a lot less painful for veterans and their families. 

Above all, I think this is going to require a lot more resources. And it will require 

a real attitude change within the bureaucracies. Folks are there to help servicemembers and families, not tell them what can’t be done. 

With that, Mr. Chairman, let me stop and let the witnesses have their say. 

Chairman AKAKA. Without objection, your statement will be included in the record. 

Senator Brown? 

STATEMENT OF HON. SHERROD BROWN, 

U.S. SENATOR FROM OHIO 

Senator BROWN. Thank you very much, Mr. Chairman, Ranking 

Member Burr. Senator Dole, thank you for your service to our 

country, both in wartime and in the Senate, and fellow Clevelander 

Madam Secretary, nice to see you today. Thank you for your service. 

12 

Everyone always says the right thing about veterans at hearings 

like this and as elected officials and at all the right veterans’ halls 

and all the right celebrations and all the patriotic gatherings. Yet 

this institution has made some terrible mistakes and some terrible 

choices when it comes to veterans’ health care, I think. We have 

always had plenty of money for war. We have always had plenty 

of money for tax cuts, for especially the top one or two or 5 percent 

in this country. 

Yet the sacrifice in this war that we are in now has hardly been 

spread evenly in the population and so many of the people that 

have gained the most have sacrificed the least. There has not been 

enough money for body armor, not enough money for MRAP, not 

enough resources, as Senator Murray’s comments point out, not 

enough resources for VA health care. We have a lot of work to do. 

By passing the Veterans’ Organizations Independent Budget, the 

military construction bill that Senator Murray played such a major 

role in, it is very much an important first step. Coordination, as 

several have said, including Senator Craig, coordination and making it really seamless, more than just a word of DOD and VA, is 

so very, very important. Extending, as the Commission recommends, extending family and medical leave, establishing a caseworker that will work with families of soldiers to coordinate care 

and services is so very important. A timely and accurate disability 

rating is so very important. 

Particularly, we need to improve the diagnosis and treatment of 

PTSD and all that we have seen coming from this war, and I know 

that Senator Dole’s feelings and Secretary Shalala’s feelings are so 

strong about that. I have spent, as so many of us have, much of 

the last 4 years meeting with soldiers, welcoming the troops home, 

encouraging them to get the treatment they need when they resist 

for good reason: because they want to integrate themselves back 

into their workplace; their families; their communities. It is so very 

important that this transition be done right and this Commission’s 

recommendations will help there. 

One last point. Ohio has one of the lowest average payments for 

disability compensation—well below the national average. We are 

a large State with a huge veteran population and we need to do 

better. That is partly an issue we can help fix within the VA. It 

is partly an Ohio issue. We need to work together to do all of that. 

I am so appreciative of the service of not just Senator Dole and 

Secretary Shalala, but our other panelists, too; and I thank the 

Chairman. 

Chairman AKAKA. Thank you very much, Senator Brown. Now 

we will hear from Senator Hutchison. 

STATEMENT OF HON. KAY BAILEY HUTCHISON, 

U.S. SENATOR FROM TEXAS 

Senator HUTCHISON. Thank you, Mr. Chairman. First, I want to 

say to Secretary Shalala and Bob Dole, there has not been a better, 

more committed advocate for veterans in this Nation in our history 

than you, Bob Dole, and thank you so much for continuing from 

your great service in World War II to helping those who have followed you. Thank you. And Madam Secretary, you had another 

full-time job. You didn’t need to take this on, but you did and we 

13 

all so appreciate it, that you would once again suit up for your 

service outside of your regular duties, which we all know are huge. 

So thank you both very much. 

Let me say a couple of things. I am the Ranking Member on the 

Veterans Affairs and Military Construction Appropriations Subcommittee, so I have been dealing with the issues of funding, of 

course, for veterans, but also trying to make sure that we have the 

seamless transition. Now, you did in your report address this issue, 

suggesting that we have the rapid transfer of patient information 

between DOD and VA. But I do want to say that this is something 

where the VA is really leading. 

We have the state-of-the-art electronic medical records in the VA 

system. It was never brought home better than after Katrina in 

New Orleans when the whole Veterans’ Hospital had to be vacated 

and not one record was lost—not one. So our veterans in New Orleans got superb treatment wherever they were, wherever they evacuated, and that is a testament to the system. Of the 155 VA hospitals, every one is set with the electronic records, so we know 

there is a system that works. 

However, as has been said here, it is the transition to DOD, and 

the anecdotal information that we get is phenomenal. In Houston, 

for instance, I was called because our veterans who were injured 

and therefore retired with disabilities were waiting months and 

even almost a year for their disability benefits. So we immediately 

went to the VA and they tasked people to go down to try to fix that 

hiatus because we just didn’t have enough people processing. 

I know that because the VA system is so good, if we put our 

minds to it and we take your direction, which you also saw, and 

bring DOD up to the same standards so that people can have a 

seamless transition, that everyone will be ahead. It is inexcusable 

for someone injured in Iraq or Afghanistan to go on medical disability and not get their benefits for three to nine or 10 months. 

It is just inexcusable. So that is the issue that I think we have to 

address immediately and I really think it is in DOD and matching 

those up. 

So thank you for your service. Thank you for being here to report 

to us, and we will follow up, I assure you, on your recommendations. Thank you. 

Chairman AKAKA. Thank you very much, Senator Hutchison. 

Now we will hear from Senator Isakson. 

STATEMENT OF HON. JOHNNY ISAKSON, 

U.S. SENATOR FROM GEORGIA 

Senator ISAKSON. Well, thank you very much, Chairman Akaka. 

I appreciate you and the Ranking Member doing this. Senator 

Dole, it is a pleasure to see you again. Secretary Shalala, thank 

you for your service to the country. 

My remarks will be limited to the seamless transition issue. I 

want to commend you on your recommendations and the focus on 

that and point out what I have in a couple of previous hearings 

that we have had. 

General Schoomaker did a great job in Augusta with the Augusta 

VA, called the Uptown VA Hospital, and the DOD facility, Eisenhower Medical Center, created a seamless transition of treatment 

14 

and rehabilitation for wounded warriors coming back that is really 

second to none. In fact, I told the story previously, and I will tell 

it one more time at the risk of being repetitive because I think it 

is so important. 

I met a Sergeant Harris when I was at the Augusta VA. She had 

gone to Iraq and on the second day of her deployment had a Traumatic Brain Injury from an exploding IED. She came back to the 

States. DOD treated her. They could not correct it, so she was severed from the military and went to the VA hospital. They corrected 

the Traumatic Brain Injury and reenlisted her in the military and 

she was on active duty at the Augusta Eisenhower Medical Facility, which shows when you have a good seamless transition and 

continuous care it is of immeasurable benefit to our wounded warriors. 

So I commend you on your recommendations on that, your recommendations on electronic records and evaluations. All are critically important to seeing to it our veterans get the very best and 

the timeliness of care, and I thank you again for both of your service to the country. 

Chairman AKAKA. Thank you very much, Senator Isakson. I am 

pleased to welcome our first panel. We are fortunate to have two 

highly distinguished public servants testifying before the Committee today. 

I am honored to welcome the Co-Chairs of the President’s Commission on Care for America’s Returning Wounded Warriors, 

former Senator Bob Dole of Kansas and Donna Shalala, Secretary 

of Health and Human Services during the Clinton administration. 

Senator Dole and Secretary Shalala were called by the President 

to lead an evaluation of the care and services provided to America’s 

wounded servicemembers when they return home from battle. They 

are here today to share their findings and recommendations with 

the Committee. 

Senator Dole and Secretary Shalala, we are pleased to have you 

here today and look forward to your testimony. Your full statements will appear in the record of the hearing and you may begin 

with your statement, Secretary Shalala. 

STATEMENT OF HON. DONNA E. SHALALA, CO-CHAIR, PRESIDENT’S COMMISSION ON CARE FOR AMERICA’S, RETURNING 

WOUNDED WARRIORS 

Ms. SHALALA. Thank you very much, Chairman Akaka, Ranking 

Member Burr, distinguished Members of this Committee. Before I 

begin, let me introduce one member of the Commission who has 

joined us, Ed Eckenhoff, who runs the National Rehabilitation Hospital, a private rehabilitation hospital here in Washington, D.C., 

one of the leading experts on rehabilitation in this country; and 

Marie Michnich, who was our Executive Director, who is at the Institute of Medicine of the National Academy of Sciences; and Dr. 

Sue Hosek from the RAND Corporation, one of the leading experts 

in military health, who was our Research Director; and Dr. Karen 

Geiss from the Medical College of Wisconsin, who was the Deputy 

Executive Director of our Commission. We had a very short period 

of time so we literally grabbed talented people from all over this 

country to come join us to do our work. 

15 

It was a privilege to serve on the President’s Commission with 

Senator Dole. We never had a disagreement. He is fun to work 

with, but more importantly, he knows this system and cares deeply 

about what happens to these young men and women who come 

back from conflict. 

Of our nine Commissioners, four were severely injured in current 

or past conflicts and one was the wife of a soldier from Iraq. This 

was not a Commission of the usual suspects. It was a Commission 

that had a very high percentage of young people who had current 

information and current experiences and included people who had 

not been on commissions before but took a fresh look at these 

issues. 

We presented six groundbreaking patient- and family-centered 

recommendations, and one of the important things about our recommendations is they were not bureaucracy-centered. They were 

patient-centered and family-centered. We tried to look at the issues 

from the point of view of the people that were directly affected, as 

opposed to the people that provided just the services. 

Our report, which is called ‘‘Serve, Support, and Simplify,’’ we believe is not only short, but it is a blueprint for and certainly a very 

clearly outline for the kinds of changes we believe must take place. 

Let me also emphasize, as General Scott will, that our recommendations stand on the report of others. We built upon other 

recommendations. We looked carefully at the Bradley Commission 

and all the previous commissions as well as more recent commissions. 

Our six recommendations do not require massive new programs 

or a flurry of new legislation. We identified with the six recommendations 34 specific action steps that must be taken to implement the six recommendations. Only six of the 34 require Congressional action, and that is what I want to focus on today. I want to 

talk about those six that require action by Congress and then Senator Dole will discuss how the recommendations will work together 

to create a new system. 

The first action step calls for Congress to simplify the DOD and 

VA disability systems. I realize in this town the word ‘‘simplify’’ is 

not often used, but I think that our point here is it ought not to 

take an expert to understand the system. Any injured soldier or 

member of their family ought to be able to understand what is 

going to happen to them and what benefits are available to them 

and how the disability system works. 

Right now, DOD and VA assess each servicemember’s disability 

for completely different reasons. DOD needs to determine if they 

can continue to do their job despite their medical condition. If they 

can’t, then they must discharge the servicemember. The degree of 

disability, the length of time spent in service depends on the 

amount of military compensation and benefits. 

DOD generally only rates a condition that prevents the servicemember from doing their job. The VA determines how disabled a 

veteran is based on every medical condition that occurred was 

made worse while in the military service. The degree of disability 

is part of how the VA determines what benefits, services, and the 

amount of compensation the veteran will get. 

16 

Over the years, this evaluation system has become really convoluted as we tried to fix problems and that is the point we are 

making today. People of good will in this Congress and in the agencies, every time they had a problem they added a new regulation, 

a new requirement, a new piece of legislation, and that is why the 

system is so convoluted and so complex today. 

We recommend simplifying the system. DOD retains their authority to determine fitness to serve. If a servicemember whose 

health conditions make them unfit for duty, they would be separated from the military with a lifetime annuity payment based on 

their rank and years of military service. They don’t have to wait 

20 years. If they get severely injured, they have been in for 11 

years, they can’t any longer serve in the military. They would leave 

the military with an annuity payment based on their rank and that 

11 years of service. 

This recommendation brings DOD in line with other employers 

of choice. That is the way the employment system works where you 

have an annuity system in this country, and it is a very important 

step in maintaining a volunteer Army, from our point of view. 

We also believe that only one physical exam should be performed 

rather than the two required now—one by each department—and 

that that physical should be performed by DOD. The VA then 

would assume all responsibility for establishing the disability rating based on that physical and for providing all disability compensation. 

So you split the two responsibilities based on their expertise and 

the appropriate role for each department, but it is the VA that 

makes the disability determination. It is a much simpler system. 

It supports those that are transitioning between active duty and 

veteran status and it puts the DOD in the right frame. They provide the necessary military strength and expertise to keep our Nation safe and secure. They can determine their own fitness standard for serving. 

Now, obviously, there are some soldiers that the DOD will find 

a job for even though they have an injury—an amputation, for example—and that is really for them to work out with those soldiers. 

They have an interest in doing that. They would like to keep people 

employed. But if the decision is that that soldier, sailor, or Marine 

should go over to the VA system, they would leave with an annuity. 

They would go to the VA system and get their disability rating, the 

disability payment, and some other things that we recommend. 

The second action step out of the six is that we recommend 

health coverage for servicemembers who are found unfit because of 

conditions that were acquired in combat, supporting combat, or 

preparing for combat. We believe that Congress should authorize 

comprehensive lifetime health care coverage and pharmacy benefits 

for those servicemembers and their families through DOD’s 

TRICARE program, and the important phrase here is ‘‘and their 

families.’’ 

Many of these young people can take a job, but finding a job that 

has benefits that will cover their families is probably a real challenge. This will change their lives if this benefit is available. We 

really believe it will help them to find employment because they 

will have a lot more choices. 

17 

Our third action step is to ask Congress to clarify the objectives 

for the VA disability payment system by revising the three types 

of payments which are currently provided to many veterans. The 

primary objective should be to return the disabled veteran to normal activities insofar as possible and as quickly as possible by focusing on education, training, and employment. We recommend 

changing the existing disability compensation payments for injured 

servicemembers to include three components: Transition support, 

earnings loss, and quality of life. 

Transition payments are, of course, temporary payments to help 

with expenses as disabled veterans integrate into civilian life. Veterans should receive either 3 months of base pay if they are returning to their communities and not participating in further rehabilitation, or an amount to cover living expenses while they are participating in education or work training programs. We also believe 

that the time for participating in these training programs should 

be expanded to 72 months for those who may need to attend parttime. Most of the students in this country are not going to school 

full-time. They are going to school part-time, and our veterans, our 

investments in these veterans ought to reflect what is happening 

in the larger society. 

Second, earnings loss payments. We should make up for any 

lower earning capacity remaining after transition and after training. That is what we mean by modernizing the system. Earnings 

loss payments should be credited to Social Security earnings and 

would end when the veteran retires and claims Social Security benefits. Now, the President has a slightly different recommendation 

in this area. 

In addition, we believe that quality of life payments should be 

provided to disabled veterans, and these payments are based on a 

more modern concept of disability, and that is our point about the 

current disability system. It is very old fashioned. No one except 

this government is paying disability payments this way any longer. 

Everybody has quality of life payments as part of the payment 

scheme. We need to take into account an injury’s impact on an individual’s total quality of life, independent of the ability to work. 

And if you look at the private sector payments, they combine these 

two when someone has a disability. 

We also call for the disability status of veterans to be reevaluated periodically, and we see this as a positive provision that would 

ensure that all disabled veterans are seen by a health professional 

at least every few years. What we don’t want is for the payment 

to go out of date for an individual veteran. 

By simplifying and modernizing the DOD and VA disability systems, we will make the systems less confusing, we will eliminate 

payment inequities, and we will provide a foundation with appropriate incentives for injured veterans. 

Our fourth action step asks you to authorize the VA to provide 

lifetime treatment for PTSD for any veteran deployed to Iraq or Afghanistan that needs such services. This presumptive eligibility for 

the diagnosis and treatment of PTSD should occur regardless of the 

length of time that has transpired since the exposure to combat 

events. 

18 

One of the things that we learned from talking to young veterans 

is that when they get out, they want to get out, and many of them 

are asked but they don’t answer because they want to go home. 

They have got to be able to come back and get evaluated. We are 

involved in very intense urban fighting, often against civilian combatants, and many servicemembers witness or experience acts of 

terrorism. Many of these servicemembers have deployed multiple 

times. We need to make sure that those services are available forever for these servicemembers. 

Next, we ask Congress to strengthen support for military families. The fact that a wife has to give up whatever she is doing, 

whether it is school or a job, and other family members—we met 

husbands, we met mothers that were giving up their positions. We 

have asked that they be provided benefits, as well, as caregiving 

benefits. We have asked for more intensity in the family support 

systems that are made available. We have asked that the Family 

and Medical Leave Act, which Congress has been supportive of, 

goes from 12 weeks to up to 6 months for a family member of a 

servicemember who has come back with a related injury and meets 

the eligibility requirements. 

The military does a very good job of getting family members to 

the bedside of an injured servicemember. That is not the problem. 

It is once they get there and the kinds of services that we provide 

for them and what we say to them about their lifetime responsibilities in attendant care. That is our responsibility as a Nation. They 

will do it if they must, but it seems to us fundamentally unfair that 

we are not providing more support to these family members, and 

we have made a series of recommendations. 

Mr. Chairman, I believe the government can work to improve the 

lives of its citizens. I also believe that when we fix problems, we 

often add to their complexity. I, of course, had to manage the Medicare program, which is an example of that kind of complexity. 

Here, we have a chance to think clearly about the system and to 

simplify it, make it more straightforward, make it fairer, and invest resources where they will really make a difference. 

Thank you very much, and I will yield to my colleague, Senator 

Dole. 

[The prepared statement of Ms. Shalala follows:] 

PREPARED STATEMENT OF DONNA E. SHALALA, CO-CHAIR, PRESIDENT’S COMMISSION

ON CARE FOR AMERICA’S RETURNING WOUNDED WARRIORS

Good morning Chairman Akaka and distinguished Members of the Committee. 

Thank you for the opportunity to testify today, along with my fellow Co-Chair, Senator Bob Dole, about the recommendations our Commission presented to the President, Congress and the public in late July. 

It was a true privilege to serve on the President’s Commission on Care for America’s Returning Wounded Warriors, especially with Senator Dole, whose knowledge 

of and experience with veterans’ issues was invaluable during our short Commission 

tenure. We were joined by a remarkable group of commissioners, with their own 

unique experiences and expertise. Of our nine commissioners, four were severely injured in current or past conflicts and one was the wife of a soldier from Iraq who 

was severely burned. 

The Commission presented six groundbreaking patient and family centered recommendations that make sweeping changes in military and veterans’ health care 

and services. At the heart of these recommendations is our belief in a system of care 

and benefits that enables injured or ill service men and women to maximize their 

successful transition, as quickly as possible, back to their military duties or civilian 

19 

life. Our report—Serve, Support, Simplify—is a bold blueprint for such a system. I 

respectfully request that this report be submitted for the record. 

Let me take a moment here to emphasize that our efforts built upon the recommendations and reports of others—most of them here today. We are united in 

our call for change. We were not duplicative of these recommendations, but added 

to them in significant ways. 

Our six recommendations do not require massive new programs or a flurry of new 

legislation. We identify 34 specific action steps that must be taken to implement the 

six recommendations. Only six of these 34 items require legislation, and that’s what 

I will focus on today. 

I will summarize the actions that require legislation, and, then, Senator Dole will 

discuss how all of our recommendations would work together to create the best system of care to return our wounded warriors to optimal health and productivity. 

Our first action step calls for Congress to simplify the DOD and VA disability systems. Right now, these Departments assess each servicemember’s disability for different reasons. DOD needs to determine if servicemembers can continue to do their 

job despite their medical condition. If they can’t, then the DOD must discharge the 

servicemembers. The degree of disability and the length of time spent in service determine the amount of military compensation and benefits. DOD generally only 

rates the condition that prevents the servicemembers from doing their job. VA determines how disabled a veteran is based on every medical condition that occurred or 

was made worse while in military service. The degree of disability is part of how 

the VA determines what benefits, services, and amount of compensation the veteran 

will get. Veterans can ask the VA to rate additional disabilities at any time. 

Over the years, the disability evaluation system has become convoluted as we 

tried to fix problems. What we created is a system that is confusing and takes too 

long. In our national survey of injured servicemembers, less than half understood 

the DOD’s disability evaluation process. And, only 42 percent of retired or separated 

servicemembers who had filed a VA claim understood the VA process. The system 

is dysfunctional and we need to fix it. 

We recommend that DOD retain authority to determine fitness to serve. Servicemembers whose health conditions make them unfit for duty would be separated 

from the military with a lifetime annuity payment based on their rank and years 

of military service. This recommendation brings the DOD in line with other employers of choice—an important step in maintaining an all volunteer professional military force. 

We believe that only one physical exam should be performed, rather than the two 

required now—one by each Department—and it should be performed by the DOD. 

The VA should assume all responsibility for establishing the disability rating based 

on that physical and for providing all disability compensation. 

It is a much simpler system that better supports the needs of those transitioning 

between active duty and veteran status. It modernizes the system and allows the 

two Departments to focus on their unique and separate missions. DOD must provide 

the necessary military strength and expertise to keep our Nation safe and secure. 

DOD should determine fitness standards and provide for the health and readiness 

of the military workforce. As an employer, DOD must also provide retirement benefits. The VA’s mission is to care for our Nation’s veterans by providing appropriate 

benefits and services. 

In our second action step, we recommend health care coverage for servicemembers 

who are found unfit because of conditions that were acquired in combat, supporting 

combat, or preparing for combat. Congress should authorize comprehensive lifetime 

health care coverage and pharmacy benefits for those servicemembers and their 

families through DOD’s TRICARE program. 

We believe this action item would help these individuals find employment that 

best fits their needs and talents instead of making a career choice based on whether 

family health care coverage is provided. 

In our third action step, we would like Congress to clarify the objectives for the 

VA disability payment system by revising the three types of payments currently provided to many veterans. The primary objective should be to return disabled veterans 

to normal activities, insofar as possible, and as quickly as possible, by focusing on 

education, training, and employment. We recommend changing the existing disability compensation payments for injured servicemembers to include three components: transition support, earnings loss, and quality of life. 

‘‘Transition Payments’’ are temporary payments to help with expenses as disabled 

veterans integrate into civilian life. Veterans should receive either 3 months of base 

pay, if they are returning to their communities and not participating in further rehabilitation; or an amount to cover living expenses while they are participating in 

education or work training programs. We also believe that the time allowed for parVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00023 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
20 

ticipating in these training programs should be expanded to 72 months for those 

who might need to attend part-time. 

‘‘Earnings Loss Payments’’ make up for any lower earning capacity remaining 

after transition and after training. Initial evaluation of the remaining work-related 

disability should occur when training ends. Earnings loss payments should be credited as Social Security earnings and would end when the veteran retires and claims 

Social Security benefits. 

In addition, we believe that ‘‘Quality of Life Payments’’ should be provided to disabled veterans. These payments are based on a more modern concept of disability 

that takes into account an injury’s impact on an individual’s total quality of life— 

independent of the ability to work. 

We also call for the disability status of veterans to be reevaluated every 3 years 

and compensation adjusted, as necessary. We see this as a positive provision that 

would ensure all disabled veterans are seen by a health professional at least every 

few years. 

By simplifying and modernizing the DOD and VA disability systems, Congress 

will make the systems less confusing, eliminate payment inequalities, and provide 

a foundation with appropriate incentives for injured veterans to return to productive 

life. 

Our fourth action step calls on Congress to authorize the VA to provide lifetime 

treatment for PTSD for any veteran deployed to Iraq or Afghanistan in need of such 

services. This ‘‘presumptive eligibility’’ for the diagnosis and treatment of PTSD 

should occur regardless of the length of time that has transpired since the exposure 

to combat events. 

The current conflicts involve intense urban fighting, often against civilian combatants, and many servicemembers witness or experience acts of terrorism. Five hundred thousand servicemembers have been deployed multiple times. The longer 

servicemembers are in the field, the more likely they are to experience events— 

which can lead to symptoms of PTSD. The consequences of PTSD can be devastating. The VA is a recognized leader in the treatment of combat-related PTSD, 

with an extensive network of specialized inpatient, outpatient, day hospital, and residential treatment programs. Therefore, we ask that any veteran of the Iraq or Afghanistan conflicts be able to obtain prompt access to the VA for diagnosis and 

treatment. 

Next, we ask Congress to strengthen support for our military families. 

In our travels across the country, it become abundantly clear that we not only 

needed to help the severely injured, we needed to help their loved ones too. These 

loved ones are often on the front lines of care and they are in desperate need of 

support. Therefore, we call upon Congress to make servicemembers with combat related injuries eligible for respite care and aide and personal attendant benefits. 

These benefits are provided in the current Extended Care Health Option program 

under TRICARE. Presently, DOD provides no other benefit for care-giving. Yet we 

know that many families are caring for their injured servicemember at home—and 

many of these servicemembers have complex injuries. These families, forced into 

stressful new situations, don’t need more anxiety and confusion, they need support. 

Families are unprepared to provide 24/7 care. Those that try, wear out quickly. By 

providing help for the caregiver, families can better deal with the stress and problems that arise when caring for a loved one with complex injuries at home. 

We also recommend that Congress amend the Family and Medical Leave Act 

(FMLA) to extend unpaid leave from 12 weeks to up to 6 months for a family member of a servicemember who has a combat-related injury and meets other FMLA eligibility requirements. According to initial findings of research conducted by the 

Commission, approximately two-thirds of injured servicemembers reported that 

their family members or close friends stayed with them for an extended time while 

they were hospitalized; one in five gave up a job to do so. 

Getting family members to the bedside of an injured servicemember is not the 

problem. The services have developed effective procedures to make this happen, and 

the private sector has stepped up to provide temporary housing. Because most injured servicemembers recover quickly and return to duty, the family member’s stay 

may be short. However, for those whose loved one has incurred complex injuries, 

the stay may last much longer. Extending the Family and Medical Leave Act for 

these families will make a tremendous difference in the quality of their lives. Congress enacted the initial Family and Medical Leave Act in 1993, when I was Secretary of Health and Human Services. Since then, its provisions have provided over 

60 million workers the opportunity to care for their family members when they need 

it most—without putting their jobs on the line. 

We are pleased to see that many Members of Congress have embraced this proposal and we hope to see it enacted soon. 

21 

Mr. Chairman, I believe that government can work to improve the lives of its citizens. But sometimes, we fix problems by adding more complexity that in turn creates problems. What we’ve done with the Commission’s recommendations is strip 

some of that away to simplify the system, to go back to basic principles and to make 

necessary programs more patient and family centered. 

We have been truly heartened by the response our report has received in the 

White House, the halls of Congress and throughout the country. The Nation has rallied behind the need to help those who have put their lives on the line in service 

to our country. We have met with the White House and the Departments of Veterans Affairs and Defense and are pleased to report that they are moving forward 

on implementing those recommendations requiring administrative action. We are 

optimistic that Congress will do the same for those recommendations that require 

legislation. 

On behalf of the Commission, I want to thank the Committee again for the opportunity to discuss our recommendations. I look forward to joining Senator Dole in answering your questions. 

STATEMENT OF HON. BOB DOLE, CO-CHAIR, PRESIDENT’S 

COMMISSION ON CARE FOR AMERICA’S RETURNING WOUNDED WARRIORS 

Senator DOLE. Mr. Chairman, thank you very much, and my colleagues, thank you very much. I want to tell you, Senator Isakson, 

I talked to Doug Bernard yesterday about what is happening in 

Augusta and it really appears to be a great program. I think what 

you need are more participants. You have got the facilities. I am 

not sure there is anything we can do about that, but I am going 

to meet with the Executive Director tomorrow. 

And I want to thank Senator Brown because my Great Grandfather comes from Montpelier, Ohio, so I have got a little Ohio 

strain in my system somewhere. 

And Mr. Chairman, Senator Inouye and I were both in Italy in 

World War II and we were wounded a week apart and a hill apart 

and we ended up in the same hospital—in Percy Jones General 

Hospital in Michigan—with former Senator Phil Hart, whom the 

Hart Building is named after. Phil Hart was a remarkable guy and 

he wasn’t so badly injured, so he used to run errands for us and 

do all these things. He is married to Jane Briggs, and, at that time, 

the Briggs family owned the Detroit Tigers. So, we were able to go 

to baseball games—had free tickets and all that. Now they have renamed that facility the Hart-Dole-Inouye Building. Not that that 

gets us anywhere, but if we are ever there, I assume we can get 

in. [Laughter.] 

So, that is a little history. What I am trying to point out here: 

it is a different generation. And let me say right up front, because 

you are going to hear from maybe some of the veterans’ groups who 

have some problems—and we suggest that is a good thing to have 

a discussion—some are pushing back a little because of the changes 

we are making. There is always a fear that somebody may lose 

something or that somebody may gain from our recommendations. 

And I will confess, we believe we are talking about a different 

generation. If you can see these young men and women—we met 

with some yesterday at the White House—their attitude, and you 

have got Ted Wade and his wife in the audience, and what they 

want to do with their future. So, we front-loaded these recommendations with more money for education, more money for 

family services, recognizing for the first time that quality of life 

should be compensable. If you lose your sight or lose a limb, you 

22 

have gone from a ten to, what, a five, four, three. I don’t know. But 

we recognize that may be considered now by some, and we are 

going to directly address the issue, as Secretary Shalala has already pointed out. 

So, if these young men and women who are making sacrifices 

today, and as Senator Murray said, we can have different views on 

what is happening in Iraq, but we ought to have the same view on 

how we treat those who return. And one thing we never discussed 

in our Commission was politics. I knew the Secretary’s affiliation 

and she knew mine. I don’t think we ever knew the others, and we 

didn’t really care. And we never talked about cost. Cost is never 

an object. Whatever you think of the war, President Bush, or whatever, the President gave three words, said, ‘‘whatever it takes,’’ and 

that was sort of our charge. 

I must say, I have been around a long time. I have been around 

the White House a long time, as I said yesterday, not as long as 

I wanted to be around the White House—— 

[Laughter.] 

Senator DOLE [continuing]. But, I was around a long time—many 

administrations. But the White House staff is really working hard 

on our recommendations and recommendations from the Disability 

Commission in hopes that Congress will take some action this year, 

if possible. There is a conference report floating around that if the 

Veterans Committee would sign off, some of these provisions might 

be included in that conference report. What is the number, S. 1606? 

It is the defense authorization bill. But in any event, that is a technical matter that you can take care of. 

But as Secretary Shalala pointed out, what we didn’t want to do 

is load you up with 350 recommendations. Secretary Gates told us 

when we met with him a couple of months or 3 months ago, he had 

351 recommendations on his desk at that time—just DOD recommendations. So, we felt the best way to approach this is to try 

to simplify it, as the Secretary said, and reduce the number of recommendations and have some action steps and put the pressure on 

the administration to do about 90 percent of these things without 

legislation. 

So we come to Congress with a fairly limited list of things to do, 

and there is some push-back. It may be that this generation of 

young men and women, who I believe are now the greatest generation—I think we passed the baton to this generation—if they would 

do a little better than we did, that is OK. These are grandsons and 

sons of Vietnam veterans and World War II veterans, and if their 

son or grandson does a little better, has better educational opportunities, better family opportunities, that is good. That shows we are 

making progress. It shows we recognize the sacrifices that these 

young men and women make. 

So there shouldn’t be any dollar costs, and we never talked about 

dollars. We didn’t have anybody to ask, what is all this going to 

cost? I assume somebody here will think of that. We guessed maybe 

a billion dollars the first year and maybe more the second and 

third years. But again, we just wanted to do it right. 

One thing that I want to stress before I forget it, we also believe 

that if you can’t find the best care at a VA facility or a DOD facility, you ought to be able to go to a private facility. If you live in 

23 

Idaho or Kansas or Montana or wherever, you may not have a facility close by, but if there is a facility close to some disabled veteran where they can provide—whether it is PTI or PTSD or whatever it might be—excellent treatment, that ought to be available. 

You shouldn’t have to drive 400 or 500 miles and spend the night 

and do all those things in order to get excellent treatment. And I 

say that because Ed Eckenhoff here, who was on our Commission 

and who has a serious disability, is the Director of the National Rehabilitation Center and he has treated—how many? 

Mr. ECKENHOFF. Last fiscal year, 46. 

Senator DOLE. But how many Iraqi-Afghan veterans have you 

treated? 

Mr. ECKENHOFF. 46. 

Senator DOLE. Oh, 46. So they get excellent care, and you can 

look at some of the recoveries that are remarkable, because I am 

not downgrading the VA or the DOD, but I was saying in some 

cases, the private sector opportunity ought to be available. 

One thing we found, because I think the Washington Post story 

was a wake-up call for all of us, regardless of our party or whatever, veterans or non-veterans, it pointed out that we had a problem. It was primarily a facilities problem, but it became a patient 

problem if you were an outpatient and had to stay in a place like 

that. Building 18 is not part of the Walter Reed campus, but it is 

part of Walter Reed and it never should have happened. So the 

President appoints a commission. Congress has hearings. A lot of 

good things have happened, but we still haven’t passed anything 

that is going to make a real difference. 

I don’t want to take a lot of time, and you have already put my 

statement in the record, but I want to recite just three cases to give 

you an example of what can happen. 

First is a soldier injured when his Bradley Fighting Vehicle 

rolled over on an improvised explosive device and he was airlifted 

to Baghdad and received the first of over 40 operations. He was 

then taken to Landstuhl Regional Medical Center for additional 

medical care. And then he ended up at Brooke Army Medical Center’s burn center, which is the best in the world. It is a great place 

and I am certain many of you have visited there. In addition to his 

burn injury, he also had Traumatic Brain Injury and his wife 

joined him and left their son with his grandmother in Kansas. 

Over the next 2 years—some of the things that Senator Murray 

has pointed out—the family had to deal with many issues including 

military pay and a permanent change of station move, while maintaining their personal support, much needed to help their soldier 

get better. Then, when the soldier finally came home, he was severely limited in what he could do. The wife became his full-time 

caregiver. Now, obviously she doesn’t object to that, but it shouldn’t 

be necessary. She should be able to pursue her job, her school, her 

education. So, there are some provisions for care: we provide for 

respite care and additional benefits to make certain that a 

spouse—it could be a husband or a wife—can move on with their 

life and still be there. 

The second story is about a Marine corpsman who was hit by a 

rocket when his base in Iraq was attacked and he woke up a few 

days later in Bethesda Naval Medical Center, and after several opVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
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erations and amputation of his left arm, he was transferred to Walter Reed for therapy and eventually retired. 

The third story is about an officer whose convoy is ambushed by 

insurgents and rocket-propelled grenades and one grenade exploded in the leg well of the vehicle and severely injured his right 

leg. The second exploded at the rear of the vehicle, causing shrapnel wounds of his neck, shoulders, arms, and back, and he was 

evacuated and finally reached Landstuhl. After his two-and-a-half 

years at Walter Reed, they were able to salvage his leg and he is 

on the temporary disability retired list. 

Now, the reason I cite these three stories, they have several 

things in common. The medical care and compassion that these individuals received in the theater was exceptional. You go back and 

look at World War II. For every one killed, there was maybe one 

survivor. For every one killed today, I think the number of survivors is 14 or 16. It is way up there. We have made a lot of 

progress from the battlefield, and you want to give a lot of credit 

to these medics who are out there on the battlefield rescuing these 

young men and women. 

So, the survival rate is very high because of improved technology, 

improved care, improved transportation. It took me 8 weeks to get 

from Italy to Miami, Florida—my first stop—and now you can be 

wounded in Baghdad on a Tuesday and be in bed at Walter Reed 

on a Friday. That is just how it has improved. It meant life for 

many people who would have otherwise not made it. 

But, here are some of the things that happened. Each of these 

individuals encountered problems with difficult and inflexible systems. They had complex injuries and required lengthy rehabilitation. They each had case manager after case manager. We had a 

young man on our Commission, Jose ́ Ramos, who lost an arm in 

Iraq. He had so many case workers, he couldn’t remember their 

names. Now, you wonder why they don’t keep their appointments 

and don’t see the doctor and don’t get out on time. Jose ́ is just a 

great guy, and I want to thank the initiator of the provision of the 

Recovery Care Coordinator, which Secretary Shalala initiated, 

where this one care coordinator will follow that patient from the 

time they walk into Walter Reed Hospital, or wherever it may be— 

and about 26 percent of people go to Walter Reed, that is their first 

stop—and they will follow them all the way through until they go 

back to the unit, go home, or go to the VA. 

To me, that is a big, big improvement as far as moving the process along—giving that person not only the responsibility, but the 

authority to be there on the take-off and be certain that they are 

part of the team. And, I think that it is not expensive. We are talking about 50 to 100 Recovery Coordinators. It is not a big, big bureaucracy. And they are going to be trained by the Public Health 

Service and the DOD and the VA, and to the credit of the administration, that program is already underway. They have already 

started the training. I don’t know when the first ones are going to 

be available, but very soon. I thank Secretary Shalala for that. 

In addition, they had trouble scheduling outpatient visits and follow-up care was difficult. The amount of paperwork, as somebody 

mentioned, was enormous. The VA does have the best IT system 

of anyplace, any hospital, but DOD is a little behind. We had a 

25 

very fine man on our Commission, Dr. Martin Harris from the 

Cleveland Clinic, and that is what he does. He is an expert. And 

he is working now with the DOD and the VA, and we think we can 

make their systems compatible without spending a lot of big money 

and do it very quickly. 

We are also going to have a Web site where you just punch a 

button and you can find out all the services that may be available 

for a particular veteran. When is that going to be available? They 

are testing it right now. I have to check with the experts—we call 

them the three wise ladies—behind me here. 

In any event, the rest of my statement is in the record. We know 

that Congress may not agree with everything we recommended. We 

both have been around government a long time and members of 

our Commission are certainly aware of that. We would like to think 

it is a perfect product, but we know that is not the case. And, certainly we want the VSOs, the Veteran Service Organizations, to 

weigh in. But we want to make certain that everybody understands 

that we are talking about a new generation of young men and 

young women who are making sacrifices. It is a different time, different opportunities, different injuries, different technologies, and 

we think, maybe, some different compensation. They may get a few 

more dollars than maybe somebody in Vietnam. But our charge 

was only Iraq and Afghanistan. We only had 4 months. We didn’t 

have time to go back and look at the other 25 million veterans and 

say, well, we ought to do this, this, and this. 

I am just very honored. We have a great staff and we had a lot 

of help from the DOD and the VA. I think they really try. I have 

been going to Walter Reed as a patient for, I don’t know, 30 years 

or more. I think it is a great place and they have great doctors. 

One thing we were concerned about, since they are going to close, 

is: during the transition the quality of care would drop off and 

some poor guy coming here from Iraq with a bad injury would not 

get first-rate treatment. 

So, our sixth recommendation is—and I am certain everybody 

agrees with—that you keep Walter Reed up and running as a firstclass A–1 hospital until somebody finally turns off the lights. So, 

up until that final day when the move is made, they are available 

to take care of anybody with any kind of an injury that they deal 

with at Walter Reed. We also say that if they need—you know, a 

lot of these doctors don’t want to stay on a ship that is going to 

sink in about 4 years—so, we want to provide some incentives, 

some additional pay, to keep those doctors—whether they are Army 

doctors or contract doctors or nurses or therapists—keep them 

there during this transition. 

But, I know most everybody here and I know that you are concerned about veterans. We all are. It is not a partisan issue. Some 

veterans have problems. I started working with veterans when I 

was a young county attorney in Russell County, Kansas, as a service officer for the VFW and the American Legion, and later, the 

Disabled American Veterans. And so, we have had problems. We 

have always had problems. That is why they had the Bradley Commission. That is why we have had about ten commissions since 

then. It is always a work-in-progress. 

26 

Obviously, we think we can fix it. It probably won’t be perfect, 

but we need your help. Nothing is going to happen unless Congress 

steps up to the plate and says, you know, this is a pretty good idea, 

or maybe we ought to change it, or maybe it is not a good idea. 

But, I really believe you are going to like most of it, and it is because of the hard work and dedication of the staff members. 

We had two amputees on the Commission. Ed is disabled. I have 

a slight disability, and then we had the wife of this young sergeant 

who was burned over 70 percent of his body. So we had a representative Commission, as Secretary Shalala said, and I think we 

are going to continue working. We are volunteers. We will be happy 

to come back. We will be happy to sit down with staff. I know 

Karen and Sue and Marie will be happy to sit down with staff and 

go into details. We want to thank you for giving us this opportunity. 

[The prepared statement of Senator Dole follows:] 

PREPARED STATEMENT OF BOB DOLE, CO-CHAIR PRESIDENT’S COMMISSION ON CARE

FOR AMERICA’S RETURNING WOUNDED WARRIORS BEFORE THE UNITED STATES SENATE

Good morning Mr. Chairman and Members of the Committee. It is a pleasure to 

appear before you today, along with my fellow Co-Chair Donna Shalala. 

We look forward to working with you, and the other individuals here today, to 

support this Nation’s goal of assuring that our service men and woman receive the 

benefits and services they deserve. 

It has been an honor to serve on this Commission, especially with Secretary 

Shalala. I have said it before and I will say it here today, she’s been a ‘‘Triple A’’ 

co-chair. She has boundless energy and kept us going as we tackled this important 

challenge. It has been a great experience to work with her and our fellow commissioners. 

Our recommendations were guided by the Commission chaired by General Omar 

Bradley in 1956, which said: ‘‘Our philosophy of veterans’ benefits must be modernized and the whole structure of traditional veterans’ programs brought up to date.’’ 

Problems accompany change—wars change, people change, techniques change, injuries change, and we need to keep our military and veterans health care system 

up-to-date. I find it remarkable that 50 years later we are finding so much of what 

General Bradley had recommended is still relevant today. 

Secretary Shalala has outlined the action steps to be taken by Congress. I will 

now tell you how our recommendations—all of them—work to create a system that 

serves, supports, and simplifies. 

First, let me review our recommendations: 

1. Immediately Create Comprehensive Recovery Plans to Provide the Right Care 

and Support at the Right Time in the Right Place 

2. Completely Restructure the Disability Determination and Compensation Systems 

3. Aggressively Prevent and Treat Post Traumatic Stress Disorder and Traumatic 

Brain Injury 

4. Significantly Strengthen Support for Families 

5. Rapidly Transfer Patient Information Between DOD and VA 

6. Strongly Support Walter Reed by Recruiting and Retaining First Rate Professionals Through 2011. 

Now let me tell you how they would work using the experiences of three wounded 

warriors. 

The first is a soldier who was injured when his Bradley Fighting Vehicle rolled 

over an improvised explosive device. He was airlifted to Baghdad where he received 

the first of over 40 operations. He was then taken to Landstuhl Regional Medical 

Center for additional medical care and stabilization, after which he was taken to 

Brook Army Medical Center’s burn center. In addition to his burn injuries, he also 

had a Traumatic Brain Injury. His wife joined him at Landstuhl and traveled with 

him to Brook, leaving their son with his grandmother in Kansas. 

Over the next 2 years, this family had to deal with many issues including military 

pay and a permanent change of station move, while maintaining the personal supVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
27 

port needed to help their soldier get better. When the soldier finally came home, 

severely limited in what he could do, the wife became his full time caregiver. 

My second story is about a Marine corpsman who was hit by a rocket when his 

base in Iraq was attacked. He lost consciousness and woke up a few days later at 

Bethesda Naval Medical Center after several operations and amputation of his left 

arm. He was transferred to Walter Reed for occupational and physical therapy and 

eventually medically retired. 

My third story is about an officer whose convoy was ambushed by insurgents 

using small arms fire and rocket-propelled grenades. One RPG exploded in the leg 

well of his vehicle, severely injuring his right leg. The second RPG exploded at the 

rear of his vehicle causing shrapnel wounds to his neck, shoulders, arms, and back. 

He was evacuated to Al Assad, then Balad, and finally Landstuhl with operations 

on his leg at each stop. He was ultimately evacuated Walter Reed. After 21⁄2 years 

of rehabilitation and additional operations to salvage his leg, he is on the temporary 

disability retired list. 

These stories have several things in common. The medical care and compassion 

that these individuals received in theater was exceptional. Today’s military trauma 

care saves lives that would have been impossible in previous wars. The military 

medical evacuation system that removes injured servicemembers from the field of 

battle to a military treatment facility in the U.S. within 36 hours after the injury 

is nothing short of remarkable. 

However, each of these individuals encountered problems with difficult and inflexible systems. They each had complex injuries and required lengthy rehabilitation. 

They each had case manager after case manager. One told us he had over 10 and 

could never remember what they were managing, never mind their names. Communication between the providers of care and services and the servicemember were 

spotty at best and, often, didn’t happen at all. 

Scheduling outpatient visits for necessary follow up and care was difficult. The 

amount of paperwork was enormous, never ending, and redundant. Patients and 

their families had no single point of contact. Processing for a medical discharge took 

months and delayed patient and family decisions. At Walter Reed, outpatients exceeded the facility’s capacity to house them, creating the problems of Building 18. 

Had our recommendations been in place, each of these individuals would have had 

a recovery coordinator assigned at the time they arrived at a stateside military hospital. The recovery coordinator would have developed a recovery plan along with the 

patient’s medical team and other personnel designed to return the patient to optimal functioning. 

The recovery plan would make the best treatment and services available—including those in the VA or the private sector. The plan would not stop after the patient’s 

discharge from the hospital, but continue to guide recovery through outpatient care, 

rehabilitation, and any necessary retraining or education. The recovery coordinator 

would serve as a single point of contact for the patient and family. 

We recommended that the recovery coordinator be part of an elite unit of the Public Health Service. We did so because we thought it best to place these individuals 

outside of either the DOD or VA. Part of this reasoning was because we were concerned that VA or DOD employees would not be allow to effectively reach out to 

the other Department, marshalling needed services, with any degree of authority. 

We also recommended that Walter Reed be supported until it closes. Perhaps 

some of the difficulties with outpatient clinic appointments and medical hold and 

holdover at Walter Reed would not have been so problematic if our recommendation 

had been in effect. 

Fortunately, only one of the individuals I mentioned had a Traumatic Brain Injury and none have developed Post Traumatic Stress Disorder. We recommended 

that the DOD and VA aggressively prevent and treat TBI and Post Traumatic 

Stress Disorder. 

New ways of protecting our servicemembers from these devastating conditions 

would be developed and implemented. Military leaders, VA and DOD medical providers, family members and caregivers would have access to educational programs 

to better understand these problems and how to help. 

Health care providers in both the DOD and the VA would be using the most contemporary clinical practice guidelines to assess and evaluate servicemembers and 

veterans for these conditions. 

More mental health professionals would be available in the DOD and VA. Anyone 

concerned he or she might have PTSD could go to the VA, an internationally recognized expert in combat related PTSD, to get care. 

Families, such as the one in my first story, also need support and help. With our 

recommendations, the grandmother, who took a leave of absence from her job to 

28 

stay with her grandson, would be able to take an additional 3 months under an enhanced provision within the Family Medical Leave Act. 

The wounded warrior’s wife would be able to get respite care or aid and attendant 

care through the ECHO program within TRICARE. As the primary caregiver for her 

wounded husband, she needs assistance, assistance that currently does not exist in 

the DOD. 

She would also get training and counseling to help care for her husband. 

All three injured individuals had to deal with mountains of paperwork—paperwork that was frequently lost or unavailable at critical process decision points. In 

this day of electronic everything, it is frustrating to fill out form after form, repeating the same information over and over again. 

But the problem with information technology should not be solved by starting 

over—that will just delay things. Instead, we have recommended that DOD and VA 

be held to a scorecard for documenting the progress of information sharing. While 

we all want interoperability of medical records, we don’t have to wait for this goal 

to become reality. Much can be made visible now. 

We have also recommended the development of a web portal that will provide tailored information to each servicemember and veteran specific to their situation. We 

understand that this effort is currently underway and we are ready to try the product. 

We have also recommended a complete reform of the current disability evaluation 

and compensation system as Secretary Shalala has just told you. 

Under this recommendation, each of our wounded warriors would be evaluated as 

to whether they could perform any military duty by the DOD. If not, each would 

be medically discharged with an annuity based on rank and time in service. They 

each would get TRICARE for themselves and their family. 

The single medical exam performed by the DOD to determine fitness to serve 

would also serve as the exam used by the VA to determine the disability rating 

using an updated rating schedule. The disability rating determines what VA benefits and services the veteran could receive, and the VA’s disability compensation. 

Each would get to select one of two transition payments to take effect upon discharge. They could elect to get 3 months of basic pay, or enroll in an educational 

or training program with an enhanced stipend for up to 72 months. 

At the end of the 3 months or after completing the educational program, each 

would get a quality of life payment based on their specific injuries. They would also 

get an additional payment to make up for any earnings loss. 

We realize that adopting a new system requires a leap of faith for many. We are 

therefore, recommending that two studies be done in the short term. We need to 

determine the right amount of transition pay. We also need to determine what a 

quality of life payment would look like. Once these are completed, and we should 

not take forever, reforming the current disability evaluation and compensation system should move forward. 

For those of you familiar with the Commission’s members, you will recognize the 

individuals in the stories. One is Chris Edwards, whose wife, Tammy Edwards, 

served as a Commissioner. The other stories belong to Jose ́ Ramos and Marc 

Giammatteo, two of our other Commissioners. I want to personally thank all the 

Commissioners for their dedication and hard work. 

I have one last story. This soldier was hit by machine gun fire when he tried to 

assist a wounded comrade. It took 9 hours to evacuate him from the battlefield and 

24 hours to further evacuate him to a field hospital. It took almost 2 months after 

his injury to evacuate him to a stateside Army Hospital. He underwent 9 operations, 

survived a blood clot and, over a period of 3 years learned to adapt to his disability 

through rehabilitation, with his mother at his side. His community chipped in to 

pay his hospital bills and one private sector surgeon performed 7 additional operations at no charge. 

Of course, this last guy is me. I only bring my story up to show the differences 

between now and then. We should always try to improve on what has gone before. 

This may mean that some of the more recent wounded warriors get benefits that 

I don’t and that’s OK. 

I really believe that these are really bold recommendations and doable, but it requires a sense of urgency and strong leadership. 

We stand ready to assist you in any way as we work together to create a system 

that serves our bravest men and women who have made the ultimate sacrifice for 

our Nation. 

Thank you. 

29 

RESPONSES TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO

SENATOR BOB DOLE AND SECRETARY DONNA SHALALA

Comprehensive Recovery Plans 

Question 1. The idea of a coordinated recovery plan is one I embrace fully. The 

Committee-reported bill on traumatic brain injury includes this concept. However, 

I am trying to understand more fully the Commission’s recommendation for a single 

recovery coordinator. The final report of the Commission urged the development of 

a corps of recovery coordinators within the Public Health Service. At the hearing, 

you talked about a much larger role for VA in this process, with VA taking the lead 

in all respects. When did this change and was the Commission involved in this 

change? 

Response. In our recommendations regarding the Recovery Plan and Coordinator, 

we recommended placing the Coordinators within an elite unit of the Public Health 

Services. Since our report was issued, we understand that the VA has requested 

that the Coordinators be placed within the VA and trained by a cadre of personnel 

from the PHS, VA and DOD. The Commission was not involved in this change. 

Question 2. Should VA assume the responsibility for the Recovery Care Coordinators, does this mean that VA will be responsible for coordinating the care of seriously injured servicemembers upon their arrival at a military hospital? As I understand it, some of these servicemembers will either return to active duty and not be 

enrolled in the VA system for years or spend months or years in the DOD medical 

system going through recovery and rehabilitation. My question is, do you believe 

this care coordination role is one VA should be performing prior to a servicemember’s separation from the military? 

Response. We thought long and hard before placing the Coordinators outside of 

the two Departments. We were concerned that placing the individuals wholly within 

either the VA or the DOD would make it unlikely that the Coordinators would be 

able to function as we envisioned. The Coordinators must be able to operate across 

the two Departments and the private sector to access the best care and services for 

an injured servicemember. Their work should commence as soon as possible after 

the injury and continue throughout the recovery period, which can indeed be quite 

long. We were concerned that if the Coordinators resided within the VA, the services 

would not allow them full access to DOD/service resources or the ability to bring 

them to bear for the injured servicemember (and vice versa). We were also concerned that belonging to either department might constrain the use of private 

sources of care. 

Impact on VA Claims Process 

Question 3. Your report recommends that VA update the entire disability rating 

schedule to reflect current injuries and modern concepts of the impact of disability 

on quality of life. Given that a comprehensive overhaul of the rating schedule has 

not been done in over 50 years, I agree that such an endeavor is long overdue. However, at a time when VA already faces a sizable claims backlog, imposing a new rating schedule would require an expansive commitment to re-training staff to use the 

new schedule. Did your study consider the impact such a enormous undertaking 

would have on the already overburdened claims process? 

Response. Most of the current backlog is from veterans already receiving disability compensation and applying for an increase. Under our system, with the 3- 

year automatic review, the workload would be more predictable and more easily 

managed. Failing to update, and appropriately maintain, the current disability rating system is a disservice to our injured servicemembers. PTSD and TBI are not 

adequately addressed in the current VASRD. Quality of life is reflected in some of 

the ratings, but not others. The schedule does not reflect significant advances in 

medical technology for amputation and other conditions. Yes, current raters would 

need to be trained in a new system—a system that will ultimately benefit veterans. 

The added resources needed to make the transition would be modest in comparison 

to the budget for veterans’ disability programs. 

Expert Consultation 

Question 4. As you noted in your Op-Ed in Tuesday’s Washington Post, the VA 

disability system is confusing. The Veterans’ Disability Benefits Commission had 

the support of Mr. Robert Epley, who has served in various capacities at VA, including former Director of the Compensation and Pension Service. Can you please tell 

me who from VA was available to assist the Commission by providing expert advice? 

Response. Dr. Gail Wilensky, one of our Commissioners, was the co-chair of the 

2003 President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans. This 2-year effort focused considerable attention on improving the seamless 

30 

transition to veteran status. As one of the nation’s leading health economists and 

policy experts, Dr. Wilensky also has expertise in disability systems. The three Commissioners who were in the system and became advocates for other servicemembers—Tammy Edwards, Marc Giammatteo, and Jose ́ Ramos—gave us a most 

important servicemember’s perspective. Our recommendations covered both the 

DOD and VA disability (and retirement) systems and our staff included senior staff 

from both systems. In addition, we consulted with the Veterans’ Disability Benefits 

Commission senior staff, Admiral Cooper and his senior staff, GAO’s veterans’ disability analysts, several of the experts who served on the Institute of Medicine panels, and officials in the Office of the Undersecretary of Defense for Personnel and 

Readiness and the military services. Our research director, Susan Hosek, had significant expertise from her 35 years as a RAND researcher, including 6 years as 

director of RAND’s preeminent defense manpower research group. She was also a 

member of the President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans. 

Survey 

Question 5. Over 40 percent of those who responded to the survey were active 

duty servicemembers and thus not yet eligible for VA disability compensation. These 

servicemembers would likely not have had the sort of contact with VA to be able 

to make a knowledgeable response to survey questions regarding the VA compensation system. 

• How were their responses weighted in comparison to recently separated or 

medically retired veterans who had actual experience with VA? 

• Do you know how many survey respondents had actually sought VA disability 

compensation? 

• I understand that the response rate to the telephone survey was less than thirty percent and that, for some subsets of the survey, the response rate was in the 

single digits. How does such a low response rate affect the validity of the survey? 

Response. As of the end of May 2007, 10,185 servicemembers met the criteria for 

our survey: (1) medically evacuated from theater to the U.S. for deployment-related 

injuries or illnesses or (2) subsequently diagnosed with PTSD and (3) separated/retired for no more than 2 years. The last criteria was necessary because of DOD survey regulations but data on the flow of casualties out of theater indicated that this 

criterion eliminated very few. Of these, only 1,715 had separated or retired from 

military service. We included all of these individuals in the sample for the survey 

and they accounted for 29 percent of the sample and 26 percent of the responses. 

We developed weights so that we could present findings that were representative 

of the population we sampled. The survey’s questions about VA disability evaluation 

were asked only to the separated/retired group. We also separately tabulated the results for the other questions since we knew that this group—most of whom were 

injured relatively early—may have had different experiences. 

Among survey respondents who had separated or retired, 89 percent had filed a 

VA disability claim and almost all the others planned to do so. Of those who had 

filed, 58 percent had completed the process by the time of the survey. 

The overall response rate was 30 percent and there was almost no difference 

across sub-groups (e.g., military service, component, age, rank, sex, category of injury). There were two reasons for non-response: inability to locate the respondent 

during the 2–week period the survey was in the field and refusal by those we were 

able to locate. We located 50 percent of the sample and completed interviews with 

60 percent of them. Only 15 percent refused the survey outright. Our response rates 

were at least comparable to rates on similar DOD surveys of military personnel, 

even though these surveys are in the field for months, not weeks, and involve more 

follow-up. The response rates were well above what we anticipated based on experience with this population. 

Different Eras vs. Different Systems 

Question 6. Should the disability system be changed in the manner in which you 

recommended, how do we reconcile veterans from different eras receiving different 

benefits? Do we run the risk of disadvantaging older veterans from World War II, 

Korea and Vietnam? 

Response. As with all transitions, some individuals may be more comfortable with 

their current status and not wish to change. This should be allowed. For those that 

wish to come under the new system, they should be allowed an election period. 

Going forward, all medically discharged servicemembers would come under the new 

system. Ultimately, the decision rests with Congress. 

31 

Disability Appeals 

Question 7. Should VA be given responsibility for making the sole disability determination for servicemembers being medically retired from the military, what process did you envision for servicemembers to appeal a VA disability decision with 

which they disagree? 

Response. Under our recommendations, the DOD determines fitness to serve and, 

when a member is found medically unfit and no longer ‘‘employable’’ in any military 

capacity, provides a retirement annuity. Prior to discharge, the servicemember could 

appeal the finding of unfit and petition for retention, as they do now. The discharged servicemember, now technically a veteran, would get his or her disability 

rating from the VA. The current system of disability rating appeal within the VA 

can still be used to adjudicate any challenge. 

Question 8. What do you believe would be the impact on VA’s resources if it took 

on the responsibility for handling these claims that are now managed by DOD? 

Response. While we were not able to actually quantify the exact impact, we believe that there is a net efficiency in having only one physical exam (by DOD) and 

one disability evaluation determination (by VA). As our survey shows, all servicemembers who are medically discharged from military service currently file a VA disability claim and the number of new VA claims will not change under the new system. Since DOD will conduct a physical exam that meets VA requirements for disability evaluation, there will be many fewer physical exams performed by the VA. 

VA Information Technology 

Question 9. I could not agree more with the Commission’s assessment that VA 

and DOD need to move quickly to get clinical and benefit data to users. I note your 

action plan established a 12-month time line for VA and DOD to make this happen. 

This is certainly a noble goal but, as I am sure you know, DOD and VA have been 

working toward sharing health information for the past decade without great success and VA internally has been working a similar process for benefits information 

for well over a decade. 

How does the Commission envision the Departments meeting such a short time 

line for comprehensive data sharing? 

Response. Commissioner Martin Harris, CIO for the Cleveland Clinic and an expert in health information systems, worked closely with our staff experts to evaluate 

the two departments’ plans for information interoperability and progress in implementing those plans. Given progress to date, the Departments agreed with Dr. Harris’ conclusion that they most information can be made available in the short term 

(viewable), thus the year time line. The departments should be held accountable for 

data-exchange outcomes, not process. We have provided a scorecard to use in this 

regard. We fully understand the frustration with the slow progress in achieving 

interoperability. We were encouraged with the recent electronic availability of the 

DD214. 

Unemployment Compensation for Ex-Servicemembers 

Question 10. With respect to your Commission’s suggestion for ‘‘transition payments’’ during the first 3 months following discharge from active duty. How do those 

payments relate to the benefits available through the Unemployment Compensation 

for Ex-Servicemembers (UCX) program? 

Response. The UCX is a state based and run unemployment compensation program. It provides income for ex-servicemembers after active duty while they search 

for a job. Because this is a state run program, eligibility and benefits vary. Our recommendation was for those servicemembers found unfit and medically retired. They 

would receive a standard 3 months of full pay while transitioning between active 

duty and work. This would supplement UCX for those who meet the state requirements. 

Chairman AKAKA. Thank you very much, Senator Dole. Without 

objection, your statement will be included in the record. 

Senator DOLE. I don’t know what it says. I forgot to read it. 

[Laughter.] 

Chairman AKAKA. Thank you both for your statements and we 

do have questions here. 

One of the Commission’s recommendations is that Congress enable all veterans who need PTSD care to receive it from VA. We 

have worked very hard this year to ensure a solid level of resources 

so that VA could continue to improve their efforts in PTSD. But, 

32 

I am unaware of any existing impediment in law or otherwise 

which now bars veterans from getting care for PTSD. My question 

to you is, what exactly is the basis for this recommendation? 

Ms. SHALALA. Well, I think we want to make sure that there is 

a presumption that anyone can walk in forever, whether or not 

they have gotten care before, and we want to make it clear that 

there ought not to be a time constraint, because we know that 

PTSD can show up a year later or 2 years later. 

And one of the points that Senator Dole keeps making is that 

this is a different generation. Many of them want to go home immediately. They are asked the question, is there something we 

should know? Are you feeling, you know, any symptoms after coming back? They all answer no, and then a year later or 6 months 

later or 2 years later, it shows up. So, I think that making it very 

clear that they have access to services, lifetime services, is extremely important. 

Chairman AKAKA. Thank you. 

Senator DOLE. Could I ask Sue to make a point on that? 

Chairman AKAKA. Please state your name, also. 

Senator DOLE. Sue Hosek with the RAND Corporation. 

Ms. HOSEK. Yes. Currently, veterans get 2 years’ eligibility at the 

VA after they leave the service, but after that time—and PTSD 

symptoms can appear after that time—they first have to go 

through the process of being declared eligible, and our concern was 

that some of these people need to be seen immediately and not wait 

for the disability evaluation to occur. 

Chairman AKAKA. Thank you. Thank you very much. You know 

that—— 

Ms. SHALALA. It ought to be clearly a walk-in service so that people can be seen right away. 

Senator BURR. Well, we have a polytrauma center in Richmond 

which does a good job with PTSD and TBI. 

Ms. SHALALA. Which we visited. 

Chairman AKAKA. I do appreciate that your Commission was 

tasked with focusing on improving the care and benefits for those 

returning from the wars in Iraq and Afghanistan. My question to 

both of you gets to the crux of the challenge we face as we work 

to effect meaningful disability reform. Do you believe there should 

be a separate disability process for servicemembers who are wounded, injured, or become ill in a combat zone versus those who suffer 

disabilities elsewhere? 

Senator DOLE. No. Our view is once you are in uniform, you don’t 

have to be shot at to be injured, or while in the line of duty. If it 

is somebody who is derelict in his duties and, you know, drugs or 

something like that are involved, then there is a question. But, I 

think I have gotten it right—it is across-the-board. 

And ‘‘combat-related’’ is not a narrow definition. Maybe General 

Scott can elaborate on that when he comes up here. But, as soon 

as you sign up in the Army, you are getting ready for combat. You 

may never get there, but you are training for it, so it is a pretty 

broad term. 

Chairman AKAKA. What is your opinion—this has to do with 

quality of life—what is your opinion of the recommendation made 

by the Veterans Disability Benefits Commission that until a sysVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
33 

tematic methodology is developed for evaluating and compensating 

for the impact of disability on quality of life, that there should be 

an immediate interim 25 percent increase to compensation rates? 

Senator DOLE. My view is that we are going to—this is going to 

be done very quickly. There is going to be a commission determining what a quality of life payment would be for, say, an amputee or someone who lost sight, somebody with severe burns; and 

that commission is going to report back to Congress. Congress has 

to have a say, and should have a say. And that is not going to be 

very far off. So, I think by the time we start one system, getting 

ready for the other system, I am not certain—if it is going to take 

4 or 5 years, I would say maybe it is a good idea. But this ought 

to be done in 6 months. 

Ms. SHALALA. Quality of life payments are well established in the 

private sector. An internal study ought to set some standards for 

us, and I agree with Senator Dole to keep the pressure on, getting 

the facts and getting this set up. 

Senator DOLE. You know, this is going to be a significant amount 

added to somebody’s loss of earnings. We have got two new benefits 

here. The transition payment, which Secretary Shalala discussed— 

there is going to be a commission to look at that, whether it ought 

to be 3 months of base pay, whether it will be something else. 

And then we have got this quality of life payment, which is based 

on, I assume, the kind of injury. But we are talking about things 

that maybe you won’t be able to do. You know, people have a social 

life. Maybe you won’t be able to dance, or maybe you can’t play the 

piano like before. Maybe there are things you can’t do that really 

affect your quality of life. We think it is time it is recognized and 

paid for. 

Chairman AKAKA. Thank you. Senator Burr? 

Senator BURR. Thank you, Mr. Chairman. 

Let me just point to the fact that I think this is a great team. 

Both of you bring unusual experience and expertise and you have 

a passion that blends very well. I sat here listening to the Chairman and your comments. It reminded me of the words of Thomas 

Jefferson when he said, ‘‘I am not an advocate of frequent changes 

in laws and constitutions, but laws and institutions must advance 

to keep pace with the progress of the human mind.’’ 

Really, the heart of what you have talked about recognizes the 

fact that we have got generations in this system. And are we the 

ones that are going to recommend—do you put the focus on the 

current and the future ones and begin to distinguish the challenges 

that our troops are faced with coming out of the conflicts today, 

and the types of wounds that they have got and the uniqueness of 

that, in comparison to everybody else in the system. And isn’t it 

time that we begin to recognize that there are two systems, because there are two sets of injuries. 

Senator DOLE. Now that is—go ahead. 

Senator BURR. No. I want to go to the fact that some of the veterans’ organizations have expressed concern with creating a new 

disability system even though it only applies prospectively, and 

I—— 

Senator DOLE. If you like what you are in, you can stay there. 

34 

Senator BURR. That is right. What are the challenges that you 

two see associated with a swift implementation of the recommendations to this new disability system? 

Senator DOLE. For you to persuade these people who are opposed 

to it to get on board. There are not many. I mean, I think there 

are some legitimate concerns that I think you can all address. But 

just to say that, ‘‘Well, we don’t want any change, we like this 600 

pages of band-aids we have been putting on over the years’’—but 

again, I want to make the generational divide. Somebody has to 

stand up and say it is a different kind of warfare; it is a different 

generation. We have got to look ahead, as General Bradley did in 

1956, and say, well, it is about time after, what, 51 years or whatever it is. Maybe we ought to move ahead. 

What you need to do, really, is to get a group of these young men 

and women, the Wades, for example, and others, to tell you how 

they feel about it, because they are different than our generation. 

I never thought I got enough money, of course. I am an average 

American veteran. You never think you get quite enough. But we 

think we have addressed some of those concerns and we want to 

work with the veterans’ groups. 

Have you got anything to add there? 

Ms. SHALALA. You know, the problem with change is that everybody thinks you are doing it because you are trying to save money. 

You start out with this kind of attitude that if you take on a system, particularly a complex system, you are trying to reduce the 

budget. In this case, that is not what we are trying to do at all. 

Are there managerial challenges to creating this transition? Not 

really. I have implemented very complex changes—welfare reform, 

for example; major changes in the Medicare system; Social Security 

Disability went through a major change. It is possible at a managerial level to implement a transition, because you are only dealing 

with new people coming in. Anyone that has the current system 

and loves it can keep it—anyone who has already been evaluated. 

What you are doing is introducing a new system, and if it is only 

focused on the new people, it is relatively easy to put in place. 

And, as I have indicated, there is private sector experience here. 

You are not inventing something that hasn’t been tried in the private sector. In the case of family support, we are simply saying, 

add more resources. Be more sensitive to women and to heads of 

households. Don’t think of the family members as people who have 

to coordinate care. Give them the option of going on with their professional lives, in many cases, and having the kind of support system and quality support system they think their loved one deserves 

and needs. 

So, some of it is an investment in resources, but most of it is 

things that we know how to do. We certainly have to work with the 

definitions. But the numbers will be relatively small in the transition. 

Senator BURR. Secretary Shalala, did any of the Commission 

members worry about whether the VA could handle two disability 

systems? 

Senator DOLE. I don’t think so, and we had VA people detailed 

to us. Top-level people worked with our three wise ladies and I 

don’t think—— 

35 

Senator BURR. So, we can be fairly confident that the Commission came to a consensus that this was not a problem. We can handle two systems. 

Let me ask one last thing. My time has run out, but the White 

House made a proposal yesterday—they publicly made their proposal. There were differences. There were changes from that of 

your recommendation. Could you highlight those changes? I know 

you alluded to one of them dealing with the Social Security earnings. 

Ms. SHALALA. Right. They spend more money. They eliminate— 

they allow you to keep your Social Security at the same time, for 

example, was one change that they recommended. I am not sure 

that I have all of them—— 

Senator DOLE. They expand TRICARE, too. 

Ms. SHALALA. They expand TRICARE more dramatically than we 

did. Whatever they did, they added as opposed to restricted our 

recommendations, and while we discussed that at some point—yes, 

the main thing was the earnings loss component, that that earnings loss component should disappear when the veteran begins to 

receive Social Security. The administration has altered that proposal and not made the loss of earnings subject to the FICA tax 

and they don’t stop that earnings—that income when the person 

gets on Social Security. So they make it for a lifetime. 

Senator DOLE. That is one big objection one or two of the VSOs 

had, so that has been resolved. 

Senator BURR. Well, my hope, and I believe I can speak for the 

entire Committee, is that we know if we can find consensus between the VSOs and the administration and both of the Commissions that are recommending, we can get legislation as quickly as 

what you said, Senator Dole. 

Ms. SHALALA. And, I think we want to be very clear about the 

veterans’ groups who we have all worked with. I haven’t worked as 

extensively as Senator Dole. We would not have the kind of substantial system we have in this country without their advocacy. I 

fully understand that they should question every proposal rigorously, because they are absolutely in the right place in terms of 

who they represent. 

We are simply saying, look, we think that we can make it even 

better for future generations. We can simplify it. We all ought to 

be able to understand this. This system took me—I spent a lifetime 

understanding health care systems and complex organizations. It 

took me a while to kind of get my arms around and try to understand it. We ought not to have government programs that require 

expertise to understand. 

Senator BURR. Thank you both. 

Chairman AKAKA. Thank you very much, Senator Burr. 

Senator Murray? 

Senator MURRAY. Thank you, Mr. Chairman. 

Thank you both for really taking the time to look at this through 

the patients’ eyes and the veterans’ eyes rather than through the 

bureaucratic lens that too often, I think, gets focused on the system. I really appreciate the work that you and the Commission did 

on this. 

36 

I heard Senator Tester say earlier, too often, it is like the veteran 

is fighting the system rather than the system working for you, and 

just listening to it, it sounds like you are trying to change that 

mindset of the VA, which is really important. 

One of my concerns is we do not have a Secretary of the VA currently. We haven’t received a recommendation from the administration or anyone sent over here for that position. Are you concerned that the implementation of this, which is going to put a lot 

of pressure on the VA to do, it is going to take somebody at the 

top to really keep that culture that you are talking about, are you 

concerned that we don’t have a head of the VA right now and are 

you working with the administration to get someone? 

Ms. SHALALA. I am not. 

Senator DOLE. I think we were asked that question yesterday, 

which is a good question. Right now, Deputy Secretary Gordon 

Mansfield meets every week with Gordon England of DOD and 

they have these weekly meetings and they are really moving ahead 

with these recommendations. In fact, they have been given a mandate by the White House to move ahead. But obviously, the sooner 

we have somebody on board who is really going to push this program—— 

Senator MURRAY. And who comes with the right mindset, too. 

Senator DOLE. I think that is going to be very soon. 

Senator MURRAY. Okay. 

Senator DOLE. It will be up to, of course, your confirmation, but 

I think you will have a nominee—— 

Senator MURRAY. Well, I would assume, though, that you would 

want the nominee to have that culture and mindset that you are 

speaking about, as well, so—— 

Senator DOLE. We hope the nominee is asked before he is nominated or she is nominated that they have looked at this and they 

have looked at the other commission and they can support it vigorously. 

Senator MURRAY. Some of the critics are concerned that a lot of 

your recommendations are Executive Branch implemented, not 

Legislative Branch implemented. Are you concerned about that at 

all? 

Ms. SHALALA. Well, I think that reflects a certain shrewdness on 

our part to try to make sure—— 

Senator MURRAY. Oh, you trust us less than them? 

Ms. SHALALA. No. No, not that. But we wanted to move immediately. We actually divided up what required legislation and what 

didn’t require legislation. 

Senator MURRAY. Is there a time line for the administration—— 

Ms. SHALALA. We expect, I think, almost everything to be done 

within a year. We did not give them a lifetime for implementation, 

and each of us is checking on—for instance, Dr. Harris is right on 

top of the IT recommendations. Senator Dole has been over on a 

regular basis to ask questions. Our staffs have been over to see 

how the implementation is going. So, we did not walk away from 

this and we did divide up the recommendations so that—I am a big 

believer in identifying the short-term things that you can do internally and then the longer-term things that require legislation—— 

37 

Senator DOLE. Right. We could probably provide a list to the 

Committee of what the administration—— 

Senator MURRAY. Has done already? 

Ms. SHALALA. And an update on all of that. 

Senator MURRAY. I think that would be helpful. 

Ms. SHALALA. But we actually thought about it, to make sure 

that things were getting done. 

Senator MURRAY. OK. Well, specifically, I wanted to ask you, one 

of the biggest differences between your report and the report produced by the Veterans Disability Benefits Commission is the way 

in which you do compensate combat-injured versus non-combat-injured veterans. The way I hear you, your approach creates benefits 

specifically for combat and combat-related injuries and the Veterans Disability Benefits Commission compensates veterans based 

on the severity of their disability, not on the circumstances or the 

location. I am a little bit confused about what you consider to be 

combat injury. Is everything—if you are training for combat and 

you are here—is that considered combat injury? 

Ms. SHALALA. Our definition of combat-related is very broad and 

it only applies to two provisions under our disability plan. The first 

is: that those found unfit due to combat-related injury or illness 

would receive a lifetime TRICARE coverage; and the second is, that 

these individuals would receive quality-of-life payments from the 

VA for life, as well. That definition includes those training for combat—— 

Senator MURRAY. So, if you are training here, that would be—— 

Ms. SHALALA. If you are training for combat its part of our definition. So it is very broad. 

Senator MURRAY. What if you—— 

Senator DOLE. We tried line of duty; we tried combat-related. We 

want to make it broad. And we were told by DOD, well, once you 

sign up for whatever it is, whatever service, you are, in effect, 

training for combat someday. So—— 

Senator MURRAY. Okay, so it includes training. What about intheater non-combat—— 

Ms. SHALALA. Yes. 

Senator MURRAY. Your vehicle rolls over—— 

Ms. SHALALA. Yes. 

Senator MURRAY [continuing]. Is that considered combat? 

Ms. SHALALA. Absolutely. Absolutely. And you could look at the 

two systems we recommended. We were focused on these Afghanistan and Iraqi wars, trying to set up a system. But again, we believe we have one plan and we used as broad a definition as we 

could. But, that is, in part, for Congress to decide. 

Senator MURRAY. OK. One other quick question. You have recommended a single medical exam, which I think makes a whole lot 

of sense. But, I am worried that that means, perhaps, the government could arbitrarily cut off a veteran without giving him a 

chance to appeal. Can you tell me how a veteran would deal with 

an appeal? Do they have the opportunity to disagree with the disability rating? 

Ms. SHALALA. They would always have an appeal. We asked 

DOD to do the exam based on standards that they and the VA 

agree to. So there is a single exam—— 

38 

Senator MURRAY. And once they leave DOD, they have that 

exam—— 

Ms. SHALALA. They have that exam. They take it over to VA—— 

Senator MURRAY. Do they have a chance then—— 

Ms. SHALALA [continuing]. And VA then looks at the whole person. 

Senator MURRAY. OK. Do they have a chance then to appeal 

that? 

Ms. SHALALA. There is always an appeal process. I don’t know of 

a program without an appeal process. 

Senator DOLE. In fact, we make certain that the DOD examiner 

understands that one can have disabilities and still be fit for duty. 

But, we want that examiner to hand over to the VA everything 

that may be wrong with that individual, so they can make an appropriate rating. 

Ms. SHALALA. And that is why the two agencies define what is 

covered in the physicals. So, the whole thing goes over to VA and 

then the disability determination is done over there. 

Senator MURRAY. Okay. 

Senator DOLE. I think there is a feeling, Senator Murray, that 

the VA is a little more generous, too, with the ratings, so from the 

standpoint of the veteran, I think that is a plus. 

Ms. SHALALA. And the advantage is there, because DOD is only 

making a fit/unfit [determination], though they are making a comprehensive exam. But you don’t leave the DOD without your annuity in hand—— 

Senator MURRAY. Okay. 

Ms. SHALALA. Even if you have only had 5 years or 3 years, 

based on your rank, you leave with an annuity that you have forever, no matter what happens over at the—— 

Senator MURRAY. And just so I understand, too, you have this 

one-time decision that you can stay with the current system or 

transition to this. Is there any provision for somebody who decides 

down the road a couple of years that that doesn’t work for them, 

or do you just say—I mean—it is going to be a very confusing time 

for people to have to make that decision. 

Ms. SHALALA. It is soldiers and sailors and Marines from October 

1 of 2001 on, and what you are asking is if they have already had 

their rating, if they decide later they want to come into the new 

system whether they could. We didn’t stipulate—— 

Senator DOLE. We left it open. 

Ms. SHALALA. We left that question open and that obviously is 

something that Congress—— 

Senator MURRAY. I believe in the administration’s draft legislation they are saying—— 

Ms. SHALALA. The administration said, ‘‘no.’’ We left that open. 

Senator MURRAY. You didn’t—— 

Ms. SHALALA. Our recommendation was to leave it—— 

Senator MURRAY [continuing]. Are you—— 

Ms. SHALALA [continuing]. We left it open for Congress to make 

that decision. 

Senator MURRAY [continuing]. Are you concerned, then, with a 

massive—— 

Ms. SHALALA. No. 

39 

Senator MURRAY [continuing]. With a big change—— 

Ms. SHALALA. I am not concerned with big numbers if you go 

from 2001 on. I think most people will probably stick with their 

current system if they have already gone through the evaluation 

process, and—— 

Senator DOLE. We have a young man on the Commission, Jose ́

Ramos, who is in the current system and I think it is working for 

him. If he wanted to change—— 

Ms. SHALALA. He could. 

Senator DOLE. He could do that, right? 

Senator MURRAY. He has a one-time chance to make that decision under the administration’s legislation. 

Ms. SHALALA. Yes, under the administration’s legislation. Under 

ours, we left that open, which means the Congress just makes a 

judgment about that. And, when you are in a transition period, you 

may make a different decision, just for the transition period of 

maybe a certain number of years, as opposed to long-term. 

Senator MURRAY. Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Murray. 

Senator Webb? 

STATEMENT FROM HON. JIM WEBB, 

U.S. SENATOR FROM VIRGINIA 

Senator WEBB. Thank you, Mr. Chairman, and Senator Dole and 

Secretary Shalala. I did watch your testimony from my office. I 

have a couple of questions from the testimony, and I want you to 

know that I am not walking in here cold right now. Further, I 

didn’t move down to this seat to get away from Senator Tester. It 

is the only seat that has a microphone. 

With respect to PTSD, I, as many know, worked on the Veterans 

Committee on the House side for four years as a committee counsel 

and when we were doing a lot of pioneering of that program and 

I would support what you are doing on that because PTSD sort of 

oscillates through your life. There are relatively few, in the experiences that we had, who would be leaving the military and be diagnosed with PTSD, and yet down the road, in my experience, it sort 

of popped up in about an 8-year cycle and then about a 20-year 

cycle with people who had served in Vietnam, so I would fully support that. 

I would like to make a point just from having watched the testimony and having worked in this area off and on all of my adult 

life. It is one I hope we don’t lose as we start analogizing to the 

civilian employment structure, and that is that a volunteer force is 

not per se a career force. This is not a direct analogy to civilian 

employment. There are a lot of people who enlist in the military 

for reasons other than normal employment opportunity—because 

they love their country or they have got a family tradition, people 

who don’t really intend to stay for a career. 

It is for that reason that I have very strong feelings about readjustment assistance in addition to the types of things that we have 

been talking about here. I know, Senator Dole, you mentioned 

many times in your testimony about the need to focus on education, the fact that cost shouldn’t be an issue when we look at 

40 

that. You mentioned these people since 9/11, we keep calling them 

the new greatest generation. 

I introduced a bill—this is not directly under the purview of your 

recommendations, but it is important when we are talking about 

how we are going to help people transition into the future. I introduced a bill to give the people who have served since 9/11 the same 

G.I. educational benefits as the people who came back from World 

War II received. It is not true today, and I think that it is a great 

oversight in the veterans’ law that we have not done that. 

I was wondering, Senator Dole, if you could mention to us how 

important the educational piece was for you in terms of putting together your life after having served. 

Senator DOLE. Well, there were 16 million of us in World War 

II and I think 8.5 million took advantage of the G.I. Bill. The G.I. 

Bill was signed down in the Mayflower Hotel, in room 320, and one 

of the big principals happened to be the National Commander of 

the American Legion, who happened to be a Kansan at that point. 

In any event, it made a big difference—not only the education 

piece, but the other benefits that were in the G.I. Bill; and it barely 

passed the Congress, as you probably remember, no more than four 

or five votes. It wasn’t something that just sort of swept through 

the Congress. There was a lot of debate about it, and I don’t know 

what the objections could have been. 

I think it is the single most important piece of legislation when 

it comes to education, in how it changed America, than anything 

I can think of. Because, if you get a college education, then you 

want your children to get a college education, and a lot of us didn’t 

have any money. Our parents didn’t have any money. And suddenly, we had this opportunity. They even gave me a left-handed 

typewriter, a recording machine that I could take to class because 

I wasn’t able to write then with my left hand. I had the best notes 

in class. I was very popular around test time every year. And they 

ought to take the same care of the veterans today. 

Senator WEBB. Well, the program they have today is basically a 

peacetime program. The individual sort of has to pay in $100 a 

month for the first year. They all pretty much have to, even though 

it is supposedly voluntary. We have been doing analysis. It doesn’t 

even take care of, say, 20 percent of what the costs would be at one 

of the better institutions, where after World War II, people got everything. 

We had the VA testifying in front of us when I mentioned this 

and they said that to do the World War II G.I. Bill today would 

be too complicated because you had to look at different tuition payments and different schools, and I just have a hard time believing 

that. We put, I think, 7.8 million people through regular college 

after World War II and they did it with a stubby pencil on the back 

of a memo pad, they were able to figure it out. So I can’t—— 

Senator DOLE. I am reminded that the vocational rehabilitation 

program provides, I think—one of our Commission members is a 

Harvard student, and, of course, it costs quite a bit to go to Harvard. I have never known why, but—— 

[Laughter.] 

Senator DOLE [continuing]. So, there is money there—— 

41 

Senator WEBB. I benefited from that program after Vietnam. I 

was in vocational rehabilitation when I went to law school. I think 

we can—I hope we can—get your support for this for all people. For 

instance, on something like PTSD, there are a lot of these things 

that aren’t manifesting themselves immediately that would come 

under the rubric of the type of issues that you are talking about 

today, and the No. 1 thing that I can think of in terms of trying 

to help people readjust back into civilian life is a good education. 

Ms. SHALALA. And Senator Dole came out with a great idea, and 

that is for every year people stay in, we increase the stipend, which 

actually incentivizes people to stay in for longer than a year in the 

program. I think that is very important. 

Senator DOLE. Ten percent a year. We give them a 10-percent increase. 

Ms. SHALALA. You look at the drop-out rate in the education programs that you are currently funding and it looks like an innercity high school. 

Senator WEBB. People can’t keep up. They can’t go to community 

college on the Montgomery G.I. Bill. 

Ms. SHALALA. And I had a young man who contacted me because 

he wanted to go to the University of Miami. When he called, he 

was in Miami, though he called up to Tampa. They offered him 

enough money to go to a community college, but he wanted a specialized kind of course. Now, we have made an effort to accommodate him and get him fit together with our programs, because I 

was hardly going to turn him away. 

Those kinds of investments will make a huge difference in the 

long run for us, and we just have to fit it with modern systems. 

There is lots of aid available in the States and from the Federal 

Government, but it is the wrap money to make sure it is possible 

for them to go full-time. So, that is why we want to extend the time 

for those that go part-time, but we also have to know what we are 

doing and it should not be to keep people down at a certain income 

level. 

But the incentive system, I think is terrific, because it encourages—you get more resources as you stay in school. 

Senator WEBB. Thank you very much. Mr. Chairman, if I may 

say one other thing, years ago when I worked on the veterans’ programs, Senator Dole had an incredible reputation. I am not saying 

anything people don’t already know, but wherever he was traveling, he was known to go to the VA hospitals in that area and not 

allow media to go with him, just to go in and talk to veterans. 

Again, I am not saying anything people don’t know, but we couldn’t 

have a better person and a greater national treasure doing this job. 

Thank you. 

Chairman AKAKA. Thank you very much, Senator Webb. 

Senator Tester? 

Senator TESTER. Thank you, Mr. Chairman, and I want to apologize to the panel for having to go to a Banking markup meeting. 

There are some things that I want to visit and I will be as brief 

as possible. 

Montana, as you both know, is a very rural State. You both know 

we have a high percentage of folks in the military. We have a high 

percentage of veterans. I think out of 930,000 people, we have 

42 

about 110,000 veterans. It is extremely rural. And I think, Senator 

Dole, in your comments, you talked about disabled veterans in 

rural areas being able to access private care in the areas of TBI 

and PTSD. Do you see that being applicable in other areas? I am 

talking about specialty care, routine care, anything like that—do 

you see any benefits of allowing that to happen in rural or frontier 

areas? 

Ms. SHALALA. I do certainly. I visited some of the conversions 

and actually helped fund some of the conversions of hospitals to rehabilitation centers in Montana. You have some very interesting 

ways of using existing facilities, and there is no question in my 

mind that for certain kinds of rehabilitation that you would have 

some facilities. We would have to do a treatment plan and make 

sure that it fits with whatever the treatment plan is, so that people 

go home and use existing facilities and take advantage of doctors 

in rural areas or in the small towns. But, I certainly have spent 

enough time in Montana looking at the health care system to know 

that if you had a treatment plan, a way of getting accountability 

to make sure that you are measuring progress, we certainly should 

take advantage of what is available. 

Senator DOLE. There is a Sergeant Edmondson that I think 

maybe Senator Burr is familiar with in New Bern, North Carolina, 

who has a bad TBI. He was able to negotiate to go to the Rehabilitation Institute of Chicago for treatment, where he made remarkable progress. Now, I know we don’t have any cities like that in 

Kansas or Montana, or facilities like that. Then again, Ed Eckenhoff on our Commission has had 46 Iraq-Afghan veterans in the rehabilitation center here. So, the answer is, we live out in the country and we have got to make it easy for these people from the 

standpoint of their cost; and some are in wheelchairs, so it is hard 

to travel. We would like to have them get there and back in the 

same day, if possible. 

Ms. SHALALA. We have a lot of experience in telemedicine. Senator Murray has been interested in it a long time, and taking advantage of that. Medicine has changed, so the key is the treatment 

plan, the accountability, and our ability to tailor it to what works 

for an individual. 

Senator TESTER. Thank you. Thank you for your answers. I 

couldn’t agree more, although I will tell you from a telemedicine 

standpoint, when it comes to PTSD or TBI, I have some concerns 

about that. 

Ms. SHALALA. In fact, you need a place with expertise in those 

areas. I also want to make it clear that most of the expertise in 

this country in TBI and PTSD is in the veterans hospitals and in 

the military. The research that is going on, the clinical research 

that is going on, while there are some private sector centers, 

there’s nothing like what is going on in the military and in veterans hospitals in this country. 

Senator TESTER. Well, I certainly appreciate that. I can tell you 

that my opinion has changed dramatically over the last—since the 

first of January—in that, I think that in rural areas there is a real 

need that is not being met because of distance; and so, thank you 

for your answers and thank you for your testimony, too. 

Chairman AKAKA. Thank you very much, Senator Tester. 

43 

Before going to panel two, let me ask the Members if anyone has 

any questions for a second round. 

[No response.] 

Chairman AKAKA. Thank you very much. I want to thank our 

first panel very, very much. Your testimony, your comments, your 

advice and recommendations have been very helpful. 

Senator DOLE. Thank you. 

Chairman AKAKA. Thank you. 

I now welcome our second panel. Lieutenant General Terry Scott 

joins us today as Chairman of the Veterans Disability Benefits 

Commission. Under General Scott’s leadership, the Veterans Disability Benefits Commission recently completed an extensive 2-year 

review of the benefits and services provided to disabled veterans by 

the Departments of Defense and Veterans Affairs. 

Patrick Dunne is Assistant Secretary for Veterans Affairs for Policy and Planning. He appears before this Committee today representing the Task Force on Returning Global War on Terror Heroes, an interdepartmental panel assembled to address administrative barriers to the care of wounded servicemembers. 

Former VA Secretary Togo West joins us today as Co-Chair of 

the Department of Defense’s Independent Review Group on Rehabilitative Care and Administrative Processes at Walter Reed Army 

Medical Center and National Naval Medical Center. Secretary 

West served as Secretary of the Army and Secretary of Veterans 

Affairs during the Clinton Administration. He will present the 

Independent Review Group’s perspective on how DOD can improve 

the care of wounded servicemembers. 

I thank all of you for joining us today and look forward to your 

testimony. Your full statements will appear in the record of the 

hearing, and in the interest of time, please try to limit your direct 

statement to 5 minutes. 

So at this time, I would like to call on General Scott for your 

statement. 

STATEMENT OF LIEUTENANT GENERAL JAMES TERRY SCOTT, 

U.S. ARMY (RET.), CHAIRMAN, VETERANS DISABILITY BENEFITS COMMISSION 

General SCOTT. Chairman Akaka, Ranking Member Burr, Members of the Committee, it is a great pleasure to appear before you 

again today representing the Veterans Disability Benefits Commission. I had the opportunity to testify before you in the joint session 

with the Armed Services Committee last April and it is a real 

pleasure to be back. 

I would like to introduce some of the Commissioners who were 

able to be present here today, Commissioner Brown, Commissioner 

Carroll, Commissioner Cassiday, Commissioner Grady, Commissioner Jordan, Commissioner McGinn, Commissioner Surratt, and 

Commissioner Wynn. This lady and gentlemen devoted a lot of 

time to the two-and-a-half years that the Commission was meeting, 

and we met once a month in Washington until the last couple of 

months and we met twice a month from then on. Also, I would like 

to recognize the efforts of the Executive Director, Mr. Ray Wilburn, 

who has done a tremendous job of keeping things moving when the 

Commissioners were not present. 

44 

Sir, you asked today that I focus directly on areas of overlap between the recommendations of our Commission and those of the 

President’s Commission on Care for America’s Wounded Warriors, 

the Dole-Shalala Commission, and the Task Force on Returning 

Global War on Terror Heroes (also known as the Nicholson Task 

Force), and the DOD Independent Review Group (known as the 

Marsh-West Group). 

You also asked for our views on how to improve the VA and DOD 

collaboration and cooperation, and how could we resolve the longstanding issue of creating a VA–DOD Electronic Health Record. So, 

per your request, sir, that is what I am going to address here 

today. 

First, let me say that there is a tremendous amount of consistency in the findings and recommendations of these four reports. I 

prepared for the record, and passed to your staff, a matrix that listed the four commissions and the subject areas that they covered. 

I commend that to the staff and to the Members if they have the 

time to read it, because it lays out in detail how each of the four 

commissions addressed each of the important issues. 

It is, of course, well known that the scope of these four commissions was quite different, and this resulted in some variations in 

some areas of the recommendation. For instance, our commission 

was not chartered to address the issues at Walter Reed, per se, and 

we did not. 

All of us want to see improvements in benefits and services for 

the injured and disabled servicemembers and veterans. I might 

make a couple of points here. We found nine areas with considerable overlap among the reports and some areas with some limited 

overlap or some differences, or perhaps it was differences of interpretation. 

The Veterans Disability Benefits Commission believes that all 

disabilities and injuries should be compensated based on the severity of the disability, and I believe that was covered in the question 

and answer portion of the last session, so I will go on from that. 

Our Commission also believed that VA disability compensation 

should not end and be replaced with Social Security at retirement 

age, and we provided some hypotheticals as to what effect that 

would have on the severely-disabled veterans. So, I will be glad to 

respond to questions on that later, but that may be a moot issue 

since, apparently, the legislation will not have that in it. 

I will talk briefly, sir, about the VA and DOD disability process. 

All four reports address the problems with the process used when 

servicemembers are determined to be fit or unfit for military duty. 

We conducted a detailed analysis of those separated or retired as 

unfit for duty during the 7-year period from 2002 to 2006 and compared their ratings with ratings subsequently completed by the VA. 

We found that the combined ratings by the VA were higher, on average, than the ratings by the services. When comparing the ratings for individual diagnosis, VA ratings were statistically significantly higher than those of the services. 

We concluded that there should be a realignment of the process, 

and that is essentially the same conclusion reached by the DoleShalala Commission, the Independent Review Group, and the Nicholson Task Force. We also believe that the services should deterVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00048 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
45 

mine if the servicemember is fit or unfit, and VA should be responsible for assigning disability ratings. The Dole-Shalala Commission 

made the same recommendation. 

In redesigning the VA disability process and specifying the benefits available for those servicemembers, we should recognize that 

the overwhelming proportion of servicemembers medically discharged as unfit do not meet the several definitions of severely disabled. 

Our Commission did not specify which department should conduct this single examination. In fact, we believe that in some locations, it might be best determined by the capabilities of the two departments at that local level. 

All four study groups recommended developing a case management system for severely injured servicemembers and their families to ensure that the right care and support at the right time and 

in the right place. A single case manager should have overall responsibility. The other commissions agreed. 

Family support is addressed by all of the study groups except the 

Nicholson Task Force. The families of the severely injured are assisting in the care and rehabilitation of these wounded warriors. 

Our Commission recommended that VA be authorized to provide 

similar services to those provided by DOD to families of the severely injured. We also recommended extending the CHAMP VA 

medical care to caregivers of 100 percent disabled veterans, and 

providing a caregiver allowance. We recommended eliminating any 

TRICARE co-pays and deductibles for the severely disabled because 

we do not believe the injured should have to pay in any way for 

their injuries. 

Regarding Post Traumatic Stress Disorder and Traumatic Brain 

Injury.—All four reports recommend improvements in awareness; 

research; treatment; staffing; and diagnosis examination of Post 

Traumatic Stress Disorder and Traumatic Brain Injury. Our Commission focused more on compensating and rating these conditions, 

and we recommend a holistic approach to PTSD be established that 

couples compensation, treatment, and vocational assessment. We 

also believe that reevaluation should occur every 2 to 3 years to 

gauge treatment effectiveness and encourage wellness. Regarding 

Traumatic Brain Injury, we recommend including medical criteria 

for this diagnosis as a priority in the revision of the VA schedule 

for rating disabilities. 

Regarding ancillary benefits.—Our Commission recommended increases to several benefits that have not kept pace with the cost 

of living, extending eligibility in some cases to burn victims, and 

expanding the auto and housing allowances. We also recommended 

eliminating the premiums for Traumatic Servicemembers Group 

Life Insurance, as we do not believe that the servicemember should 

have to insure themselves for traumatic injuries. Perhaps most importantly, our Commission recommends establishing a pre-stabilization allowance similar in theory to that recommended by the 

Dole-Shalala Commission. 

Regarding quality of life.—As was mentioned in the Q and A before, both our Commission and the Dole-Shalala Commission recommend a compensation payment for the impact of disability on 

quality of life. Current compensation payments do not provide payVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00049 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
46 

ment above that required to offset earnings loss. Therefore, there 

is currently no compensation for the impact of disability on quality 

of life for most veterans. While permanent quality of life measures 

are developed and implemented, we recommend that compensation 

payments should be increased up to 25 percent with priority to the 

more severely disabled, and we provide some hypotheticals that 

show how that might be. 

In other words, the 100 percent disabled person might get a 25 

percent boost for quality of life, whereas the 10 percent disabled 

might get a very much smaller boost in payments for quality of life. 

So, it would be scaled based on the severity of the disability—it is 

an ‘‘up to 25 percent,’’ not a flat 25 percent across the board, as 

has been quoted in some of the media. 

Vocational rehabilitation.—All but the Independent Review 

Group addressed vocational rehabilitation. Both the Dole-Shalala 

Commission and our Commission found that the effectiveness of 

the program is not currently assessed and that graduates are not 

followed except for a very brief time period. Both Commissions recommend either an incentive bonus of up to 25 percent—that would 

be the Dole-Shalala—or exploring incentives as a way to encourage 

completion of vocational rehabilitation. The Nicholson Task Force 

focused on using existing programs and opportunities in that regard. 

Concurrent receipt.—Regarding concurrent receipt of military retirement and VA disability, our Commission found that these two 

are different programs with entirely different missions. DOD retirement recognizes years of service and VA disability payments compensate for impairment in earnings and should compensate for impact on quality of life. Over time, Congress should eliminate the 

ban on concurrent receipt for all military retirees and for all 

servicemembers who are separated from the military due to service-connected disabilities. Priority should be given to those veterans 

who separate or retire with less than 20 years of service, with a 

disability rating of greater than 50 percent, or a disability as a result of combat. 

Payment offsets should also be eliminated for survivors of those 

who die in service or retirees who die of service-connected causes 

so that these survivors can receive both the VA Dependency and 

Indemnity Compensation, known as DIC, and DOD survivors’ benefit, known as SBP. 

The Dole-Shalala Commission also recommends that DOD compensate for years of service, while VA compensates for disability. 

Hazards exposures and presumptions.—Our Commission and the 

Nicholson Task Force both addressed hazards and exposures, but 

in different ways. Our Commission recommended a new presumption process as proposed by the Institute of Medicine. The new 

process includes enhanced registries of servicemembers and veterans based on exposure, deployment, and disease histories. And 

sir, I commend, particularly to the staff but also to the Members, 

this report done by the IOM. This subcommittee was chaired by Dr. 

Jonathan Simmet from Johns Hopkins, and I think that he provided all of us with some truly innovative ideas about how to address the issue of presumptions of disability. 

47 

Improving VA and DOD collaboration.—In addition to assessing 

the areas of overlap among the four reports, you asked my views 

on how to improve collaboration and cooperation between VA and 

DOD. We found many encouraging signs and also areas which need 

improvement. The Joint Executive Council has demonstrated how 

both departments can benefit from coordinated planning and increased cooperation. The results are evident in specific initiatives, 

including the integration of the North Chicago VA Medical Center 

and the Naval Health Clinic-Great Lakes. This coordinated treatment of severely injured in dedicated polytrauma centers is also 

very effective. However, we believe the JEC planning effort can be 

significantly improved by including specific milestones and designating responsible officials for each. 

Successfully transitioning servicemembers to civilian life is crucial and ensuring that servicemembers understand the benefits and 

services that are available to them is essential. The Transition Assistance Program and the Disabled Transition Assistance Program 

briefing should be mandatory and adequately funded. 

After leaving service, many veterans find it difficult to prove that 

injuries and diseases that occur later in life are the result of military service. We believe that all separating servicemembers should 

receive a separation examination to establish a baseline for medical 

conditions. 

There is one way of expediting disability benefits in effect now. 

It is called a Benefits Delivery at Discharge process. It is available 

at 140 military facilities and these claims are processed at two VA 

locations. We believe that this Benefits Delivery at Discharge 

should be available to virtually all separating members, including 

Guard and Reserve. 

One cause for delay in claims processing, even in the BDD process, is the availability of the discharge document. Our Commission 

recommends that DOD immediately provide VA with an authenticated electronic document so that processing can begin right away. 

Lastly, sir, on IT compatibility.—All the reports address the absolute necessity for the VA and the DOD to have compatible information systems, but also to recognize that this will not solve all 

problems. Much has been said about the goal of seamless transition, which is not a current reality. Not all of DOD’s medical and 

personnel records are electronic, and those that are electronic are 

not yet fully compatible between the services, much less between 

VA and DOD. There has been an agreement to create a joint Inpatient Electronic Record that would be instantly accessible. We do 

believe that development and implementation of this information 

system should be expedited and that a detailed management plan 

should be developed with a lead agent designated and with specific 

milestones and plan completion dates. 

In conclusion, VA and DOD have much to gain by greater coordination. Servicemembers and veterans have even more to gain by 

the two departments working together. A lot of valuable work has 

been done. However, a great deal of work remains, and the only 

way the goal of a reasonably seamless transition will ever be realized is if the two departments are required to develop realistic 

challenging goals with specific milestones. 

48 

Congress should review these plans and oversee progress. Congress also has a responsibility to ensure that sufficient funding is 

provided to accomplish the goals and objectives contained in these 

IT plans. 

Sir, that ends my oral statement and I will gladly answer any 

questions after the other presentations. 

[The prepared statement of General Scott follows:] 

PREPARED STATEMENT OF JAMES TERRY SCOTT, LTG, USA (RET), CHAIRMAN, 

VETERANS’ DISABILITY BENEFITS COMMISSION

Chairman Akaka, Ranking Member Burr, and Members of the Committee: It is 

my pleasure to appear before you today representing the Veterans’ Disability Benefits Commission. 

You asked that I focus directly today on areas of overlap between the recommendations of our Commission and those of the President’s Commission on Care for 

America’s Returning Wounded Warriors (the Dole-Shalala Commission), the Task 

Force on Returning Global War on Terror Heroes (the Nicholson Task Force), and 

the DOD Independent Review Group (the Marsh/West Group.) You also asked for 

views on how to improve VA and DOD collaboration and cooperation and to resolve 

the long standing issue of creating a VA/DOD electronic health record. 

First, let me say that there is a tremendous amount of consistency among the 

findings and recommendations of the four reports. The scope of the four efforts was 

quite different and this resulted in variations in some areas. But we all want to see 

improvements in benefits and services for injured and disabled servicemembers and 

veterans. Our Commission generally agrees with the advice provided by the Independent Review Group and the Task Force and more recently by the Dole-Shalala 

Commission, but we differ with two of the Dole-Shalala suggestions. We believe that 

all disabilities and injuries should be compensated based on severity of disability 

and not be limited to combat or combat-related injuries. Nor does our Commission 

believe that VA disability compensation should end and be replaced with Social Security at retirement age. 

For our own purposes, we prepared a matrix comparing the findings and recommendations of the four reports which I am pleased to share with the Committee. 

I caution that the matrix is not intended to be exhaustive nor a verbatim listing 

of all findings and recommendations. Rather it is a broad overview that I found useful. 

The matrix contains a description of each study group’s focus and a brief summary of findings and recommendations and a summary of topics that overlap. The 

major topics with considerable overlap are: VA/DOD Disability Process; Case Management; Family Support; IT Compatibility; PTSD; TBI; Ancillary Benefits; Quality 

of Life; and Vocational Rehabilitation. Other topics with limited overlap include: 

Concurrent Receipt; Hazards and Exposures; Combat/Combat Related, Social Security, and Walter Reed. Our Commission addressed all of these topics except Walter 

Reed, which was not within the scope of our charge. 

VA/DOD DISABILITY PROCESS

All four reports addressed the problems with the process used when servicemembers are determined to be fit or unfit for military duty. Our Commission conducted a detailed analysis of those separated or retired as unfit for duty during the 

7-year period from 2000 through 2006 and compared their ratings with ratings subsequently completed by VA. We found that the combined ratings by VA were higher, 

on average, than ratings by the Services. For example, individuals rated zero percent by the Services were rated an average of 30 percent by VA and those rated 

30 percent by the Services were rated an average of 56 percent by VA. Among individuals rated by the Services as zero, 10, or 20 percent, VA rated them 30 percent 

or higher 61 percent of the time. This was largely because VA rated 2.4 to 3.3 more 

conditions than the Services. When comparing the ratings for individual diagnoses, 

VA ratings were statistically significantly higher than the Services for 10 of 13 frequent diagnoses analyzed. 

We concluded that there should be a realignment of the process and this is essentially the same conclusion reached by the Dole-Shalala Commission, the Independent Review Group, and the Nicholson Task Force. We also believe that the 

Services should determine if the servicemember is fit or unfit and VA should be responsible for assigning disability ratings to all conditions found as part of a single, 

49 

comprehensive examination. The Dole-Shalala Commission made the same recommendation. 

In redesigning the VA/DOD disability process and specifying the benefits available 

for these servicemembers, it may be appropriate to focus specifically on the severely 

disabled. However, we should also recognize that the overwhelming proportion of 

servicemembers medically discharged as unfit do not meet the several definitions of 

severely disabled. During the 7-year period 2000 through 2006, there were 83,008 

servicemembers medically discharged as unfit. DOD rated 81 percent of these as 0 

through 20 percent disabled and provided separation pay. Only 5,060 (6.1 percent) 

were rated by DOD as 50 percent through 100 percent and, of these, only 1,478 (1.8 

percent) were rated 100 percent. The process and the benefits should be appropriate 

for all servicemembers found unfit, not just the severely disabled. 

Our Commission did not specify which department should conduct the single examination; in fact we believe that this should be determined more by the capabilities of the two departments at the local level. Our Commission extensively reviewed 

the examination process used by VA with the advice of the Institute of Medicine and 

made recommendations relating to the use of templates, training and certification 

of examiners, and quality assurance. Completion of a thorough and comprehensive 

examination is essential for accurate ratings and these recommendations should be 

addressed no matter which department conducts the examinations. 

CASE MANAGEMENT

All four study groups recommended developing a case management system for severely injured servicemembers and their families to ensure the right care and support at the right time and in the right place. A single case manager should have 

overall responsibility. The Dole-Shalala Commission also recommended comprehensive recovery plans. Improving case management is a key topic upon which there 

is strong agreement. 

FAMILY SUPPORT

Family support is addressed by all of the study groups except the Nicholson Task 

Force. The families of the severely injured are assisting in the care and rehabilitation of these wounded warriors. Some are sacrificing jobs, careers, homes, and 

health insurance, and facing a tremendous impact on their own health in order to 

support their injured family members. Our Commission recommended that VA be 

authorized to provide similar services as currently provided by DOD to families of 

the severely injured. We also recommended extending ChampVA medical care to 

caregivers (currently this benefit is provided only to dependents of 100 percent disabled veterans, not caregivers) and providing a caregiver allowance. We also recommended eliminating any TRICARE copays and deductibles for the severely disabled because we do not believe the injured should have to pay in any way for their 

injuries. We feel that our recommendations would more fully meet the needs of the 

families and caregivers of all severely disabled. The Dole-Shalala Commission would 

limit TRICARE coverage to only families of those unfit due to combat-related injuries. 

PTSD AND TBI

All four reports recommend improvements in awareness, research, treatment, 

staffing, and diagnosis/examination of Post Traumatic Stress Disorder (PTSD) and 

Traumatic Brain Injury (TBI). Our Commission focused more on compensating and 

rating these conditions and recommend that a ‘‘holistic’’ approach to PTSD be established that couples compensation, treatment, and vocational assessment. We also believe that re-evaluation should occur every 2 to 3 years to gauge treatment effectiveness and encourage wellness. Regarding TBI, we recommend including medical criteria for this diagnosis as a priority in the revision to the VA Schedule for Rating 

Disabilities. 

ANCILLARY BENEFITS

Our Commission recommended increases to several benefits that have not kept 

pace with cost of living, extending eligibility in some instances to burn victims, and 

expanding auto and housing allowances. We also recommended eliminating the premiums for Traumatic Servicemembers’ Group Life Insurance (TSGLI) as we do not 

believe servicemembers should have to insure themselves for Traumatic Injuries. 

Perhaps most importantly, our Commission recommends establishing a pre-stabilization allowance of up to 50 percent of current compensation for up to 5 years 

to address the real out-of-pocket expenses for the severely disabled. The DoleVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00053 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
50 

Shalala Commission recommended a transition pay of 3 months’ base pay or longerterm payments if participating in rehabilitation, education, or training. This is conceptually similar to our Pre-stabilization recommendation. 

QUALITY OF LIFE

Both our Commission and the Dole-Shalala Commission recommend a compensation payment for the impact of disability on quality of life. We believe the level of 

compensation should be based on the severity of disability and should make up for 

average impairments of earnings capacity and the impact of disability on 

functionality and quality of life. It should not be based on whether it occurred during combat or combat training; or the geographic location of injury, or whether the 

disability occurred during wartime or a time of peace. Current compensation payments do not provide payment above that required to offset earnings loss. Therefore, 

there is currently no compensation for the impact of disability on quality of life for 

most veterans. While permanent quality of life measures are developed and implemented, we recommend that compensation payments should be increased up to 25 

percent with priority to the more seriously disabled. 

VOCATIONAL REHABILITATION

All but the Independent Review Group addressed vocational rehabilitation. Both 

the Dole-Shalala Commission and our Commission found that the effectiveness of 

the program is not currently assessed and graduates are not followed except for a 

very brief time period. Both commissions recommend either an incentive bonus of 

up to 25 percent (Dole-Shalala) or exploring incentives as a way to encourage completion. The Nicholson Task Force focused on using existing programs and opportunities. 

CONCURRENT RECEIPT

Regarding concurrent receipt of military retirement and VA disability payments, 

our Commission found these to be two different programs with entirely different 

missions. DOD retirement recognizes years of service and VA disability payments 

compensate for impairment in earnings and should compensate for impact on quality of life. 

Over time, Congress should eliminate the ban on concurrent receipt for all military retirees and for all servicemembers who are separated from the military due 

to service-connected disabilities. Priority should be given to veterans who separate 

or retire with less than 20 years of service and a service-connected disability rating 

of 50 percent or greater or disability as a result of combat. Payment offset should 

also be eliminated for survivors of those who die in service or retirees who die of 

service-related causes so that the survivors can receive both VA Dependency and Indemnity Compensation (known as DIC) and DOD Survivors Benefit Plan (known as 

SBP.) 

The Dole-Shalala Commission also recommends that DOD compensate for years 

of service while VA compensates for disability. 

HAZARDS AND EXPOSURES

Our Commission and the Nicholson Task Force both addressed hazards and exposures but in different ways. The Nicholson Task Force recommended creating a center of excellence and a registry for embedded shrapnel or fragments from blast injuries. Our Commission recommended a new presumption process as proposed by the 

Institute of Medicine. The new process includes enhanced registries of servicemembers and veterans based on exposure, deployment, and disease histories. 

IMPROVING VA AND DOD COLLABORATION

In addition to assessing areas of overlap among the four reports, you asked my 

views on how to improve collaboration and cooperation between VA and DOD. Our 

Commission made several recommendations that we believe would enhance benefits 

and services for servicemembers and veterans, both while they are transitioning 

from the military to civilian status and for many years in the future. We found 

many encouraging signs and also areas which need improvement. 

The Joint Executive Council (JEC) established by statute has demonstrated how 

both departments can benefit from coordinated planning and increased cooperation. 

We applaud the results that are evident in specific initiatives. These include the integration of the North Chicago VA Medical Center and the Naval Health Clinic 

Great Lakes (named last week for astronaut James Lovell), in the coordinated treatment of severely injured in dedicated poly trauma centers, and in shared rehabilitaVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
51 

tion units. These are all indications of how joint efforts can benefit both departments and improve service to veterans and servicemembers. However, we believe 

that the JEC planning effort can be significantly improved by including specific 

milestones and designating responsible officials for each. We also suggest that transition coordination and effectiveness could be improved by including the Department 

of Labor and the Social Security Administration in some capacity in the JEC since 

these organizations have major transition roles. 

Successfully transitioning servicemembers to civilian life is crucial and ensuring 

that servicemembers understand the benefits and services that are available to 

them is essential. Information is disseminated through the Transition Assistance 

Program (TAP) and the Disabled Transition Assistance Program (DTAP.) We believe 

that the TAP briefings should be mandatory for all separating servicemembers, especially the Guard and Reserves and those in medical hold status. Currently, these 

briefings are not mandatory in all Services. In addition, we found that funding for 

these briefings has been static for the last decade and we recommend that adequate 

funding be provided. All servicemembers should be knowledgeable about benefits 

prior to leaving the service. 

After leaving service, many veterans find it difficult to prove that injuries and diseases that occur later in life are the result of military service. The veteran, with 

the assistance of VA, has to produce evidence that the condition originated in service. This is made more difficult because not all separating servicemembers receive 

separation examinations; only those who intend to file a claim for VA disability benefits. We believe that all separating servicemembers should receive a separation examination to establish a baseline for medical conditions. An entrance examination 

is required to enter active duty and a separation examination should be required 

to leave active duty. 

Application for disability benefits is expedited through the Benefits Delivery at 

Discharge (BDD) process which is currently available at some 140 military facilities 

and these claims are processed at two VA locations. Two problems exist with the 

BDD process: (1) it is not available unless the individual has an established date 

of discharge and is within 180 days of that date; and (2) it is not available at all 

locations. Those on medical hold or on the temporary disability retired list are often 

precluded from participating in BDD and Guard and Reserves often separate at locations where BDD is not available. We believe that BDD should be available to virtually all separating servicemembers, including Guard and Reserves. 

One cause for delay in claims processing even in the BDD process is availability 

of the DD–214 discharge document. Our Commission recommends that DOD immediately provide VA with an authenticated electronic document so that processing can 

begin right away. 

IT COMPATIBILITY

All of the reports address the absolute necessity for VA and DOD to have compatible information systems. All recognize the importance of this capability but also 

recognize that this will not solve all problems. 

Much has been said over the past several years about ‘‘seamless transition.’’ This 

is an admirable goal but it is not a current reality. Not all of DOD’s medical and 

personnel records are electronic and those that are electronic are not yet fully compatible between the Services, much less between VA and DOD. The AHLTA and 

VistA systems are not compatible. AHLTA may provide a more modern platform 

than VistA, but significant functions in the older VA system are not available to 

DOD users. For example, inpatient discharge summaries and digital images are not 

yet available in AHLTA. Therefore, DOD cannot easily transfer these types of information to VA upon a servicemember’s discharge or transfer for medical care without 

paper copies first being scanned. In January 2007, VA and DOD announced an 

agreement to create a joint inpatient electronic record that would be instantly accessible to clinicians in both departments. As far as we know, the departments have 

not committed to a completion date although the Nicholson Task Force identified 

January 31, 2008 as the date for completion of an analysis of alternatives. 

Veterans Benefits Administration continues to use paper claims folders and has 

no long-term plan to convert them to electronic records. Both VA and DOD will have 

to continue to use paper records well into the future. Plans need to be made to convert existing paper records and finally be able to exclusively use electronic records 

at some time in the future. 

Our Commission believes that development and implementation of compatible information systems should be expedited. We also agree with the Government Accountability Office that a detailed project management plan should be developed 

with a lead agent designated and with specific milestones and planned completion 

52 

dates. We understand why the departments are reluctant to establish planned completion dates since they will be expected to achieve those goals. However, we believe 

that planned completion dates for specific actions are absolutely essential in order 

to estimate resource requirements and to monitor progress. 

Compatible electronic systems will greatly enhance the ability of both departments to share information and work together. This critical interface will also improve claims processing and avoid some of the unfortunate cases that ‘‘slip through 

the cracks’’ during the transition from VA to DOD. 

In conclusion, VA and DOD have much to gain by greater coordination and collaboration but servicemembers and veterans have even more to gain by the two departments working better together. A lot of valuable work has been done by VA and 

DOD and they should be commended for the progress made. However, a great deal 

of work remains and the only way that the goal of a reasonably seamless transition 

will ever be realized is if the two departments are required to develop realistic, yet 

challenging, goals with specific milestones. Joint ventures, sharing agreements, and 

integrations should be the norm rather than the exception. Congress should review 

the plan and oversee progress. Congress also has the responsibility to ensure that 

sufficient funding is provided to accomplish the goals and objectives contained in the 

plan. 

Veterans’ Disability Benefits Commission 

Table 1.—Commission/Task Force Comparisons: Primary Topics and Areas of Overlap 

Study Group Topic Veterans’ Disability 

Benefits Commission 

Independent Review 

Group GWOT Task Force PCCWW 

VA/DOD Disability 

Process.

Realign disability evaluation process— 

Services determine 

fitness for duty, VA 

rates disability.

DOD should overhaul 

the DES system by 

implementing a single physical exam 

(as described by 

GAO 2004). The 

services should consistently be determining fitness for 

duty & VA provides 

disability rating. 

DOD should also expand the Disability 

Advisory Council, 

Conduct quality assurance reviews on 

previous 0–20 percent & EPTS cases, 

Evaluate loss of 

function due to 

burns similar to 

amputation.

Joint process whereby 

VA/DOD cooperate in 

assigning a disability evaluation, 

determining fitness 

for retention, level 

of disability retirement & VA compensation.

Restructure disability & 

compensation systems—DOD/VA 

should create a single, comprehensive 

standardized medical exam that DOD 

administers, DOD 

maintains authority 

over fitness & pays 

for years of service 

while VA establishes 

rating, compensation & benefits. 

Case Management Intensive case management with an 

identifiable lead 

agent.

Create tri-Service policy & guidelines for 

case management 

services & training, 

Assign single primary care physician 

& case manager.

System of case & comanagement.Comprehensive Recovery Plans & Coordinators with HHS as 

lead. 

Family Support ...... Authorize VA to provide 

family services, Extend health care & 

allowance to caregivers, Eliminate 

SBP–DIC offset, 

Eliminate TRICARE 

co-pays & deductibles for severely injured families.

Provide family education on benefits, 

Survey families on 

their needs, Assign 

family advocates.

None ............................. Strengthen support for 

families through 

TRICARE Respite 

Care & Aid and Attendant Benefit,* 

Caregiver training, 

Extend FMLA for 6 

months, All combatrelated injured families should have full 

TRICARE coverage. 

53 

Veterans’ Disability Benefits Commission—Continued 

Table 1.—Commission/Task Force Comparisons: Primary Topics and Areas of Overlap 

Study Group Topic Veterans’ Disability 

Benefits Commission 

Independent Review 

Group GWOT Task Force PCCWW 

IT Compatibility ..... Expedite development 

& implementation of 

compatible information systems with a 

detailed plan, milestones, & lead 

agency, Use IT to 

improve claims cycle 

time.

Streamline transition 

by rapidly developing a standard 

automated system 

interface for a bilateral exchange of 

clinical and administrative info between DOD & VA 

(Described in 2003 

PTF).

Enhance VA computerized Patient Record 

System & electronic 

enrollment, VA 

needs to develop a 

patient tracking application compatible 

with DOD, Create a 

TBI database, Improve VA’s access to 

military health 

records & create an 

interface with DOD, 

Create OIF/OEF identifiers and markers 

for polytrauma, Improve IT interoperability between VA & 

HHS Indian Health 

Services.

Rapidly transfer patient information, 

Create a 

MyeBenefits Web 

site. 

PTSD ...................... Holistic approach that 

couples treatment, 

rehabilitation, compensation & re-evaluation for wellness, 

Revise Rating 

Schedule for PTSD, 

Baseline level of 

benefits, PTSD exam 

process, Examiner & 

rater training & certification, research 

on Military Sexual 

Trauma.

Functional/cognitive 

measures & 

screenings upon 

entry & post-deployment, comprehensive & universal 

clinical practice & 

coding guidelines 

for blast injuries 

and TBI with PTSD 

overlay to include 

recording of exposures to blast in 

patient record. VA/ 

DOD create center of 

excellence for TBI 

and PTSD treatment, 

research & training.

Provide Outreach & 

Education to Community Health Centers on VA benefits 

& services (to reach 

vets with PTSD).

VA should care for all 

OIF/OEF vets with 

PTSD & (with DOD) 

improve prevention, 

diagnosis & treatment, reduce PTSD 

stigma. DOD should 

address its mental 

health shortage, 

Disseminate clinical 

practice guidelines 

to all providers. 

TBI ......................... Update the Rating 

Schedule for TBI.

Functional/cognitive 

measures & 

screenings upon 

entry & post-deployment, comprehensive & universal 

clinical practice & 

coding guidelines 

for blast injuries 

and TBI with PTSD 

overlay to include 

recording of exposures to blast in 

patient record. VA/ 

DOD create center of 

excellence for TBI 

and PTSD treatment, 

research & training.

Screen all GWOT veterans for TBI.DOD/VA should prevent, 

diagnose, & treat 

TBI, Partner with the 

private sector on TBI 

care, Disseminate 

clinical practice 

guidelines to all 

providers. 

54 

Veterans’ Disability Benefits Commission—Continued 

Table 1.—Commission/Task Force Comparisons: Primary Topics and Areas of Overlap 

Study Group Topic Veterans’ Disability 

Benefits Commission 

Independent Review 

Group GWOT Task Force PCCWW 

Ancillary Benefits .. Adjust & extend A&A, 

Extend auto & housing allowances to 

veterans with severe 

burns, Eliminate 

TSGLI premiums, 

Improve SDVI & 

VMLI, Increase benefits to original intention, Adjust automatically for inflation, Provide a Stabilization Allowance, 

Research additional 

ancillary benefits.

DOD should partner 

with VA to provide 

treatment, education 

& research in prosthesis care, production & amputee 

therapy, Allow VA 

patients to use Military and private 

prosthetist.

Expedite Adapted 

Housing and Special 

Home Adaptation 

Grants, Expand HUD 

National Housing 

Locator, Enhance 

capacity to provide 

Dental care through 

VA & private sector.

Transition (3 months of 

base pay or longterm) payments, 

Earnings-loss payments, All unfit 

combat-related injured should receive 

full TRICARE coverage. 

Quality of Life ....... Compensate for 3 consequences: work 

disability, loss of 

functionality & QOL, 

VA develop measures for QOL loss, 

but in the meantime 

create up to 25 percent QOL payment, 

Research health-related QOL & need 

for additional ancillary benefits, Increase SMC to address impact on 

QOL.

Survey patients on 

their needs.

None ............................. Determine appropriate 

QOL payments. 

Vocational Rehabilitation & Employment (VR&E).

Test VR&E incentives, 

Review & revise 12- 

year time limit, Expand VR&E to all 

medically separating 

servicemembers, & 

allow all service 

disabled veterans 

access to VR&E 

counseling, VR&E 

should screen all IU 

applicants, increase 

VR&E staffing, 

tracking, & resources.

None ............................. Extend VR&E evaluation determination 

time limit, Expand 

eligibility for SBA 

Patriot Express 

Loans, Increase Career Fairs & integrate Hire Vets First 

Campaign, Provide 

Credentialing, Certification, Financial 

Aid Education Assistance, & Employment rights, Develop 

Wounded Warrior Intern & Wounded 

Veterans Readjustment Work Experience Programs.

VR&E effectiveness is 

not well established 

and should offer 

completion incentives of up to a 25 

percent bonus. 

Concurrent Receipt Eliminate the ban ....... None ............................. None ............................. Create a DOD Annuity 

payment based on 

rank & years of 

service. 

Hazards & Exposures.Create a new structure 

for Presumption 

based on casual relationship using four 

categories.

None ............................. Create an embedded 

Fragment Surveillance Center and 

Registry.

None. 

55 

Veterans’ Disability Benefits Commission—Continued 

Table 1.—Commission/Task Force Comparisons: Primary Topics and Areas of Overlap 

Study Group Topic Veterans’ Disability 

Benefits Commission 

Independent Review 

Group GWOT Task Force PCCWW 

Combat/CombatRelated.Benefits based on severity of disability, 

not on circumstances or location.

None ............................. None ............................. Benefits and process 

specifically for combat/combat-related 

injuries only. 

Social Security/Disability Compensation for 

Earnings.

Compensation for earnings loss continues 

for life.

...................................... ...................................... Compensation for 

Earnings Ends when 

retirement Social 

Security begins. 

Walter Reed National Military 

Medical Center 

(WRNMMC).

None ............................. Accelerate BRAC construction projects for 

WRNMMC & new 

complex at Belvoir, 

New command and 

control structure for 

WRNMMC, Apply 

regulatory relief to 

A–76 process, Survey patients & families, Staff & train 

Med Hold(over) personnel, reevaluate 

efficiency wedge, 

Assign a senior facility engineer to 

oversee non-medical 

maintenance, Modernize facility assessment tools & 

prioritize repairs.

None ............................. Recruit & retain firstrate professionals 

for WRAMC through 

2011 with resources 

and incentives to 

hire civilian health 

care professionals & 

admin staff. 

* This refers to the Aid and Attendant benefit under TRICARE’s Extended Care Health Option, and not VA’s Aid and Attendance benefit. 

Table 2.—Other Veterans’ Commissions & Task Forces: Purposes, Findings and 

Recommendations 

Entity Chairperson Charged by Purpose Report 

Date 

Findings & Recommendations 

IRG on Rehabilitative Care & 

Admin @ Walter 

Reed & National 

Naval (Bethesda).

Former VA Secretary Togo West 

& Former Army 

Secretary & Congressman John 

Marsh.

Secretary of 

Defense.

Review continuum 

of care, leadership & oversight 

issues resulting 

in deficiencies 

reported at Walter Reed Scope: 

Walter Reed patients & families.

4/11/07 Problems resulted from a 

failure of leadership, 

loss of resources & 

spending authority 

under BRAC, contracting 

out, nursing and other 

staff shortages, challenges of signature injuries, & failure of the 

Medical Holdover system. Other reports have 

recommended changes 

to the MEB/PEB process 

over the last 10 years, 

but none have been implemented, which the 

IRG endorsed as well as 

a combined DOD/VA 

evaluation system. 

56 

Table 2.—Other Veterans’ Commissions & Task Forces: Purposes, Findings and 

Recommendations—Continued 

Entity Chairperson Charged by Purpose Report 

Date 

Findings & Recommendations 

Task Force on Returning Global 

War on Terror 

(GWOT) Heroes.

R. James Nicholson, Secretary of 

Veterans Affairs.

Executive 

Order of 

the President.

Improve the delivery of Federal 

services and 

benefits to 

GWOT servicemembers & veterans. Scope: All 

GWOT servicemembers & veterans.

4/19/07 There were 25 recommendations. Action 

areas included health 

care, case management, 

continuity of care, TBI 

screening, VA Liaisons 

at military facilities, 

small business loans, 

education, career training, employment rights, 

financial aid, housing 

locator, electronic tracking between systems, 

dental, rural health, VA/ 

DOD joint disability 

process & exams, VR&E 

extension, & home adaptation. Recommendations can be accomplished within existing 

authority & resources. 

Outreach should cover 

TAP/DTAP attendance, 

job fairs, vets preference, & a GWOT newsletter, comprehensive 

database of Federal 

services & benefits. 

President’s Commission on Care for 

America’s Returning Wounded 

Warriors (PCCWW).

Former Senator Bob 

Dole & Former 

HHS Secretary 

Donna Shalala.

Executive 

Order of 

the President.

Recommend Improvements for 

transition, highquality services 

for returning 

wounded troops, 

access to benefits & services. 

Scope: Wounded 

OIF/OEF servicemembers, veterans, families.

7/25/07 There were 6 recommendations: (1) Immediately 

creating a comprehensive recovery plan with 

a lead Recovery Coordinator; (2) Completely restructure the disability 

systems so DOD determines fitness and VA 

disability benefits; (3) 

Aggressively prevent & 

treat PTSD & TBI; (4) 

Significantly strengthen 

support for families with 

amendments to TRICARE 

& FMLA; (5) Rapidly 

transfer patient info, & 

develop a Federal benefits Web site, and; (6) 

Strongly support Walter 

Reed by recruiting & retaining 1st-rate professionals through 2011. 

57 

Table 2.—Other Veterans’ Commissions & Task Forces: Purposes, Findings and 

Recommendations—Continued 

Entity Chairperson Charged by Purpose Report 

Date 

Findings & Recommendations 

Veterans’ Disability 

Benefits Commission.

LTG James Terry 

Scott (USA, Ret.).

PL 108–136 .. Appropriateness of 

Benefit, level of 

Benefit, Determination Standards. Scope: All 

disabled servicemembers, veterans, families.

10/3/07 113 recommendations that 

focused on: compensation for quality of life & 

a 25 percent allowance 

until VA develops measures; line of duty; earnings disparity for service 

connected veterans with 

mental disorders & 

young entry; VA Rating 

Schedule revisions, especially for PTSD, TBI, & 

IU; A holistic approach 

for PTSD that couples 

compensation, treatment, rehabilitation, & 

re-evaluation; caregiver 

health care & an allowance; presumption 

standards for exposures; 

DOD disability evaluations and separation 

exams with Services determining fitness for 

duty & VA adjudicating 

a rating; concurrent receipt and survivor concurrent receipt; IT interoperability; & joint ventures, sharing agreements, & integration. 

* Final report. 

Table 3.—Total Recommendations 

Veterans’ Disability Benefits 

Commission Independent Review Group GWOT Task Force PCCWW 

113 20 25 6 

* 23 action items. 

EXECUTIVE SUMMARY

The Veterans’ Disability Benefits Commission was established by Public Law 

108–136, the National Defense Authorization Act of 2004. Between May 2005 and 

October 2007, the Commission conducted an in-depth analysis of the benefits and 

services available to veterans, servicemembers, their survivors, and their families to 

compensate and provide assistance for the effects of disabilities and deaths attributable to military service. The Department of Veterans Affairs (VA) expended $40.5 

billion on the wide array of these benefits and services in fiscal year 2006. The Commission addressed the appropriateness and purpose of benefits, benefit levels and 

payment rates, and the processes and procedures used to determine eligibility. The 

Commission reviewed past studies on these subjects, the legislative history of the 

benefit programs, and related issues that have been debated repeatedly over many 

decades. 

Congress created the Commission out of concern for a variety of issues pertinent 

to disabled veterans, disabled servicemembers, their survivors, and their families. 

Those matters included care for severely injured servicemembers, treatment and 

compensation for Post Traumatic Stress Disorder (PTSD), the concurrent receipt of 

military retired pay and disability compensation, the timeliness of processing disVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00061 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
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1Lincoln, Abraham, Second Inaugural Address, March 4, 1865, http:// 

www.ourdocuments.gov/doc.php?flash=true&doc=38. 

abled veterans’ claims for benefits, and the size of the backlog of those claims. Another area of concern was the program known as Individual Unemployability, which 

allows veterans with severe service-connected disabilities to receive benefits at the 

highest possible rate if their disabilities prevent them from working. The Commission gave these issues special attention. 

The Commission received extensive analytical support from the CNA Corporation 

(CNAC), a well-known research and consulting organization. CNAC performed an 

in-depth economic analysis of the average impairment of earning capacity resulting 

from service-connected disabilities. In addition, to assess the impact of disabilities 

and deaths on quality of life, CNAC conducted surveys of disabled veterans and survivors. To gain insight into claims processing issues, CNAC surveyed raters from 

VA and representatives of veterans’ service organizations who assist veterans in filing claims. CNAC also completed a literature review and a comparative analysis of 

disability programs similar to those provided by VA. 

The Commission received expert medical advice from the Institute of Medicine 

(IOM) of the National Academies. Required by statute to consult with IOM, the 

Commission asked the institute to conduct a thorough analysis of the VA Schedule 

for Rating Disabilities (hereafter the Rating Schedule) and a study of the processes 

used to decide whether one may presume that a disability is connected to military 

service. In addition, the Commission examined two studies that IOM conducted for 

VA about the diagnosis of PTSD and compensation to veterans for that disorder. 

Unfortunately, a third IOM study—of the treatment of PTSD—was not completed 

in time to be considered by the Commission. Additionally, the Commission conducted eight field visits and held numerous public sessions. 

GUIDING PRINCIPLES

The Commission wrestled with philosophical and moral questions about how a 

Nation cares for disabled veterans and their survivors and how it expresses its gratitude for their sacrifices. The Commission agreed that the United States has a solemn obligation, expressed so eloquently by President Lincoln, ‘‘. . . to care for him 

who shall have borne the battle, and for his widow, and his orphan . . .’’1

In going about its work, the Commission has been mindful of the 1956 Bradley 

Commission principles, which have provided a valuable and historic baseline. This 

Commission’s report addresses what has changed and what has endured over those 

five decades and throughout our Nation’s wars and conflicts since the Bradley report. Many of the changes—social, technological, cultural, medical, and economic— 

that have taken place during that time span are significant and must be carefully 

considered as our Nation renews its compact with our disabled veterans and their 

families. This long-term context, a history of both significant change and key elements of constancy from the 1950’s to the 21st century, provides the solid basis for 

this Commission’s principles, conclusions, and recommendations. 

This Commission identified eight principles that it believes should guide the development and delivery of future benefits for veterans and their families: 

1. Benefits should recognize the often enormous sacrifices of military service as 

a continuing cost of war, and commend military service as the highest obligation 

of citizenship. 

2. The goal of disability benefits should be rehabilitation and reintegration into 

civilian life to the maximum extent possible and preservation of the veterans’ dignity. 

3. Benefits should be uniformly based on severity of service-connected disability 

without regard to the circumstances of the disability (wartime v. peacetime, combat 

v. training, or geographical location.) 

4. Benefits and services should be provided that collectively compensate for the 

consequence of service-connected disability on the average impairment of earnings 

capacity, the ability to engage in usual life activities, and quality of life. 

5. Benefits and standards for determining benefits should be updated or adapted 

frequently based on changes in the economic and social impact of disability and impairment, advances in medical knowledge and technology, and the evolving nature 

of warfare and military service. 

6. Benefits should include access to a full range of health care provided at no cost 

to service-disabled veterans. Priority for care must be based on service connection 

and degree of disability. 

59 

7. Funding and resources to adequately meet the needs of service-disabled veterans and their families must be fully provided while being aware of the burden on 

current and future generations. 

8. Benefits to our Nation’s service-disabled veterans must be delivered in a consistent, fair, equitable, and timely manner. 

With these principles clearly in mind, the Nation must set the firm foundation 

upon which to shape and evolve a system of appropriate—and generous—benefits 

for the disabled veterans of tomorrow. 

The Commission believes that just as citizens have a duty to serve in the military, 

the Federal Government has a duty to preserve the well-being and dignity of disabled veterans by facilitating their rehabilitation and reintegration into civilian life. 

The Commission believes that compensation should be based on the nature and severity of disability, not whether the disability occurred during wartime, combat, 

training, or overseas. It is virtually impossible to accurately determine a disease’s 

origin or to differentiate the value of sacrifice among veterans whose disabilities are 

of similar type and severity. Setting different rates of compensation for the same 

degree of severity would be both impractical and inequitable. 

Disabled veterans require a range of services and benefits, including compensation, health care, specially adapted housing and vehicles, insurance, and other services tailored to their special needs. Compensation must help service-disabled veterans achieve parity in earnings with nonservice-disabled veterans. Compensation 

must also address the impact of disability on quality of life. Money alone is a poor 

substitute for the consequences of the injuries and disabilities faced by veterans, but 

it is essential to ease the burdens they experience. 

It is the duty of Congress and VA to ensure that the benefits and services for disabled veterans and survivors are adequate and meet their intended outcomes. IOM 

concluded that the VA Rating Schedule has not been adequately revised since 1945. 

This situation should not be allowed to continue. Systematic updates to the Rating 

Schedule and assessments of the appropriateness of the level of benefits should be 

made on a frequent basis. 

Excellent health care should be provided in a timely manner at no cost to veterans with service-connected disabilities (i.e., service-disabled veterans) and, in the 

case of severely injured veterans, to their families and caregivers. 

The funding and resources necessary to fully support programs for service-disabled veterans must be sufficient while ensuring that the burden on the Nation is 

reasonable. Care and benefits for service-disabled veterans are a cost of maintaining 

a military force during peacetime and of fighting wars. Benefits and services must 

be provided promptly and equitably. 

RESULTS OF THE COMMISSION’S ANALYSIS

The analyses conducted by the Commission with the assistance of IOM and CNAC 

provide a consistent and complementary picture of many aspects of veterans’ disability compensation. 

ENSURE HORIZONTAL AND VERTICAL EQUITY

For veterans to receive proper compensation for their service-connected disabilities, the VA Rating Schedule must be designed so that ratings result in horizontal 

and vertical equity in terms of compensation for average impairments of earning capacity. Horizontal equity means that persons with the same ratings percentage 

should have experienced the same loss of earning capacity. Vertical equity means 

that loss of earning capacity should increase in proportion to an increase in the degree of disability. A comparison of the earnings of disabled veterans with those of 

veterans who lacked service-connected disabilities revealed that the average amount 

of earnings lost by disabled veterans generally increased as disability ratings increased. In addition, mortality rates rose with degree of disability. Thus, vertical equity is achieved. The average earnings loss was similar across different types of disabilities except for PTSD and other mental disorders, indicating that horizontal equity also is generally being achieved at the level of body systems. 

ENSURE PARITY WITH NONDISABLED VETERANS

Overall, disabled veterans who first apply to VA for compensation at age 55 (the 

average age) receive amounts of money that are nearly equal to their average loss 

of earnings as a consequence of their disabilities among the broad spectrum of physical disabilities. 

The earnings of a representative sample of nondisabled veterans were compared 

with the sum of earnings plus compensation of disabled veterans to determine the 

60 

extent to which disability compensation helps disabled veterans achieve parity with 

their nondisabled counterparts. Among veterans whose primary disabilities are 

physical, those who are granted Individual Unemployability are substantially below 

parity; those who are rated 100 percent disabled and who enter the system at a 

younger age (45 years or less) are slightly below parity; and those who enter at age 

65 or older are above parity. For those whose primary disabilities are mental, the 

sum of earnings plus VA compensation is generally below parity at average age of 

entry, substantially below parity for severely disabled individuals who enter the system at a younger age, and above parity for those who enter at age 65 or older. Also, 

among veterans whose primary disabilities are mental, those rated 10 percent disabled are slightly below parity. Thus, parity is generally present with respect to 

earnings loss except among individuals whose primary disabilities are mental, 

among the younger severely disabled, and among those granted Individual 

Unemployability. 

COMPENSATE FOR LOSS OF QUALITY OF LIFE

Parity in average loss of earnings means that disability compensation does not 

compensate veterans for the adverse impact of their disabilities on quality of life. 

Current law requires only that the VA Rating Schedule compensate service-disabled veterans for average impairment of earning capacity. However, the Commission concluded early in its deliberations that VA disability compensation should recompense veterans not only for average impairments of earning capacity, but also for 

their inability to participate in usual life activities and for the impact of their disabilities on quality of life. IOM reached the same conclusion; moreover, it made extensive recommendations on steps to develop and implement a methodology to 

evaluate the impact of disabilities on veterans’ quality of life and to provide appropriate compensation. 

The Commission concluded that the VA Rating Schedule should be revised to include compensation for the impact of service-connected disabilities on quality of life. 

For some veterans, quality of life is addressed in a limited fashion by special monthly compensation for loss of limbs or loss of use of limbs. Some ancillary benefits attempt to ameliorate the impact of disability. However, the Commission urges Congress to consider increases in some special monthly compensation awards to address 

the profound impact of certain disabilities on quality of life and to assess whether 

other ancillary benefits might be appropriate. While a recommended systematic 

methodology is developed for evaluating and compensating for the impact of disability on quality of life, the Commission believes that an immediate interim increase of up to 25 percent of compensation should be enacted. 

A survey of a representative sample of disabled veterans and survivors was conducted to assess their quality of life and other issues. The survey found that among 

veterans whose primary disability is physical, their physical health is inferior to 

that of the general population for all levels of disability, and their physical health 

generally worsens as their level of disability increases. Physical disabilities did not 

lead to decreased mental health. For veterans whose primary disability is mental, 

not only were their mental health scores much lower than those of the general population, but their physical health scores were well below population norms for all levels of mental disability. Those veterans with PTSD had the lowest physical health 

scores. 

The survey also sought to address two specific issues through indirect questions. 

There are concerns that service-disabled veterans tend not to follow medical treatments because they fear it might impact their disability benefits. This premise was 

not substantiated. Likewise, when questioned whether VA benefits created a disincentive to work, only 12 percent of respondents indicated they might work or work 

more if not for compensation benefits; thus, this is not a major issue. 

UPDATE THE RATING SCHEDULE

The Rating Schedule consists of slightly more than 700 diagnostic codes organized 

under 14 body systems, such as the musculoskeletal system, organs of special sense, 

and mental disorders. For each code, the schedule provides criteria for assigning a 

percentage rating. The criteria are primarily based on loss or loss of function of a 

body part or system, as verified by medical evidence; however, the criteria for mental disorders are based on the individual’s ‘‘social and industrial inadaptability,’’ 

meaning the overall ability to function in the workplace and everyday life. 

IOM concluded that it has been 62 years since the VA Rating Schedule was adequately revised and made a series of recommendations for immediately updating the 

Rating Schedule and requiring that it be revised on a systematic and frequent basis. 

The Commission generally agrees with these recommendations; however, the ComVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00064 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
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mission does not agree that the revision should begin with those body systems that 

have not been revised for the longest time period. Rather, the Commission recommends that first priority be given to revising the mental health and neurological 

body systems to expeditiously address PTSD, other mental disorders, and Traumatic 

Brain Injury. A quick review by VA of the Rating Schedule could be completed to 

determine the sequence in which the other body systems should be addressed, and 

a timeline should be developed for completing the revision. 

To emphasize the importance and urgency of revising the Rating Schedule, the 

Commission urges Congress to require that the entire schedule be reviewed and updated as needed over the next 5 years. Congress should monitor progress carefully. 

Thereafter, the Rating Schedule should be reviewed and updated on a frequent 

basis. 

INDIVIDUAL UNEMPLOYABILITY

The Individual Unemployability (IU) program enables a veteran rated 60 percent 

or more but less than 100 percent to receive benefits at the 100 percent rate if he 

or she is unable to work because of service-connected disabilities. IU has received 

considerable attention recently because the number of veterans granted IU increased by 90 percent. The Commission found this increase to be explained by the 

aging of the cohort of Vietnam veterans. 

DEVELOP PTSD-SPECIFIC RATING CRITERIA AND IMPROVE PTSD TREATMENT

Concerning PTSD and other mental disorders, it is very clear that having one set 

of criteria for rating all mental disorders has been ineffective. IOM recommended 

separate criteria for PTSD. Similarly, the CNAC survey of VA raters found that raters believe separate criteria for PTSD would enable them to rate PTSD claims more 

effectively. In addition, the earnings analysis described above demonstrates that 

there is a disparity in earnings of those with PTSD and other mental disorders and 

that the current scheme for rating all mental disorders in five categories of severity—10, 30, 50, 70, and 100 percent—does not result in adequate compensation. It 

is also unclear why 31 percent of those with PTSD as their primary diagnosis are 

granted IU, especially since incapacity to work is part of the current criteria for 

granting 100 percent for PTSD and other mental disorders. It would seem that 

many of these veterans should be awarded 100 percent ratings without IU. The 

Commission agrees with the IOM recommendation that new Rating Schedule criteria specific to PTSD should be developed and implemented based on criteria from 

the Diagnostic and Statistical Manual of Mental Disorders. 

The Commission believes that a new, holistic approach to PTSD should be considered. This approach should couple PTSD treatment, compensation, and vocational 

assessment. The Commission believes that PTSD is treatable, that it frequently recurs and remits, and that veterans with PTSD would be better served by a new approach to their care. There is little interaction between the Veterans Health Administration, which examines veterans for evaluation of severity of symptoms and treats 

veterans with PTSD, and the Veterans Benefits Administration, which assigns disability ratings and may or may not require periodic reexamination. It is evident that 

PTSD reexaminations have been scheduled with less frequency in recent years due 

to the backlog of disability claims. It is also evident that case management of PTSD 

patients could be improved through greater interaction between the therapy received in Vet Centers and treatment in VA medical centers. IOM concluded that the 

use of standardized testing and the frequency of reexaminations should be recommended by clinicians on a case-by-case basis, but did not suggest how that would 

be achieved. The Commission suggests that treatment should be required and its 

effectiveness assessed to promote wellness of the veteran. Reexaminations should be 

scheduled and conducted every 2 to 3 years. 

IMPROVE PERFORMANCE OF VOCATIONAL REHABILITATION AND EMPLOYMENT

The Commission believes that the goal of disability benefits, as expressed in guiding principle 2, is not being met. In spite of the studies done and recommendations 

made in recent years, the Vocational Rehabilitation and Employment (VR&E) program is not accomplishing its primary goal. The Commission believes that recent 

studies have provided the necessary analyses and that VA possesses the necessary 

expertise to remedy this failure. Simply put, VA must develop specific plans and 

Congress must provide the resources to quickly elevate the performance of VR&E. 

62 

ALLOW CONCURRENT RECEIPT

The Commission carefully reviewed whether disabled veterans should be permitted to receive both military retirement benefits and VA disability compensation. 

The Commission also reviewed whether the survivors of veterans who die either on 

active duty or as a result of a service-connected disability should be allowed to receive both Department of Defense (DOD) Survivor Benefit Plan (SBP) and VA Dependency and Indemnity Compensation (DIC). Currently, military retirees with 

service-connected disabilities rated 50 percent or higher are authorized to receive 

both benefits, which are being phased in over the next few years. Survivors are not 

authorized to receive both benefits. The Commission is persuaded that these programs have unique intents and purposes: military retirement benefits and SBP are 

intended to compensate for years of service, while VA disability compensation and 

DIC are intended to compensate for disability or death attributable to military service. It should be permissible to receive both sets of benefits concurrently. 

In addition, the Commission believes that those separated as medically unfit with 

less than 20 years of service should also be able to receive military retirement and 

VA compensation without offset. Currently, those receiving ratings of less than 30 

percent from DOD receive separation pay, which must be paid back through deductions from VA compensation for the unfitting conditions before VA compensation is 

received. Those receiving DOD ratings of 30 percent or higher and a continuing disability retirement have their DOD payments offset by any VA compensation. Priority among medical discharges should be given to those separated or retired with 

less than 20 years of service and disability rating greater than 50 percent or disability as a result of combat. 

ALLOW YOUNG, SEVERELY INJURED VETERANS TO RECEIVE

SOCIAL SECURITY DISABILITY INSURANCE

Among the benefits available for disabled veterans, those not able to work may 

be eligible for Social Security Disability Insurance (SSDI). To be eligible for SSDI, 

an individual must have worked a minimum number of quarters, be unable to work 

because of medical conditions, not have income above a minimum level, and be less 

than 65 years of age. At 65, SSDI converts to normal Social Security at the same 

amount. Some very young servicemembers who are severely injured may not have 

sufficient quarters to qualify for SSDI. The Commission recommends eliminating 

the minimum quarters requirement for the severely injured. Only 61 percent of 

those granted IU by VA and 54 percent of those rated 100 percent by VA are receiving SSDI. Considering the very low earnings by those rated 100 percent and the exceptionally low earnings of those granted IU, it is apparent that either these veterans do not know to apply for SSDI or are being denied the insurance. Increased 

outreach should be made and better coordination between VA and Social Security 

should result in increased mutual acceptance of decisions. 

REALIGN THE VA–DOD PROCESS FOR RATING DISABILITIES

The Commission also assessed the consistency of ratings by DOD and VA on individuals found unfit for military service by DOD under 10 U.S.C. chapter 61. Some 

83,000 servicemembers were found unfit between 2000 and 2006. DOD rated 81 percent of those individuals as less than 30 percent and discharged them with severance pay, including over 13,000 who were found unfit by the Army and given zero 

percent ratings. 79% of these servicemembers later filed claims with VA and received substantially higher ratings. The reasons for the higher ratings are that VA 

rates about three more conditions than DOD, and at the individual diagnosis level 

VA assigns higher ratings than DOD. 

The Commission finds that the policies and procedures used by VA and DOD are 

not consistent and the resulting dual systems are not in the best interest of the injured servicemembers nor the Nation. Existing practices that allow servicemembers 

to be found unfit for pre-existing conditions after up to 8 years of active duty and 

that allow DOD to rate only the conditions that DOD finds unfitting should be reexamined. Servicemembers being considered unfit should be given a single, comprehensive examination and all identified conditions should be rated and compensated. 

The Commission agrees with the President’s Commission on the Care of Returning Wounded Warriors that the DOD and VA disability evaluation process should 

be realigned so that the military determines if the servicemember is unfit for service 

and awards continuing payment for years of service and health care coverage for 

the family while VA pays disability compensation. However, in accordance with one 

of our key guiding principles, the Commission believes that benefits should not be 

63 

limited to combat and combat-related injuries. Nor does the Commission believe 

that VA disability compensation should end and be replaced with Social Security at 

retirement age. 

LINK BENEFITS TO COST-OF-LIVING INCREASES

In its review, the Commission found that the ancillary and special-purpose benefits payments and award limits are not automatically indexed to cost of living. A 

few of these benefits have not been increased in many years, and as a result, some 

no longer meet the original intent of Congress. The Commission recommends that 

Congress raise ancillary and special-purpose benefits to the levels originally intended and provide for automatic annual adjustments to keep pace with the cost of 

living. 

SIMPLIFY AND EXPEDITE THE PROCESSING OF DISABILITY CLAIMS AND APPEALS

VA disability benefits and services are not currently provided in a timely manner. 

Court decisions, statutory changes, and resource limitations have all contributed to 

this unacceptable situation. Numerous studies over the years have assessed the 

processing of both claims and appeals and have made numerous recommendations 

for change. Still, veterans seeking disability compensation face a complex process. 

The population of veterans is steadily decreasing with the passing of veterans of 

World War II and the Korean War. Yet, the aging of the Vietnam Era veterans 

means that they are filing original and reopened claims in large numbers. Technology offers opportunities for improvement, but it is unlikely to solve all problems. 

The Commission believes that increased reliance on best business practices and 

maximum use of information technology should be coupled with a simplified and expedited process for well-documented claims to improve timeliness and reduce the 

backlog. The Commission is aware that a significant increase in claims processing 

staff has been recently approved but is also aware that the time required for training and the slow development of job experience will limit the speed with which results can realistically occur. 

The Commission believes that claimants should be allowed to state that claim information submitted is complete and waive the normal 60-day timeframe permitted 

for further development. 

IMPROVE TRANSITION ASSISTANCE

A smooth transition from military to civilian status is crucial for veterans and 

their families to quickly adjust to civilian life. This goal, often expressed as ‘‘seamless transition,’’ has yet to be fully realized, although VA and DOD have made significant improvements during the past few years. The two departments’ medical and 

other systems are not truly compatible, and both departments will have to rely on 

paper records for many years. Perhaps the single most important step that can be 

taken to assist veterans, particularly those who are disabled and their families, and 

to reduce the lengthy delays plaguing claims processing would be to achieve electronic compatibility. In addition, the Commission believes that making VA benefit 

payments effective the day after discharge will help ease the financial aspect of 

transition. 

IMPROVE SUPPORT FOR SEVERELY DISABLED VETERANS AND THEIR CAREGIVERS

Severely disabled servicemembers who are about to transition into civilian life 

need far more support and assistance than is currently provided. An effective case 

management program should be established with a clearly identified lead agent who 

has authority and responsibility to intercede on behalf of disabled individuals. The 

lead agent should be an advocate for servicemembers and their families. In addition, 

VA should be authorized to provide family assistance similar to that provided by 

DOD up until discharge. TRICARE deductibles and copays are costs incurred by the 

severely disabled; the Commission believes that these costs should be waived. In addition, consideration should be given to expanding health care and providing an allowance for caregivers of the severely disabled. Currently, health care is only provided for the dependents of severely disabled veterans but not for parents and other 

family members who are caregivers. 

IMPLEMENT A NEW PROCESS FOR DETERMINING PRESUMPTION

Various processes have been used to create presumptions when there are uncertainties as to whether a disabling condition is caused by military service. Presumptions are established when there is evidence that a condition is experienced by a 

sufficient cohort of veterans and it is reasonable to presume that all veterans in that 

64 

cohort who experience the condition acquired the condition due to military service. 

The Commission asked IOM to review the processes used in the past to establish 

presumptions and to recommend a framework that would rely on more scientific 

principles. IOM conducted an extensive analysis and recommended a detailed and 

comprehensive approach that includes the creation of an advisory committee and a 

scientific review board, formalizing the process and making it transparent, improving research, and tracking military troop locations and environmental exposures. 

Perhaps most importantly, the approach includes using a causal effect standard for 

decisionmaking rather than a less-precise statistical association. The Commission 

endorses the recommendations of the IOM but expresses concern about the causal 

effect standard. Consideration should also be given to combining the advisory committee on presumptions with the recommended advisory committee on the Rating 

Schedule. 

CONCLUSION

The Commission made 113 recommendations. All are important and should receive attention from Congress, DOD, and VA. The Commission suggests that the following recommendations receive immediate consideration. Congress should establish 

an executive oversight group to ensure timely and effective implementation of the 

Commission recommendations. 

PRIORITY RECOMMENDATIONS

Recommendation 4.23—Chapter 4, Section I.5 

VA should immediately begin to update the current Rating Schedule, beginning 

with those body systems addressing the evaluation and rating of Post Traumatic 

Stress Disorder and other mental disorders and of Traumatic Brain Injury. Then 

proceed through the other body systems until the Rating Schedule has been comprehensively revised. The revision process should be completed within 5 years. VA 

should create a system for keeping the Rating Schedule up to date, including a published schedule for revising each body system. 

Recommendation 5.28—Chapter 5, Section III.3 

VA should develop and implement new criteria specific to Post Traumatic Stress 

Disorder in the VA Schedule for Rating Disabilities. VA should base those criteria 

on the Diagnostic and Statistical Manual of Mental Disorders and should consider 

a multidimensional framework for characterizing disability due to Post Traumatic 

Stress Disorder. 

Recommendation 5.30—Chapter 5, Section III.3 

VA should establish a holistic approach that couples Post Traumatic Stress Disorder treatment, compensation, and vocational assessment. Reevaluation should 

occur every 2–3 years to gauge treatment effectiveness and encourage wellness. 

Recommendation 6.14—Chapter 6, Section IV.2 

Congress should eliminate the ban on concurrent receipt for all military retirees 

and for all servicemembers who separated from the military due to service-connected disabilities. In the future, priority should be given to veterans who separated 

or retired from the military under chapter 61 with 

• fewer than 20 years service and a service-connected disability rating greater 

than 50 percent, or 

• disability as a result of combat. 

Recommendation 7.4—Chapter 7, Section II.3 

Eligibility for Individual Unemployability (IU) should be consistently based on the 

impact of an individual’s service-connected disabilities, in combination with education, employment history, and medical effects of an individual’s age or potential 

employability. VA should implement a periodic and comprehensive evaluation of veterans eligible for IU. Authorize a gradual reduction in compensation for IU recipients who are able to return to substantially gainful employment rather than abruptly terminating disability payments at an arbitrary level of earning. 

Recommendation 7.5—Chapter 7, Section II.3 

Recognizing that Individual Unemployability (IU) is an attempt to accommodate 

individuals with multiple lesser ratings but who remain unable to work, the Commission recommends that as the VA Schedule for Rating Disabilities is revised, 

every effort should be made to accommodate such individuals fairly within the basic 

rating system without the need for an IU rating. 

65 

Recommendation 7.6—Chapter 7, Section III.2 

Congress should increase the compensation rates up to 25 percent as an interim 

and baseline future benefit for loss of quality of life, pending development and implementation of a quality-of-life measure in the Rating Schedule. In particular, the 

measure should take into account the quality of life and other non-work-related effects of severe disabilities on veterans and family members. 

Recommendation 7.8—Chapter 7, Section III.2 

Congress should consider increasing special monthly compensation, where appropriate, to address the more profound impact on quality of life of the disabilities subject to special monthly compensation. Congress should also review ancillary benefits 

to determine where additional benefits could improve disabled veterans’ quality of 

life. 

Recommendation 7.12—Chapter 7, Section VI 

VA and DOD should realign the disability evaluation process so that the services 

determine fitness for duty, and servicemembers who are found unfit are referred to 

VA for disability rating. All conditions that are identified as part of a single, comprehensive medical examination should be rated and compensated. 

Recommendation 7.13—Chapter 7, Section V.3 

Congress should enact legislation that brings ancillary and special-purpose benefits to the levels originally intended, considering the cost of living, and provides for 

automatic annual adjustments to keep pace with the cost of living. 

Recommendation 8.2—Chapter 8, Section III.1.B 

Congress should eliminate the Survivor Benefit Plan/Dependency and Indemnity 

Compensation offset for survivors of retirees and in-service deaths. 

Recommendation 9.1—Chapter 9, Section II.5.A.b 

Improve claims cycle time by 

• establishing a simplified and expedited process for well-documented claims, 

using best business practices and maximum feasible use of information technology; 

and • implementing an expedited process by which the claimant can state the claim 

information is complete and waive the time period (60 days) allowed for further development. 

Congress should mandate and provide appropriate resources to reduce the VA 

claims backlog by 50 percent within 2 years. 

Recommendation 10.11—Chapter 10, Section VII 

VA and DOD should expedite development and implementation of compatible information systems including a detailed project management plan that includes specific milestones and lead agency assignment. 

Recommendation 11.1—Chapter 11 

Congress should establish an executive oversight group to ensure timely and effective implementation of the Commission’s recommendations. This group should be cochaired by VA and DOD and consist of senior representatives from appropriate departments and agencies. It is further recommended that the Veterans’ Affairs Committees hold hearings and require annual reports to measure and assess progress. 

One commissioner submitted a statement of separate views regarding four aspects 

of the report. His statement is in Appendix L. 

ADDITIONAL RESOURCES: 

Electronic access to the complete report of the Veterans’ Disability Benefits Commission is available at: http://www.vetscommission.org 

Also available on the Commission’s Web site are: 

• Bios of the Commissioners 

• Commission Charter 

• Commission Charter (renewed, 2–21–2007) 

• Public Law 108–136 establishing the Commission 

• Extension of the Commission’s Charter in Public Law 109–163 

• Legislative History of VA Disability Compensation Program, Economic Systems 

Inc., Dec 2004 

• Appendices to the Legislative History (Dec 2004) 

• Literature Review of VA Disability Compensation Program, Economic Systems 

Inc., Dec 2004 

• Appendices to the Literature Review (Dec 2004) 

66 

• Commission’s Approved Research Questions, October 14, 2005 • Institute of Medicine (IOM) Summary of the PTSD Review contracted by the 

Veterans Health Administration, Mar 2006 • A History and Analysis of Presumptions of Service Connection (1921–1993) • An Updated Legal Analysis of Presumptions of Service Connection (1993–2006) • Center for Naval Analyses (CNA) Literature Review (Final), May 2006 • Appendix to the CNA Literature Review (Final), May 2006 • Veterans’ Claims Adjudication Commission (VCAC), also known as the 

Melidosian Commission Report (1996) • Blue Ribbon Panel on Claims Processing: Proposals to Improve Disability 

Claims Processing in the Veterans Benefits Administration, November 1993 • Bradley Commission Report 1956 • IOM Report to VA on Post Traumatic Stress Disorder: Diagnosis and Assessment, 2006 • Testimony of Chairman Scott at a Joint Hearing of the Senate Armed Services 

& Veterans’ Affairs Committees, April 12, 2007 • CNA Report: Findings from Raters and VSOs Surveys, May 2007 • IOM Report to VA on PTSD Compensation and Military Service, 2007 • A 21st Century System for Evaluating Veterans for Disability Benefits, IOM 

Final Report, June 2007 • Improving the Presumptive Disability Decision-Making Process for Veterans, IOM Final Report, and Executive Summary August 2007 • CNA Final Report: Final Report for the Veterans’ Disability Benefits Commission: Compensation, Survey Results and Selected Topics, August 2007 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO JAMES

TERRY SCOTT, LTG, USA (RET.), CHAIRMAN, VETERANS’ DISABILITY BENEFITS COM- MISSION

Before addressing the specific questions asked, I would like to make it clear that 

my comments are my own and do not represent the views of the other members of 

the Commission. The Commission completed its work and submitted its report on 

October 3, 2007. 

DIFFERENCES IN RECOMMENDATIONS

Question. Please compare your Commisson’s recommendation to provide a quality 

of life payment as part of disability compensation with the Dole-Shalala commission’s recommendation to revamp the entire disability system? 

Response. First, it is important to emphasize the results of the overall analysis 

that the Veterans’ Disability Benefits Commission conducted of the entire VA and 

DOD system for determining compensation for injuries, diseases, and deaths attributable to military service. Our Commission addressed the entire system, not just 

how the system addresses those found unfit for military duty As a result of our comprehensive analysis, we made a series of broad recommendations intended to significantly improve the existing system, including a realignment of the processes used 

by DOD and VA when a servicemember is found by DOD to be unfit for military 

duty. If implemented, our recommendations would result in important and major 

changes. 

Our Commission’s efforts relied extensively on analysis conducted for our Commission by the Institute of Medicine (IOM) of the National Academies and by the 

CNA Corporation (CNAC). Taken together, their work provides a picture of a disability system that needs considerable improvement but one that is generally sound. 

For example, IOM concluded that an effective system should ensure vertical and 

horizontal equity to compensate disabled veterans for average loss of earnings capacity. Horizontal equity would ensure that veterans with different types of disabilities but with similar severity of disabilities would have similar loss of earnings. 

Vertical equity would ensure that as rating severity increases, earnings loss would 

also increase. CNAC’s analysis concluded that general loss would also increase. 

CNAC’s analysis concluded that there is general parity overall with average VA 

compensation for all made service-disabled veterans about at parity with earnings 

loss and that there is not much difference among physical disorders. They did find 

significant exceptions with PTSD and other mental disorders and those who experience severe disabilities at a young age; these groups receive compensation that does 

not achieve parity with earnings loss. 

IOM concluded that compensation should be provided for more than work disability or earnings loss; it would also compensate for loss of ability to engage in 

usual life activities and loss of quality of life. The CNAC analysis provided that curVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00070 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
67 

rent compensation payments generally provide parity with respect to earnings loss 

but that there is not compensation for quality of life. In addition, the CNAC analysis 

provided an accurate assessment of the extent to which disability impacts on quality 

of life and demonstrated that health declined as degree of disability increased. 

CNAC also found that mental disorders impacted on physical health to an extent 

unanticipated. Thus, the CNAC analysis supported the independent conclusions of 

the IOM concerning compensation for impact of disability on quality of life. The 

Dole-Shalala Commission also recommended that compensation should recognized 

effects on quality of life. 

Our Commission asked the IOM to address whether some other system of evaluating disability would be preferable to the use of the VA Rating Schedule. Specifically, IOM was asked to compare and contrast the Rating Schedule to the American 

Medical Association Guides to the Evaluation of Permanent Impairment. IOM found 

that the Guides are designed for use by physicians, measures and rates impairment 

and, to some extent, daily functioning, but not disability or quality of life, and does 

not provide mental ratings. IOM recommended updating and improving the Rating 

Schedule rather than adopting an impairment schedule developed for other purposes. 

Concerning the recommendation by the Dole-Shalala Commission to ‘‘completely 

restructure’’ the disability and compensation system, my interpretation is that the 

overall focus of their report is on the processes currently used to determine whether 

a servicemember is fit or unfit for duty and to provide benefits and compensation 

for those found unfit. They recommended that the existing processes be restructured 

so that DOD determines fitness for duty and, for those unfit, DOD provides payment for time of service; VA rates the disability and compensates for disability. Our 

Commission essentially recommended the same realignment. The Dole-Shalala Commission recommended specifically that DO administer a single, comprehensive examination that could be used by both DOD and VA. Our Commission agreed that 

a single, comprehensive examinations be conducted but felt that either DOD or VA 

could administer the examination, depending on local capability of the clinical staffs. 

However, we extensively reviewed the examination process with the advice of the 

Institute of Medicine and made several recommendations to improve the examinations and ensure consistency and reliability. These recommendations include greater 

use of templates, improved training and certification of examiners, and enhanced 

quality control. These recommendations should be implemented no matter which department conducts the examinations. 

DUAL RATING SCHEDULE

Question. Based on the Commission’s work, do you believe that it is either necessary or appropriate to have two different disability ratings schedules, one for veterans of the current conflicts and one for veterans of earlier eras? 

Response. Our Commission believes that there should be a single process used 

and the benefits available should be appropriate for all veterans. The processing 

steps may vary somewhat in the case of servicemembers found unfit for duty, but 

in general, all veterans’ claims should be processed similarly and in a timely manner. Our Commission also believes that the payment rate of disability compensation 

should be based on severity of disability without regard to the circumstances of the 

disability. This is Principle 3 of our Commission’s 8 principles. We do not believe 

that veterans’ compensation should be different if the injury occurs during wartime 

or peacetime, during combat or combat-related duties, in the United States or 

abroad, or other distinctions. We believe that military service is a 24-hour a day responsibility as demonstrated by the fact that servicemembers are subject to the Uniformed Code of Military Justice continuously during active duty. In addition to 

issues of equity, such distinctions among circumstances would require subjective 

judgment on the part of rating officials and would serve to add further complexity 

into an already complex process. 

All veterans should be evaluated using the same criteria, namely the VA Rating 

Schedule and that no attempt should be made to develop and apply different criteria 

or a different Rating Schedule to veterans who served during different periods of 

time. It is clear that VA has not been successful in keeping one rating schedule up 

to date. Our Commission recognized that VA had undertaken a project to revise the 

rating schedule as a result of a critical 1989 GAS report and had published a notice 

of its intent to update the entire schedule in August 1989. IOM carefully reviewed 

the revisions to the rating schedule and found that only 373 of 798 diagnostic codes 

(47 percent) had been revised since 1990. A substantial proportion (281, or 35 percent) of the schedule’s diagnostic codes had not been revised at all since 1945 and 

18 percent (144 codes) were revised between 1945 and 1989. Our recommendation 

68 

4.23 concerning updating the VA rating schedule said that the revision of the rating 

schedule should be completed within 5 years and our report (Prepublication page 

80) indicated that five years is a realistic timetable. Our Commission felt that it 

would be important to establish a deadline that cold reasonably be met, considering 

VA’s lack of progress in the past. We meant that deadline to be a maximum, not 

an estimate for how long the revision should take. In retrospect, we should have 

expressed this more carefully as an outside limit. We did not estimate how long a 

complete revision should take. 

I believe that practical consideration also argue against attempting to create and 

maintain two separate processes and benefits. It is well known and accepted that 

VA has had an ongoing problem with timeliness of claims processing and with a 

continuing and growing backlog of claims well beyond the volume of pending claims 

needed to sustain efficient operations. During the period 2000-2006, VA received 

some 1.2 million original claims while DOD separated or retired some 83,000 

servicemembers as unfit for military duty. Thus, the number of unfit separations 

and retirements were only 6.9 percent of all original claims. 

I am also aware of proposals that would restrict benefits, particularly TRICARE 

family health care, to those with very strictly defined serious disabilities who are 

separated or retired as unfit. During the period of 2000 to 2006 reviewed by our 

Commission, less than two percent (1,478 of 83,008) of those separated or discharged as unfit were rated by DOD as 100 percent disabled and only six percent 

(5,060 of 83,008) were rated 50 percent or higher. Currently, servicemembers found 

unfit and rated 30 percent disabled or higher are eligible for TRICARE. The DoleShalala Commission recommended that all those fond unfit because of combat-related injuries should receive comprehensive health care for themselves and their 

families. As discussed previously, I do not believe a distinction should be made regarding combat-related injuries, but I agree with providing TRICARE to everyone 

found unfit. 

Chairman AKAKA. Thank you very much, General. 

Admiral Dunne? 

STATEMENT OF REAR ADMIRAL PATRICK W. DUNNE, U.S. 

NAVY (RET.), ASSISTANT SECRETARY FOR POLICY AND 

PLANNING, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Admiral DUNNE. Good morning, Mr. Chairman and distinguished 

Members of the Committee. Thank you for the opportunity to discuss the recent activities to serve our Nation’s veterans through 

improved processes and greater collaboration with DOD. 

On April 19, the President’s Task Force on Returning Global War 

on Terror Heroes issued its 25 recommendations to improve health 

care, benefits, employment, education, housing, and outreach using 

existing authority and resource levels. This report was unique in 

that it also included an ambitious schedule of action and target 

dates. Thanks to outstanding interagency cooperation, 56 of 58 action items have been completed or initiated. 

The results of these initiatives support seamless and world class 

health delivery. VA and DOD drafted a joint policy document on comanagement and case management of severely injured servicemembers. This will enhance individualized support for the wounded, severely injured, or ill servicemember and his or her family 

throughout the recovery process. 

To assist OEF/OIF wounded servicemembers and their families 

in navigating through the transition process, VA hired 106 new 

Transition Patient Advocates. These men and women, often veterans themselves, work with case managers and clinicians to ensure that patients and families can focus on recovery. 

VA also revised its electronic health care enrollment form to include a selection option for OEF/OIF to ensure proper priority of 

care. 

69 

DOD and VA work collaboratively to expand access to servicemembers’ electronic health records by jointly developing the electronic capability to transfer digital radiographs from Walter Reed, 

Bethesda, and Brooke to VA’s polytrauma centers. The capability 

for electronic transmission of historic health care data from DOD 

MTFs to VA medical centers is complete in the domains of allergies, outpatient medications, laboratory results, and radiology. Additionally, a contract was recently awarded for an independent assessment of Inpatient Electronic Health Records in VA and DOD. 

In response to the report on the President’s Commission on Care 

for America’s Returning Wounded Warriors, we are preparing a 

statement of objectives to contract for studies of quality of life and 

long-term transition benefits. 

An MOU was signed by DOD, HHS, and VA to define the role 

of the Public Health Service in the Recovery Coordinator Program. 

Two members of the Public Health Service Commission Corps are 

detailed from HHS to VA and are working with us to establish the 

Recovery Coordinator Program. 

Rulemaking is underway to revise the ratings schedule provisions for evaluating disability due to Traumatic Brain Injury and 

burns. 

Two weeks ago, the Veterans Disability Benefits Commission 

issued its report and recommendations. While some of the recommendations are similar to existing ones, others are new and we 

are carefully studying them. 

To oversee the implementation of these recommendations, VA 

and DOD established the Wounded, Ill, and Injured Senior Oversight Committee on May 3. This Committee is co-chaired by the 

Deputy Secretary of Veterans Affairs and Deputy Secretary of Defense and meets weekly. 

In a collaborative effort with DOD, VA made great strides in addressing issues surrounding PTSD and TBI across the full continuum of care. The focus has been to create a comprehensive, effective, and individual program dedicated to all aspects of care for 

our patients and their families. VA and DOD have partnered to develop clinical practice guidelines for PTSD, major depressive disorder, acute psychosis, and substance abuse disorders. Our Senior 

Oversight Committee also approved a National Center of Excellence for PTSD and TBI. 

VA and DOD are also working closely to redesign and establish 

one Disability Evaluation System. A pilot program is being finalized to ensure no servicemember is disadvantaged by this new system and that the servicemember receives high-quality medical care 

and appropriate compensation and benefits. The proposed new system will be much more efficient, and I have provided additional details in my written testimony. 

VA now has 153 Benefits Delivery at Discharge sites to speed up 

processing of applications for compensation. VA also processes the 

claims of OEF/OIF veterans on an expedited basis. 

Collaborating with DOD, we have accomplished a great deal, but 

there is still much more to do. We at VA are committed to 

strengthening our partnership with DOD to ensure our servicemembers and veterans receive the care and benefits they have 

earned. 

70 

I will be happy to answer your questions. 

[The prepared statement of Admiral Dunne follows:] 

PREPARED STATEMENT OF HON. PATRICK W. DUNNE, REAR ADMIRAL, U.S. NAVY (RET) 

ASSISTANT SECRETARY FOR POLICY AND PLANNING

Good morning, Mr. Chairman and distinguished Members of the Committee. 

Thank you for holding this hearing and providing the opportunity to discuss the recent activities of the Department of Veterans Affairs (VA) to improve benefits and 

services to our Nation’s veterans through improved processes and greater collaboration with the Department of Defense (DOD). 

The level of attention currently focused on our wounded servicemembers and their 

families is unprecedented—and rightly so. Over the past 7 months, I have had the 

privilege of being engaged in many activities dedicated to ensuring our returning 

heroes from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) 

receive the best available care and services. I join my colleagues from VA in striving 

to provide a lifetime of world-class care and support for all our veterans and their 

families. 

On March 6, 2007, by Executive Order, the President established the interagency 

Task Force on Returning Global War on Terror Heroes. VA Secretary Nicholson was 

appointed to Chair the Task Force and I was proud to support him as the Executive 

Secretary. On April 19, 2007, the Task Force issued its report to the President. The 

Task Force made 25 recommendations to improve the delivery of Federal services 

and benefits to returning servicemembers. The Report contained recommendations 

in the areas of health care, benefits, employment, education, housing and outreach 

that could be achieved with existing authority and resource levels. The report was 

unique in that it also included an ambitious schedule of milestones and actions necessary to implement its recommendations. We continue to monitor implementation 

and I am pleased to inform you that, thanks to outstanding interagency cooperation, 

as of August 28, 56 of 58 action items have been completed or initiated. 

The results of actions taken in response to recommendations in the Task Force 

Report are having a positive impact on the lives of servicemembers, veterans, and 

their families. I would like to highlight some of the progress achieved. 

In response to a Task Force recommendation, the Small Business Administration 

launched the Patriot Express Loan Initiative. This program provides a full range of 

lending, business counseling, and procurement programs to separating servicemembers, veterans, spouses, survivors, and eligible dependents. This program has 

already approved more than $23 million in loans since it began in mid-June. 

Several initiatives have and will continue to support seamless and world-class 

health care delivery. VA and DOD have drafted a joint policy document on co-management and case management of severely injured servicemembers. The goal is to 

provide individualized, integrated, interagency and intergovernmental support for 

the wounded, severely injured or ill servicemember and his/her family throughout 

the process of treatment, rehabilitation, and renewal. VA and DOD will work together to minimize fragmentation of Federal clinical and non-clinical services, improve the coordination of medical and rehabilitative care, and ensure access to all 

needed resources. 

To assist OEF/OIF wounded servicemembers and their families in navigating 

through the transition process, VA hired 100 new Transition Patient Advocates 

(TPA). These men and women, often veterans themselves, recognize the difficulty 

in understanding the many different programs and processes which come into play. 

VA TPAs work with case managers and clinicians to ensure that patients and families can focus on recovery. 

VA also revised its electronic health care enrollment form to include a selection 

option for OEF/OIF to ensure proper priority of care. 

Many advances are the result of improved records management and greater sharing and Information Technology (IT) interoperability with DOD. In response to Task 

Force recommendations, DOD and VA worked collaboratively to expand access to 

servicemembers’ electronic health records by jointly developing the electronic capability to transfer digital radiographs from Military Treatment Facilities (MTFs) at 

Walter Reed, Bethesda, and Brooke to VA Polytrauma Rehabilitation Centers. The 

capability for electronic transmission of historical health care data from DOD MTFs 

to VA Medical Centers is complete in the domains of allergies, outpatient medications, laboratory results, and radiology. Additionally, a contract was recently awarded for an independent assessment of inpatient electronic health records in the Departments of Veterans Affairs and Defense. The contract will provide recommendations for the scope and elements of a joint electronic inpatient medical record. 

71 

In July of this year, the Report of the President’s Commission on Care for America’s Returning Wounded Warriors was issued. This Commission had a greater scope 

than the Task Force and was not constrained by existing authority and resources. 

We are preparing the statement of objectives to contract for studies of Quality of 

Life and long-term transition benefits. An MOU was signed by DOD, HHS and VA 

to define the role of the Public Health Service in the Recovery Coordinator program. 

Two members of the Public Health Service commissioned corps are detailed from 

HHS to VA and are working with VA and DOD to establish the Recovery Coordinator program. Rulemaking is underway to revise the Rating Schedule provisions 

for evaluating disability due to Traumatic Brain Injury and scars. 

Two weeks ago, the Veterans Disability Benefits Commission issued its report and 

recommendations. While some of the recommendations are similar to existing ones, 

others are new, and we are reviewing them carefully. 

To ensure a seamless continuum of benefits and health care services to wounded, 

ill, and injured servicemembers, the Departments of Veterans Affairs and Defense 

began an integrative effort, and established the Wounded, Ill, and Injured Senior 

Oversight Committee (SOC) on May 3, 2007. The SOC, composed of senior military 

and civilian officials from both Departments, was established for a 12-month time 

period, and was tasked to ensure the recommendations of the task forces and committees were properly reviewed, coordinated, implemented, and resourced. The Committee is co-chaired by the Deputy Secretary of Veterans Affairs and Deputy Secretary of Defense, and meets weekly to streamline processes, mitigate potential conflicts, and expedite the two Departments’ efforts to improve support of injured 

servicemembers’ recovery, rehabilitation, and reintegration. 

Senior Veterans Affairs and Defense officials serve on the SOC. This includes the 

Service Secretaries, the Chairman of the Joint Chiefs of Staff, the Service Chiefs, 

and VA’s Under Secretary for Health, Under Secretary for Benefits, Assistant Secretary for Policy and Planning, and Deputy Assistant Secretary for Information and 

Technology. The driving principle guiding the SOC’s efforts is the establishment of 

a seamless continuum that is efficient and effective in meeting the needs of our 

wounded, ill, and injured servicemembers/veterans and their families. 

Supporting the SOC decisionmaking process is an Overarching Integrated Product 

Team (OIPT), composed of the Under Secretary of Benefits, Assistant Secretary of 

Policy and Planning, and other senior officials from VA and DOD. The OIPT reports 

to the SOC and coordinates, integrates, and synchronizes the work of eight Lines 

of Action and recommends sourcing solutions for resource needs. 

The diagram below depicts the structure supporting the SOC. The Lines of Action, 

which have Senior Executive Service Co-Leads from both Departments, establish 

plans, set and track milestones, and identify and enact early, short-term solutions. 

The Lines of Action (LOA) and their goals are: 

• LoA #1: Redesign the Disability Evaluation System 


39934.001
72 

Goal: To develop a single, supportive, and transparent disability evaluation system. • LoA #2: Address Traumatic Brain Injury/Psychological Health 

Goal: To provide servicemembers with lifelong standardized and comprehensive 

screening, diagnosis, and care for all levels of Traumatic Brain Injury and Post 

Traumatic Stress Disorder, in conjunction with education for patients and family 

members. • LoA #3: Fix Case Management 

Goal: To coordinate health care, rehabilitation, and benefits, delivery of services 

and support that will effectively guide and facilitate servicemembers and their families through necessary processes. • LoA #4: Expedite Data Sharing 

Goal: To ensure appropriate beneficiary and medical information is visible, accessible, and understandable through secure and interoperable information management systems. • LoA #5: Facilities 

Goal: To provide servicemembers and families with the best possible facilities for 

care and recovery. • LoA #6: ‘‘Clean Sheet’’ End-to-End Review 

Goal: To honor our servicemembers by providing wounded, ill, and injured personnel and their families the best quality care and a compassionate, fair, timely, 

and non-adversarial disability adjudication process—enabling servicemembers to return to the fullest, most productive and complete quality of life possible. • LoA #7: Comprehensive Legislation and Public Affairs 

Goal: To coordinate the development of comprehensive legislation that will provide the best possible care and treatment for injured servicemembers and families. 

Additionally, to keep the public informed of significant accomplishments and events. • LoA #8: Personnel, Pay, and Financial Benefits 

Goal: To provide compassionate, timely, accurate and standardized personnel, pay, 

and financial support practices for Wounded, Injured and Ill to ensure appropriate 

data sharing, quality control, and support benefits. 

In a collaborative effort with DOD, VA has made great strides in addressing 

issues surrounding Post Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI) across the full continuum of care. The focus of these efforts has been to 

create and ensure a comprehensive, effective, and individually focused program 

dedicated to prevention, protection, identification, diagnosis, treatment, recovery, 

and rehabilitation for our military members, veterans, and families who deal with 

these important health conditions. 

Since June 2007, a collaborative team of VA and DOD experts known as the ‘‘Red 

Cell’’ has worked to: (1) create an integrated, comprehensive Department of Veterans Affairs/Defense program to identify, treat, document, and follow-up those who 

experience TBI or PTSD conditions while either deployed or in garrison; and (2) determine how to build resilience, both in people and in organizations, to prevent 

issues from developing and to reduce their impact if they do occur. 

VA and DOD have partnered to develop clinical practice guidelines (CPG) for 

PTSD, Major Depressive Disorder, Acute Psychosis, and Substance Use Disorders. 

These guidelines help practitioners determine the best available and most appropriate care. 

Our Senior Oversight Committee also has approved a National Center of Excellence for PTSD and TBI. It will include liaisons from both VA and DHHS, as well 

as an external advisory panel organized under the Defense Health Board to provide 

the best advisors across the country to the military health system. This center will 

facilitate coordination and collaboration between VA and the Military Services, promoting and informing best practice development, research, education and training. 

As of the first half of fiscal year 2007, approximately 263,900 returning veterans 

have sought care from VA medical centers and clinics. Of these, about 38 percent 

have received at least a preliminary diagnosis of a mental health condition, and 18 

percent have received a preliminary diagnosis of PTSD, making it the most common, 

but by no means the only mental health condition related to the stress of deployment. Professionals with special expertise in PTSD are available in all medical centers to serve veterans with PTSD. Most are best served in outpatient programs, but 

for those with more severe symptoms, VA has inpatient and residential rehabilitation options across the country. 

VA has taken several actions at multiple levels to promote the recruitment and 

retention of mental health professionals in the Veterans Health Administration 

(VHA). In February 2007, both an Education Debt Reduction Program and an Employee Incentive Referral Initiative began. The new mental health Education Debt 

Reduction Program currently provides up to $38,000 of education loan repayment 

73 

for qualified student debt. The Employee Incentive Referral program provides a 

bonus to VA employees who refer mental health providers who are hired into VA 

positions. These initiatives have already generated significant interest. 

At the local level, opportunities have been developed for VA facilities to engage 

in local advertising and recruitment activities and to cover interview-related costs, 

relocation expenses, and provide limited hiring bonuses for exceptional applicants. 

VA has also established opportunities for supporting individual training and education activities for mental health employees, demonstrating an investment in staff 

can also have a positive impact on retention. 

Rates of hiring have increased significantly in recent months, suggesting that the 

enhanced recruitment efforts are having a positive impact. Since fiscal year 2005, 

VA has authorized 4,367 new Mental Health Enhancement positions. As of August 

31, 2007, 81 percent of these positions have been filled. 

In terms of treating TBI, VA offers comprehensive primary and specialty health 

care to our veterans, and is an acknowledged national leader in providing specialty 

care in the treatment and rehabilitation of TBI and polytrauma. Since 1992, VA has 

maintained four specialized TBI Centers. In 2005, VA established the Polytrauma 

System of Care, leveraging and enhancing the existing Brain Injury Polytrauma expertise existing at these TBI centers to meet the needs of seriously injured veterans 

and active duty servicemembers from operations in Iraq, Afghanistan, and elsewhere. The Secretary of Veterans Affairs recently announced the decision to locate 

a fifth Polytrauma Center in San Antonio TX. 

The Departments of Veterans Affairs and Defense are also working closely to redesign and establish one Disability Evaluation System (DES) for use by servicemembers. A pilot program is being explored via tabletop exercise to ensure that no 

servicemember is disadvantaged by this new system, and that the servicemember 

receives the high quality medical care and appropriate compensation and benefits 

for the residuals of his or her disabilities incurred or aggravated by military service. 

An operational pilot program should be completed in the second quarter of 2008. If 

it is as successful as we plan, this pilot program will be expanded beyond the Washington Capital Region to become the DES system, worldwide. 

The proposed new system will be much more efficient. It will produce more consistent outcomes and, with VA and DOD working together as a team, the new system will be a seamless, single process for users. We envision it cutting in half the 

time it takes for a servicemember to go through the DES, from the time the member 

is referred to a Medical Evaluation Board (MEB) to the time the member is discharged from active military service and receives his or her first payment from VA. 

An important improvement in this proposed system is that the servicemember 

will only be required to have one medical examination or series of medical examinations, depending on the severity of the potentially disqualifying conditions to meet 

the requirements of both DOD and VA. Currently, a service-specific medical examination is required for the purpose of determining a servicemember’s ability to continue on active military service based on the residual unfitting disability and the 

servicemember’s, rank, rating, or military occupational skills, and a VA medical examination is also required for the purpose of evaluating the residual of the disability 

under VA’s Schedule for Rating Disability and assigning a percentage evaluation to 

the disability. Under the current system, if servicemembers are found unfit and are 

separated or retired, they must complete the second VA exam to determine whether 

the claimed medical conditions are service-connected and represent impediments to 

full employment capability. 

Under the proposed new DES system, the one-medical-examination process collects information required by both Departments. Under this system, when the 

servicemember transitions to civilian life, VA will already have the information 

needed to immediately start paying the veteran the appropriate amount of compensation for the residuals of his or her disability incurred or aggravated by military service. 

Over the last 5 years, the Veterans Benefits Administration (VBA) service coordinators conducted more than 38,000 briefings attended by more than 1.5 million active duty and reserve personnel and their family members. Additionally, through 

the Benefits Delivery at Discharge program, servicemembers at 153 military bases 

in the United States, Germany, and Korea are assisted in filing for disability benefits prior to separation. This fosters continuity of care between the military and VA 

systems and speeds up VA’s processing of their application for compensation. Claims 

decisions can be completed prior to separation, and veterans can begin receiving VA 

compensation payments, without delay, upon separation from the military. VBA also 

processes the claims of OEF/OIF veterans who apply for VA disability compensation 

or pension on an expedited basis. 

74 

Thank you for providing me this opportunity to share with you recent activities 

in the Department of Veterans Affairs. I will be happy to answer any questions you 

may have. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY REAR ADMIRAL PATRICK W. DUNNE, U.S. NAVY (RET.), ASSISTANT SECRETARY FOR POLICY AND PLANNIING, U.S. DE- PARTMENT OF VETERANS AFFAIRS

Question 1. According to recent testimony by Mr. Dominguez, DOD’s Principal 

Under Secretary of Defense for Personnel and Readiness, DOD and VA are working 

closely to redesign and establish one disability evaluation system for use by servicemembers. I understand that this redesign was done without the benefit of knowing 

the recommendations of the Veterans Disability Benefits Commission. How is the 

redesign being carried out, what information was considered, and what are the expected outcomes? Does the redesign of the Disability Evaluation System include improved processes for all separating servicemembers or just those separating as a result of being found unfit or continued service? 

Response. The Department of Veterans Affairs (VA)/Department of Defense (DOD) 

Disability Evaluation System (DES) pilot program will begin on November 26, 2007. 

The intent of the DES pilot is to evaluate a stream-lined process designed to improve the timeliness and effectiveness of the DES program. This pilot program integrates VA and DOD processes thereby maximizing resources, eliminating duplication, and improving case management practices. The pilot will operate within the 

parameters of titles 10 and 38, United States Code and will be used for personnel 

who are separating through the medical evaluation board (MEB)/physical evaluation 

board (PEB) process. 

VA and DOD designed a program that would remove current burdens on servicemembers by simplifying the process and producing a single disability rating. A key 

feature of the DES pilot is the use of one comprehensive medical examination, using 

VA-based protocols, that is administered by DOD. This single medical exam will 

meet the needs of the PEB in determining a servicemember’s fitness for duty and 

the needs of VA for determining a total service-connected disability rating. 

To ensure a seamless transition of our wounded, ill, or injured servicemembers 

from DOD care, benefits, and services to the VA system, the DES pilot will test enhanced case management methods; identify opportunities to improve the flow of information; and identify additional resources, which may be necessary to facilitate 

successful transitions for servicemembers and families. 

Chairman AKAKA. Thank you very much, Secretary Dunne. Secretary West? 

STATEMENT OF TOGO D. WEST, JR., CO-CHAIR, INDEPENDENT 

REVIEW GROUP, REPORT ON REHABILITATIVE CARE AND 

ADMINISTRATIVE PROCESSES AT WALTER REED ARMY MEDICAL CENTER AND NATIONAL NAVAL MEDICAL CENTER 

Mr. WEST. Mr. Chairman, Ranking Member Senator Burr of my 

home State of North Carolina, Senator Murray, and Members of 

the Committee, thank you for including the Independent Review 

Group in your hearing today. I am aware—we are aware—that you 

are focusing on disability issues, but you asked us to speak to questions of overlap or cooperation between DOD and the Department 

of Veterans Affairs that are touched on by our report and that 

would assist in providing the best of care to returning servicemembers and veterans. 

I will do that quickly. You have my statement. I won’t take the 

time to go through it. I want to make two points about two issues 

that we touch on that certainly have to do with cooperation between DOD and VA. 

First of all, let me say this issue of how the two departments, 

the two largest in terms of personnel in our government, can cooperate to support servicemembers and veterans is not a new one, 

of course. We were talking about it when I was the Secretary of 

75 

Veterans Affairs, also when I was Secretary of the Army, and that 

is now turning out to be a while back. Indeed, it was before me. 

Something that was said here today, I think, is well worth saying. Let me speak specifically to the issue of electronic records. VA 

has certainly outdistanced the Department of Defense on that 

score. The fact is that the transition to an essentially paperless 

health records system is in many ways a marvel. DOD is not there, 

and although I have heard some encouraging statements both 

today and in past weeks, it is not clear to me how quickly they will 

get there. 

As General Scott pointed out—and I know you noticed his comment, it is not just that DOD as a whole is not where VA is in getting its medical records online, as it were; it is that the individual 

services are not there. They can’t even talk with each other within 

the Department of Defense. Indeed, the Army has three systems 

that can’t talk to each other. 

And so, when we talk about the objective of getting some kind 

of useful collaboration between the two departments on something 

that is as essential as the ability to put health care records in an 

electronic means and make them available so that they can go 

where a servicemember or former servicemember or veteran needs 

them to go within the two systems, we are talking about something 

that is not yet upon us, and I am concerned we will have difficulty 

getting to. I understand that the DOD part of it is a concern of another committee, but it is the concern of the entire Senate, as well. 

The Secretary of Defense and his people have made it clear that 

they understand our recommendations and the recommendations of 

the other commissions. But, I say to you, that is an area that is 

going to take a lot of pressure. Perhaps I will leave it at that and 

you can ask me questions about it later. 

Secondly, we had some strong language in the Independent Review Group’s report, as everyone else has had, concerning the disability review process. We said then, and in our testimony several 

subsequent times, that it makes no sense not to have one system. 

It is no surprise, as I say in my comments, that a department of 

government, several departments of government, can offer good rationales for having the complicated systems they have. Three levels 

of review—for example, in the Army before you get a decision, before you even get to VA, if you are a servicemember who is eventually discharged and needs to continue in the VA system. Their reasons are good: that the local commanders can make a better decision as to who is fit to return, yet you need a level further after 

that to decide, and so on. 

But, the servicemembers and their families—as you have heard 

from Senator Dole and Secretary Shalala, for example—to servicemembers and their families, it looks like an incomprehensible 

nightmare. We, as a government, should be able to resolve that. 

I am encouraged by what we are hearing in terms of moving forward with a plan to proceed. Indeed, the members of the Independent Review Group are meeting tomorrow with Assistant Secretary Cassell to talk further about DOD’s efforts to resolve its internal process. But that again is an area that will require continued oversight and urging, because we have talked about and considered improving the disability review process, as it involves both 

76 

DOD and VA for a number of years there, as well. It is not a new 

issue this year. 

Finally, the Independent Review Group was the first body called 

into action when the national scandal known as the Walter Reed 

situation broke. Shortly after Secretary Gates took over, he asked 

our group, which I have to say, in contrast to what Senator Dole 

and Secretary Shalala were able to say about their group, ours was 

the normal suspects—a couple of formers: former Secretaries of the 

Army; some former military doctors too; one a former Surgeon General of the Air Force; and the other former Congressman Schwartz, 

who is also a doctor who served as a military doctor; but also a 

former Navy nurse, Rear Admiral Kathy Martin, who was a Deputy Surgeon General; and a former Commander of Bethesda National Naval Medical Center; as well as a former command sergeant, and two other private citizens. 

I mention that to say that our focus as we met and did our deliberations, despite what the formal letters of reference may have said 

in terms of what we were called on to do, were to essentially find 

out what happened, find out why it happened, and find out what 

needed to be done to fix both that problem and its implications in 

other active duty facilities, as well. We were not asked to look at 

VA, and indeed in an early draft of our terms of reference there 

is a specific line that told us to stay away from looking at the Department of Veterans Affairs. At the suggestion of several of us, including me, that was taken out. We understood what our area was, 

but, of course it would make sense for us to look at the overlap at 

the place of transition. 

And so, our report heavily focuses on DOD and the many things 

that need to be done there. But, I have to conclude by saying with 

respect to that effort, that we found that where DOD and VA have 

been making efforts to cooperate and to collaborate, and there have 

been a number of them, the Department of Veterans Affairs has 

been better able to move ahead. You haven’t asked me for a comparison and I am not really offering one, but I am pointing out that 

the difficult challenge continues to lie in pushing that large department, which has so many different actors who have to participate, 

to bring their activities to the point where they can work together 

and mesh together with VA. 

So, I thank you for this hearing. I thank you for including us in 

it. I know you have had hearings like this before—I have heard 

them referred to—and so have others. But wherever the Senate or 

House of Representatives gathers in a Committee or in full session 

to consider these problems of our servicemembers and our veterans, there on that day is another opportunity for the improvement of what we can do for them. Thank you. 

[The prepared statement of Mr. West follows:] 

PREPARED STATEMENT OF HON. TOGO D. WEST, JR., CO-CHAIR, INDEPENDENT REVIEW GROUP

The report by the Independent Review Group is replete with findings and recommendations covering a wide range of issues and circumstances which have come 

to our attention. They converge around four core concerns. Let me pose them as 

questions. 

Firstly, who are we—as a country, as an Army, as a health care center—here at 

Walter Reed? Unfortunately, if one considers reports we have heard from servicemembers and their families about the lapses in support to them during their rehaVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00080 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
77 

bilitation phase of care, we would conclude that we may be answering that question 

in ways that are not attractive to us as an Army or as a Nation. We say so much 

about ourselves by the attitudes we display toward those who look to the Nation 

for support during the most vulnerable times of their lives. We have included a 

number of findings and recommendations involving the assignment and training of 

caseworkers, increases in the numbers of caseworkers and adjustment of the caseworker to patient ratio, assignments of primary care physicians, and attention to 

the nursing shortages. 

Secondly, who and what are we to become? The Base Realignment and Consolidation (BRAC) process and the A–76 process have caused incalculable dislocation in 

Walter Reed operations and threaten the future of both installations. 

Thirdly, how are our servicemembers doing? At every turn, the IRG has encountered servicemembers, their families, health care professionals, and thoughtful observers who point out how challenging the traumas associated with TBI (Traumatic 

Brain Injury), and PTSD (Post Traumatic Stress Disorder) have become; and how 

challenging they have been in terms of both DOD and Department of Veterans Affairs diagnosis, evaluation, and treatment. We believe there is a need for greater 

and better coordinated research in this area. We have made a detailed recommendation with respect to a center of excellence and increased attention to cooperative efforts by both the Department of Defense and the Department of Veterans Affairs. 

Fourth, how long? The IRG has operated with what is, for me, a rare sense of 

unity and consensus in our effort. If there is one issue, on which we are even more 

unified than all others, it is that the horrors that are inflicted on our wounded 

servicemembers and their families in the name of the physical disability review 

process, known in the Department of Defense as the MEB/PEB process, simply must 

be stopped. 

It is no surprise to you on the Committee, or to us on the IRG, that each part 

of the governmental process can make sound arguments to defend and explain why 

three, and in the case of the Army four, separate Board proceedings—with associated paperwork demands on the wounded servicemember and family, accompanied 

by delays and economic dislocation for assisting family members, and characterized 

prominently by inexplicable differences in standards and results—are justified. We, 

however, are a Nation which values the every day good sense of the common man 

or woman—that is why we call it common sense. And common sense says that from 

our servicemembers’ and families’ point of view this must seem a wildly, incomprehensible way to settle for servicemembers and families the question of whether the 

member must leave the service and, if so, under what conditions. We recommend 

one combined physical disability review process for both DOD and VA. (See Attachment for specific areas that require collaboration between the DOD and VA.) 

Virtually every finding and recommendation we make, then can be traced to these 

four concerns: (1) leadership and attitude; (2) the transition from Walter Reed Army 

Medical Center to Walter Reed National Medical Center; (3) the extraordinary use 

of IED (improvised explosive devices) in the current wars and their impacts on the 

brains and psyches of our servicemembers; and (4) the long-standing and seemingly 

intractable problem of reforming the disability review process. 

It is important to note that at the conclusion of the IRG investigation, Army officials said the service has resolved, or is in the process of resolving, 24 of the 26 

findings listed in the report. 

To be sure, it was the degradation in facilities that first caught the eye of media 

reporters. Important as that is, however, we believe that there is far more to be 

dealt with here than applying paint to rooms or even in crawling around basements 

to deal finally with electrical problems. We had experts of every sort assigned to 

us, and talented and experienced health professionals as part of the Independent 

Review Group itself. 

None of these concerns, however, is our bottom line: not BRAC, not facilities, not 

even the search for failures, breakdowns, or culprits. Rather our bottom line is this: 

(1) We are the United States of America. 

(2) These are our sons and daughters, brothers and sisters, uncles and aunts, even 

a grandparent or two who lie and sit wounded. 

(3) Their families are our families, we are their neighbors, and we, their fellow 

citizens and residents. 

(4) Their anguish is our anguish. 

(5) We can and must do better. 

78 

ATTACHMENT

Finding: 

There are inconsistencies within the Department of Defense and the Department 

of Veterans Affairs regulatory systems which deal with the functional loss of limb 

due to Traumatic Injury and burn. Currently, the disability system does not adequately compensate for the functional and physiological loss of limb in burn patients. 

Discussion: 

The Code of Federal Regulations, Title 38, Part IV (Veterans Affairs Schedule for 

Ratings and Disabilities) does not address specific disability ratings for burn injuries. It does thoroughly cover amputations. It also addresses many skin injuries 

such as scarring, disfigurement and dermatitis. There exists a gap for addressing 

issues specific to burn injuries. Burned skin needs extra protection from the sun and 

elements; it does not sweat normally and needs extra precautions (for example: ultraviolet protective clothing and salves) for warm/hot environments. Because there 

are not specific disability ratings for burn patients, they do not qualify for home or 

vehicle modification as an amputee patient would. 

Recommendations: 

1. The Secretary of Defense should request the Secretary of Veterans Affairs to 

update the Code of Federal Regulations, Title 38, Part IV to account for the unique 

disabilities and needs of traumatic amputees and burn victims, focused on a loss of 

function and post-service needs. This would require an expedited process for publishing the change. 

2. The Secretary of Defense should review the Physical Evaluation Board determinations of all burn cases, dating back to 2001, within 1 year after the update to 

United States Code 38. 

Finding: 

When an amputee leaves the Department of Defense medical system, the followon care, the amputee receives, may not be as technologically advanced outside the 

military medical system. 

Discussion: 

The Department of Defense, from clinical necessity, has been on the cutting edge 

of prosthetic replacement for traumatic amputation. The Department of Veterans 

Affairs has largely been focused on patients who lost a limb (or limbs) through disease or accident instead of combat. In addition, many amputees in the Veterans Affairs system are much older than those who have suffered an amputation due to 

combat. 

The Sun-Times News Group recently reported, MAJ (RET) Tammy Duckworth, 

currently the Director of the Illinois Department of Veterans Affairs, testified before 

the U.S. Senate Committee for Veterans Affairs on March 27, 2007 and stated, ‘‘The 

U.S. Department of Veterans Affairs is absolutely not ready to treat amputee patients at the high tech levels set at Walter Reed. Much of the technology is expensive and most of the Veterans Affairs personnel are not trained on equipment that 

has been on the market for several years, let alone the state-of-the-art innovations 

that occur almost monthly in this field. I recommend that the VA expand its existing SHARE program that allows patients to access private prosthetic practitioners. 

There is simply not enough time for U.S. Department of Veterans Affairs to catch 

up in the field in time to adequately serve the new amputees from Operations Iraqi 

and Enduring Freedom during these critical first 2 years following amputation. Perhaps after the end of current wars in Iraq and Afghanistan, the VA will have time 

to advance its prosthetics program.’’ Travel for prosthetic care also includes Department of Defense beneficiaries follow up post amputation patients often requires 

travel to medical centers with competent prosthetics departments. Often a patient 

does not live in a geographic area where TRICARE Prime is offered. The TRICARE 

Prime travel benefit covers per diem and travel if a patient is referred to care more 

than 100 miles away from their home. TRICARE Standard does not offer a travel 

benefit. 

Recommendations: 

1. The Secretary of Defense should pursue partnerships with the Secretary of Veterans Affairs to provide treatment; promote education and research in prosthesis 

care, production, and amputee therapy. 

2. The Secretary of Defense should pursue a partnership with the Secretary of 

Veterans Affairs to expand the Department of Veterans Affairs’ existing program to 

79 

allow patients to access the military health system and private prosthetic practitioners. 

3. Review TRICARE regulations (CFR 199.17) and update specifically to change 

them so that the geographic home of the patient does not limit access to benefits 

for prosthetic care and treatment. 

Finding: 

There are serious difficulties in administering the Physical Disability Evaluation 

System due to a significant variance in policy and guidelines within the military 

health system. 

Discussion: 

There is much disparity among the Services in the application of the Physical Disability Evaluation System that stems from ambiguous interpretation and implementation of a Byzantine and complex disability process. It is almost as if a peacetime, 

draft-era program is being applied to an all-volunteer force engaged in war. 

The Governing Statute, implementing publications and regulatory guidelines: 

Code of Federal Regulation: Title 10, USC chapter 61, provides the Secretaries of 

the Military Departments with the authority to retire or separate members for physical disability. Code of Fed reg Title 38, provides the authority for the VA. DOD Directive 1332.18, Separation or Retirement for Physical Disability; DOD Instruction 

1332.38, Physical Disability Evaluation; DOD Instruction 1332.39, Application of 

Veterans Affairs Schedule for Rating Disabilities, and applicable service specific regulations or instructions set forth the polices and procedures implementing the statute. For each respective service, the governing service specific guidelines include: 

Department of the Air Force, AFI 36–3212, Physical Evaluation for Retention, Retirement, and Separation; Department of the Army, AR 635–40, Physical Evaluation 

for Retention, Retirement, or Separation; Department of the Navy, SECNAV Instruction 1850.4E and Department of the Navy Disability Evaluation Manual. A 

Government Accounting Office (GAO) Report (2006), acknowledged the differences 

among the services and recommended improved oversight of the physical disability 

evaluation system, to which the Department of Defense agreed and indicated an intent to implement. 

‘‘The Government Accountability Office noted that eligibility criteria for disability 

programs need to be brought into line with the current state of science, medicine, 

technology and labor market conditions.’’ 

During the course of its review, the Independent Review Group identified no less 

than five Government Accountability Office reports and one Presidential Task Force 

report that noted deficiencies and made recommendations to improve the physical 

disability evaluation system. These reports include: 

• November 2004 Government Accountability Office Report: VA and DOD Health 

Care: Efforts to coordinate a single physical exam process for servicemembers leaving the military 

• September 2005 Veterans Affairs and Department of Defense Health Care: VA 

has policies and outreach efforts to smooth transition from DOD Health Care, but 

sharing of Health Information remains limited. 

• June 2006 Government Accountability Office Report: VA and DOD Health Care: 

Efforts to provide seamless transition of care for OEF and OIF servicemembers and 

veteran’s. 

• March 2006 Military Disability System: Improved oversight needed to ensure 

consistent and timely outcomes for reserve and active duty servicemembers. 

• March 2007 Government Accountability Office Report: DOD and VA Health 

Care: Challenges encountered by injured servicemembers during their recovery process. 

• 2003 President’s Task Force to Improve Health Care Delivery for Our Nation’s 

Veterans. 

Despite the comprehensive findings and recommendations in these reports, the 

Group found little evidence of action on the recommendations. 

Recommendations: 

1. The Secretary of Defense should provide recommendations to Congress to 

amend Title 10 United States Code, Chapter 61, and Title 38 United States Code, 

to allow the ‘‘fitness for duty’’ determination to be adjudicated by the Department 

of Defense and the disability rating be adjudicated by the Department of Veterans 

Affairs. 

2. Following the changes to the United States Code, the Secretary of Defense, 

should quickly promulgate regulatory guidelines and policy to the Service Secretaries. 

80 

Finding: 

The current Medical Evaluation Board/Physical Evaluation Board process is extremely cumbersome, inconsistent, and confusing to providers, patients, and families. 

Discussion: 

The physical disability evaluation system is the means by which servicemembers 

are retired or separated due to physical disability in accordance with the aforementioned references. The Department of Defense Directive (DODD) 1332.18, Section 

3.2 outlines four elements of the physical evaluation disability system: the physical 

evaluation; appellate review; counseling; and final disposition. According to the Department of Defense regulations, the physical evaluation process consists of the 

Medical Evaluation Board and the Physical Evaluation Board. The Department of 

Defense and the Department of Veterans Affairs use the Veterans Administration 

Schedule for Rating Disabilities. 

The Veterans Administration Schedule for Rating Disabilities (VASRD) is primarily used as a guide for evaluating disabilities resulting from all types of diseases 

and injuries encountered as a result of, or incident to, military service. 

Not all the general policy provisions set forth in the rating schedule apply to the 

military. Consequently, disability ratings consistently vary between the Department 

of Defense and Department of Veterans Affairs. The Services rate only conditions 

determined to be physically ‘‘unfitting,’’ compensating for loss of a military career. 

The Department of Veterans Affairs may rate any service-connected impairment, 

thus compensating for loss of civilian employability. Additionally, the term of rating 

is different among the Department of Defense and the Department of Veterans Affairs. The Services’ ratings are permanent upon final disposition. The Department 

of Veterans Affairs ratings may fluctuate with time, depending upon the progression 

of the condition. Further, the Services’ disability compensation is determined by 

years of service and basic pay; while Veterans Affairs compensation is a flat amount 

based upon the percentage rating received. 

Recommendations: 

1. The Under Secretary of Defense (Personnel & Readiness) should completely 

overhaul the physical disability evaluation system to implement one Department of 

Defense level Physical Evaluation Board/Appeals Review Commission with equitable 

Service representation and expand what is currently the Disability Advisory Council. • According to a Government Accountability Office report, a problem with the current organization is that the Council only ‘‘aims’’ to meet quarterly, but did not meet 

for a full year, to discuss issues raised by the Services. This recommended concept 

would have consolidated operational oversight and responsibility of the Physical 

Evaluation Board process, including the current Service level Physical Evaluation 

Board and Appeals Review levels of jurisdiction. This action allows for streamlining 

of personnel and resources, and eliminates the intra and inter-Service disparities of 

the disability ratings and provides a forum for implementing immediate corrective 

action. This recommended concept incorporates Veterans Affairs representation and 

ensures a seamless transition from the Department of Defense into the Department 

of Veterans Affairs health system. 

2. The Under Secretary of Defense (Personnel & Readiness) should conduct a 

quality assurance review all (Army, Navy/Marine Corps, and Air Force) Disability 

Evaluation System decisions of 0, 10, or 20 percent disability and Existed Prior to 

Service (EPTS) cases since 2001 to ensure consistency, fairness, and compliance 

with applicable regulations. 

3. The Secretary of Defense and the Secretary of Veterans Affairs should establish 

one solution. Develop and utilize one disability rating guideline that remains flexible to evolve and be updated as the trends in injuries and supporting medical documentation/treatment necessitate. Revise the current process of updating the disability ratings system to include an operation update that pushes changes to the 

field on a weekly, or as needed basis. 

Finding: 

A common automated interface does not exist between the clinical and administrative systems within the Department of Defense and among the Services, causing 

a systemic breakdown of a seamless and smooth transition from Department of Defense to the Department of Veterans Affairs. 

Discussion: 

Servicemembers should not be burdened with the arduous navigation requirements of our current system. The complexity of the physical disability evaluation 

81 

system is further perpetuated as the servicemembers transition into the Veterans 

Affairs system. Currently there is not a seamless transition. 

A ‘‘seamless transition’’ from military service to veteran status is especially critical in the context of health care, where readily available, accurate, and current 

medical information must be accessible to health care providers. 

For the administrative aspects of this process, no one system currently exists. The 

Department of Defense does not have an integrated automated system that supports 

the standardization of the clinical and administrative requirements of the physical 

disability evaluation system. Absent a corporate solution, the Services have created 

individual systems to track the servicemembers within the physical disability evaluation system. This exacerbates the process variation. 

The Air Force currently does not have an automated system. The Army currently 

uses the Medical Evaluation Board Internal Tracking Tool (MEBITT). The Navy 

uses the Medical Board On Line Tri-Service Tracking System (MedBOLTT). Each 

system serves its Service independently for Medical Evaluation Board processing; 

yet do not interface with the next step of the Physical Evaluation Disability System, 

or Physical Evaluation Board. 

The Army Physical Evaluation Board uses the Physical Disability Case Processing 

System (PDCAPS) to track Army cases once they enter the Physical Evaluation 

Board stage of the process. Using the Army as an example of the lack of interface 

between systems, during the Medical Evaluation Board phase of the process, the 

Medical Evaluation Board Internal Tracking Tool is used. During the Physical Evaluation Board phase, the Physical Disability Case Processing System is used. These 

two systems, unique to one Service, result in numerous disparities within the Army 

since the systems do not interface. From a clinical perspective, all medical documentation should be available to the servicemembers’ providers throughout the entire process. This includes the transition into the Veterans Affairs system where 

there is no continuity other than what records the servicemember carries to the Veterans Affairs. This issue has been continually addressed without resolution. 

‘‘The Department of Veterans Affairs and the Department of Defense should develop and deploy, by fiscal year 2005, electronic medical records that are interoperable, bidirectional and standards-based’’. [Refer to Recommendation 3:1 of President’s Task Force. (2003) Final report to improve health caredelivery for our Nation’s veterans. Washington, DC.] The same report recommends a single separation 

physical and electronic transmittal of the Department of Defense Form 214 (DD214) 

to the Department of Veterans Affairs. These recommendations have yet to come to 

fruition and as a result, there is a significant amount of redundancy still required 

at this point starting at the physical examination. 

Recommendation: 

The Secretary of Defense, in conjunction with the Secretary of Veterans Affairs, 

should direct the transition process be streamlined for the servicemember separating from the Department of Defense and entering the Department of Veterans 

Affairs. 

• As already identified in the Government Accountability Office report (2004), implement the single physical exam. Review the 1998 Department of Defense memorandum of understanding (MOU) between the Department of Defense and Department of Veterans Affairs, implement a common physical for use by the Services and 

the Department of Veterans Affairs for those servicemembers in the physical disability evaluation system, and allow flexibility in the timelines test or procedures 

that would eliminate redundant efforts. 

Rapidly develop a standard automated systems interface for both clinical and administrative systems that allows bilateral electronic exchange of information. Review and implement the recommendations of the 2003 President’s Task Force. 

Chairman AKAKA. Thank you very much, Secretary West. 

We have some questions for you. General Scott, we have seen 

proposed legislation that would require the Secretary of Veterans 

Affairs to conduct a 6-month study relating to disability benefits, 

and after providing Congress with the results of the study, to write 

regulations to implement the study’s findings so as to create a total 

change to the VA disability system. Based on your Commission’s 

review of VA’s disability process, do you believe that a total system 

reform can be carried out in 6 months and be done on an administrative basis with no Congressional hearings or legislative action? 

82 

General SCOTT. Mr. Chairman, you are going to have to find a 

whole lot faster moving commissioners than the group that I represented was if you can get that done in 6 months. 

I am not sure how long it would take to do the study that you 

mentioned. There was a question before about whether a study be 

completed in a brief period of time to take a look at quality of life. 

Quite frankly, one of the reasons that our Commission recommended an immediate interim fix to quality of life, which is upping the 

payment based on level of disability, was that we didn’t have a lot 

of confidence that a quick study could be done that would address 

it and it might drag on and on and on. We recognize, as did DoleShalala, that some of these people need some more immediate help 

than might occur a few years down the line. 

In regards to a complete study of the Veterans’ Disability Rating 

System, we offered in our Commission report some priorities. One 

of them was to sort out the TBI, PTSD, and other contributing 

mental ailments, so that it was clearer as to how diagnosis and 

evaluation might occur in that. And then we offered some other priorities, such as those parts of the schedule that had not been 

touched in many years might need some attention. 

But our estimate was that a system as complex as the schedule 

of disabilities was going to take a significant amount of time to— 

I don’t know whether the term is, ‘‘redo it,’’ ‘‘change it,’’ whatever; 

but I think we all recognize there is a significant challenge involved. 

So, in my personal view, sir, it probably couldn’t be done very 

well in 6 months. We recommended that the Congress put a time 

line on the VA that the entire schedule of disabilities be redone 

within a 5-year period. That was our guess as to how long it might 

take to do the entire thing. But again, sir, we offered some priorities where one might start and we would hope that those would 

be done in a more expeditious fashion. 

Chairman AKAKA. Part of my question was whether it can be 

done on an administrative basis without Congressional hearings or 

legislative action. 

General SCOTT. Sir, I think that from my own experience as a 

military officer over the years and my experience since that time, 

it would be that it was going to take all branches of Government 

working together to make this thing work. So, it appears to me, my 

personal opinion, that Congress has an important role in overseeing this rewrite, not micromanaging, but overseeing. I believe it 

is the responsibility of this Committee and the like Committee in 

the House to do just that, sir. 

Chairman AKAKA. Thank you. Secretary West, the Independent 

Review Group endorsed the consolidation of the DOD and VA disability systems so as to create a single comprehensive medical 

exam resulting in a single disability rating. However, the Independent Review Group did not recommend reforms to DOD disability retirement pay. What are your views on the Dole-Shalala 

recommendation that DOD disability retirement pay be based solely on rank and years of service and not on the degree of disability? 

Mr. WEST. Mr. Chairman, I looked at those recommendations. I 

speak for myself. The IRG has not taken a position on it. But they 

are reasonable. The division of labor is reasonable. And so, I don’t 

83 

have a problem with it. I think that makes sense. I understand 

that this Committee is trying to work through competing, or not 

necessarily competing, but several different recommendations in 

that area. I think for us, what is important is that we move as 

quickly as possible to get the clearest possible resolution for retiring and for veterans. 

I have some other views about some other parts of that, but let 

me just confine my answer to what you asked me. 

Chairman AKAKA. Thank you very much. 

Admiral Dunne, in my opening remarks, I stated how pleased I 

was that the Under Secretaries of VA and DOD were meeting 

weekly to address many of the issues we are discussing today. 

Would you please comment on all the things that SOC has done 

and is planning to do to address the recommendations of the DoleShalala Commission, the Independent Review Group, and the VA 

Task Force? 

Admiral DUNNE. Mr. Chairman, the Senior Oversight Committee, in order to deal with the recommendations, has created 

eight different groups and assigned them their recommendations 

based on those responsibilities. 

The first work group is the Disability Evaluation System. In response to the recommendations on a single comprehensive physical—at yesterday’s weekly meeting we actually came to a final decision on that single comprehensive physical and that will be used 

in the pilot for the DES system, which we will commence during 

the month of November. 

Another work group is looking at TBI and psychological health. 

The Senior Oversight Committee has been briefed on and approved 

the National Center of Excellence for TBI and Psychological Health 

and the intent is to have the ribbon-cutting for that at the end of 

November. 

We have also overseen the development of clinical practice guidelines for PTSD, for major depressive disorder, and for substance 

abuse disorders, and also the Senior Oversight Committee has reviewed programming of some $900 million to support TBI and psychological health prevention, treatment, and continued research. 

Another work group is looking at case management. They are 

working now on the development of the Recovery Coordinator Program, working together with HHS as well as DOD and VA. The 

Memorandum of Understanding between the three agencies is already in existence and has been approved. The memorandum establishing the program will be approved this month. And we are 

also in the process of developing what we are calling a Federal Individual Recovery Plan, which will take the servicemember or veteran from their first point of entry back into the United States 

where they start their care and recovery, all the way through their 

reintegration into the community or their return to duty, if they 

are able to recover sufficiently to return to duty. 

The fourth work group is looking at data sharing between VA 

and DOD, and the Senior Oversight Committee is monitoring all 

the actions that are in place right now to have all essential health 

and administrative data viewable between our two agencies by October 31, 2008, which would meet the criteria that was mentioned 

earlier this morning of getting it done within a year’s time. 

84 

We also have a contract in place to develop an analysis of alternatives for an Electronic Inpatient Health Record, and we are looking to the possibility of having some head start opportunities coming out of that contract in advance of the final deliverable, where 

we could do just that—get a head start on complete interoperability—so that, instead of just having viewable records, we have 

computable records between the two agencies. 

The data sharing group is also developing a plan for a single web 

portal that the Dole-Shalala Commission recommended so that veterans could go online and see all the benefits that are available to 

them, and track their own progress. 

And we are also developing an IT plan to support the Federal Recovery Plan, which the case management group is putting into 

place. This IT plan would be within the Web site that is being created so that those personnel who need to track an individual soldier or sailor could go online and review that and keep up to date 

with the progress. 

The facilities work group has approved the DOD housing inspection standards for medical hold and holdover personnel, and they 

are also in the process of preparing the inspection report on all 

medical hold and holdover facilities, which will be submitted to 

Congress later this year. 

A sixth work group is looking at a complete clean sheet review 

of the entire process: disability process; benefits process; et cetera; 

to say, what if there wasn’t anything in place right now? What if 

there weren’t any laws? What would you see as the ideal organization’s benefits package to put in place? 

Another work group is working on legislation, and you have the 

immediate product of their work now—creating the legislation to 

implement the Dole-Shalala recommendations. 

And an eighth work group is looking at personnel pay and financial benefits. Some examples there are: DOD and VA are now sharing information—patient administrative data—when an active duty 

servicemember comes to a VA facility. We have seen problems in 

the past where, administratively, pay purposes, et cetera, have 

been complicated, because they somehow seem to fall through the 

cracks. We believe that we have taken care of that now. 

We are also looking at implementing what we have learned to be 

the best practices for operating the TSGLI insurance system for the 

benefit of the severely injured veterans. 

Chairman AKAKA. Thank you very much. 

Senator Burr? 

Senator BURR. Thank you, Mr. Chairman. 

General, Admiral, Mr. Secretary, welcome. We can’t thank you 

all enough and your Commission members that are here and those 

that aren’t here for their time and commitment. 

I want to take an opportunity to voice a personal frustration. 

This is the most powerful country in the world. Between our military and our veterans, we have some of the brightest people that 

exist on the planet. We are going to be tasked with helping to do 

the hard part—that 10 percent that I think everybody agrees legislatively has to be done, whether you just can’t get there, you can’t 

get the critical mass administratively—somehow the authority of 

Congress says, OK, we are going to do this. 

85 

The sad part is that I don’t get a sense even if we did the legislation, that it happens tomorrow—I would only share with you my 

frustration. What takes so damn long? As powerful, as bright as we 

are, we are still talking about the DOD technologically getting up 

to where a community hospital is today. We have got community 

hospitals across the country that do remote monitoring of congestive heart patients that save money, increase the quality of life, yet 

we can’t track somebody in the system and hand it off electronically to another system, and both have existed for decades. 

I share that with you only because it is a frustration, I think, of 

all of us, as I know it is with you. I feel like we put you in an untenable position to sit in front of the table knowing that your reluctance is—well, history tells us, you can’t do it that quick. 

My only suggestion to all of us in the room and to those that 

read the testimony from this hearing is: we don’t have any choice. 

We have to do it and we have to do it quick. If we don’t, then we 

are the ones that have caused a quality of life issue with the veterans that are in the system. We have to fix it and we have to fix 

it now. 

Now let me move to some very quick questions, if I can. General, 

the Commission recommends that all applicants for individual unemployment benefits first be screened by vocational rehabilitation 

and employment counselors. In support of this recommendation, 

the Commission cited a 2005 GAO report that found only 495 of 

219,000 veterans in receipt of individual unemployment benefits 

had been evaluated by vocational counselors. My specific question 

is, what happens if, after being screened, the VA determines that 

employment is feasible, but only if a veteran receives vocational rehabilitation services? 

General SCOTT. Well, in our report, we made a number of recommendations to how we could enhance the VR&E services to disabled veterans. Our thinking on the screening process is that, basically, before we award individual unemployability to a veteran, 

that the person should be screened to see if he or she is employable. In other words, we should—— 

Senator BURR. I guess my question, going right to the heart is, 

if the determination is that they are employable, but they choose 

not to do the vocational rehabilitation proposals that have been 

laid out for them to become employable, then what do we do? 

General SCOTT. Well, we talked about that in a different context. 

When we talked about PTSD, we said that treatment, compensation, evaluation and VR&E should all occur, and they should be 

linked. So, I would say that if the problem happened to be recalcitrance, in many cases, I think we should link treatment with 

compensation. Now, I have no information that leads me to believe 

that recalcitrance is a problem, but if it is, that is a way that it 

might be addressed. 

Senator BURR. Most of, I think, the recommendations of the 

Commission have overwhelming support. I want to go to one where 

Commissioner Brady had a different view and it dealt with different compensation levels being appropriate for some veterans 

based upon the circumstances of their injury. For example, Commissioner Brady wrote the sacrifice made by soldiers entered in 

combat is greater than the sacrifice made by servicemembers inVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00089 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
86 

jured in an off-duty motorcycle accident. Can you enlighten us on 

why the Commission did not recommend that compensation rates 

take into account the veteran’s injury or the circumstances of the 

veteran’s injury? 

General SCOTT. Senator Burr, I will be happy to. First of all, let 

me say that all the Commissioners made major contributions to the 

final document. I can also say—and I think the Commissioners 

that are present will back me up—that we did not all agree on 

every aspect of every issue. We were able to achieve a consensus, 

which is found in the report. There are a few things in there that 

I can assure you that almost all the Commissioners would have 

worded a different way. 

So, having said that, the Commission as a group views service 

kind of like this: we are in a 24-hour a day, 7-day a week service 

environment. I will use myself as an example. During the 32 years 

that I was on active duty, I was subject to the Uniform Code of 

Military Justice: 24/7; on leave; on duty; in the U.S.; out of the U.S. 

If we are going to continue to require our servicemembers to work 

to a 24/7 standard, then we have to look after them in that way— 

24/7. That is the consensus of the Commission. 

Not to get too far afield here, but, we could be like the Dutch 

army, where everybody is a union member. They all work from 

eight to four and get a couple of hours off for lunch. If we went to 

a standard like that instead of the 24/7, I think there would be a 

case for looking at some sort of differentiation. But, if you are on 

duty 24 hours a day, then you should be protected 24 hours a day, 

and so—— 

Senator BURR. Rest assured, I am not a proponent of the Dutch 

system, nor am I questioning the recommendation and the fact that 

you didn’t draw that distinction. I am trying to short-cut the process we will go through, because I am sure an issue will arise dealing with, ‘‘is there an off-duty difference versus combat.’’ Understanding where the Commission was, as a whole, is extremely important. 

Admiral, very quickly, a common theme among the Commissions 

that testified today and mentioned in your report is the need for 

a formal system of case management or a central individual to coordinate all the servicemembers’ needs as they transition from 

DOD to VA. Real specifically, from what you have seen on the task 

force, do you feel that VA’s recent move to create Recovery Coordinators, and I think you mentioned Federal Recovery Plans, as 

well—is that a silver bullet, or, is this just another piece of the 

process that we have got to get right? 

Admiral DUNNE. Well, I think it is an essential part of the process, Senator. We have already moved out, and put on the VA side, 

Transition Patient Advocates in place. 106 of them have been hired 

so far, and I think they are essential to helping the family focus 

on recovery, and let the Transition Patient Advocates worry about 

those administrative things that have to happen in order for the 

recovery to take place properly. But, that is at the scene. 

We also need the Recovery Coordinators who are going to be the 

next level up, Federal Recovery Coordinators who will start at day 

one with that servicemember and track them through all the way 

to the end. And they will be overseeing and monitoring the efforts 

87 

of the Transition Patient Advocates or the Army Triad, et cetera, 

who also have key and essential jobs to make sure that our veterans and servicemembers are taken care of. So, they are going to 

have to be working together. 

Senator BURR. Admiral, as you are well aware, the VA-assigned 

case managers to our service personnel when they came in. I think 

Senator Dole was the one that said one of his Commission members who went through the process had so many case managers 

they couldn’t remember the last one’s name, so they wouldn’t have 

known who to call. I only point that out to you to say we have been 

here before. We have had the right focus. For whatever reason, I 

think the administrative side of it didn’t recognize the need for that 

personal bond, much the same as a patient-doctor relationship. 

Somebody without a medical home has a very difficult time accessing preventative care. Somebody who doesn’t have an entryway 

into the VA today has a very difficult time, and we know that to 

be the fact. It is another challenge that we have got to address in 

a different forum. 

Mr. Secretary, I am delighted to be reminded that you remember 

your home of North Carolina. I am sure your mother would be 

proud to know that. 

I am going to give you an opportunity to expand on your answer 

to the Chairman. You had possibly some additional observations 

about the Dole-Shalala legislation. You limited your answer to just 

the specific area. If there are other areas you would like to address, 

I would like to give you that opportunity. 

Mr. WEST. Thank you, Senator. I didn’t mean to sort of appear 

to promise some areas of disagreement. I don’t have any, just some 

reactions. But I am reminded, before I do, of something you said 

about your frustration with hearing that whatever we say has to 

be done, it seems to take forever to do it in a Nation like this. 

When we try to change these huge institutions like VA and DOD, 

you have heard the analogy before, I am reminded with the Admiral sitting here, about trying to turn a huge ship and it looks like 

it never happens. It doesn’t mean that we take our hands off the 

wheel. It doesn’t mean that we lessen our efforts to turn, because 

we know eventually we get it turned. 

And so frustrating as it may be when I recite how far DOD has 

in some respects against it, at the same time, when I listen to 

these task forces that are meeting, there are two, it seems to me, 

big areas of optimism. One is the fact that the two Gordons continue to meet on this. Gordon England has a reputation as a problem solver and a doer at DOD. He has certainly got the confidence 

of the President, who has had him in two different departments 

and in two different parts of the Department of Defense, Navy, 

DOD, Homeland Security, and the like, and we all know Gordon 

Mansfield and his record of achievement at VA. That is not the 

point, though. The point is the power of their offices. They run 

those departments for their principals who are trying to do other 

things, and as long as they are engaged, we will make progress on 

these things. 

The other is, there are no good things about what happened at 

Walter Reed except that it caused us as a Nation to focus on the 

problems you are discussing. I was just listening to the caseworker 

88 

discussion. We found at Walter Reed that part of the problem that 

was discussed in the press about soldiers who were expected to 

keep their appointments when they were in rehabilitation and they 

had had the kind of surgery that made it very difficult for them 

to know who was their doctor that they had to go see and what 

their appointments were and who was going to help them to do it 

and how unfair it is to the families is that you needed someone 

who was following that whole thing throughout. The solution, of 

course, could be if it were the same person who could follow the 

servicemember and family all the way through. That is why this 

focus on caseworkers is a continuing thing that we need to try to 

do and to get right. 

In terms of the various recommendations by the Dole-Shalala report, they had the opportunity to hear from us. We completed our 

work as they were starting. That was the time line that had been 

given us and the idea was that our stuff should—it is going to be 

available to inform them, and we are very happy with their elements. I did not mean to suggest anything. I think it was the particular topic that was being addressed at the time, responsibilities 

between DOD and VA as we looked at the joint scheme. 

One reaction I had was the discussion between who should do 

the physical examination. This effort is combined into one thing. I 

am reminded that one of the things we found as we talked to 

servicemembers at Walter Reed, also at Bethesda and elsewhere, 

was their mistrust of the system, of the doctors in the system, that 

the doctors somehow were biased against them—certainly the 

Army doctors, in some way, that perhaps their notes weren’t reflecting everything that they should reflect. An important part of 

the treatment and the determinations is what is in the notes of the 

attending physicians as they look at them along the way. It has a 

big impact on decisions that later get made by reviewing authorities. 

It may be well that servicemembers would be more inclined to 

see VA doctors doing that one single examination. I think the better answer is the one I heard given here, which is that even more, 

it may be even best if we look to see what the abilities are in a 

given area where the examination is to be given between the two 

services. It may not be so good as to make it an iron-clad process 

where it is a DOD physician every time that does it. I think there 

is a little area there we want to be careful about. I am sorry I took 

so much time. 

Senator BURR. No, and I didn’t mean to infer that you had disagreements with Dole-Shalala. I thought you had some additional 

things you wanted to say. You are in a unique situation, having 

served as Secretary of the Army and the Secretary of the Veterans 

Administration, but all of you are in a unique situations from the 

standpoint of the studies you have just done and the service that 

you have given. 

Mr. Chairman, I hope that they will continue to make themselves available to the Committee relative to questions that we 

might have that help us to sort through this at a faster pace than 

what Senate historical standards are, as well. I thank the Chair. 

Chairman AKAKA. Thank you very much, Senator Burr. 

Senator Murray? 

89 

Senator MURRAY. Yes. Mr. Chairman, thank you very much. I 

think none of us want to have the sound and fury of the Walter 

Reed scandal to be the sound and fury of this year, then 2 years 

come back here and we have done nothing. So, I think we all want 

to see progress made, and to that point, General Scott, you, in your 

recommendations with your Commission, seek to establish an oversight group to make sure that the Commission recommendations 

are followed on. That is not part of what we heard from the DoleShalala Commission. Can you tell us why you believe an oversight 

commission is important? 

General SCOTT. This goes back, Senator, to an earlier comment 

about how long is it going to take to get some of these things done. 

It seemed to our Commission that oversight at a couple of levels 

was critical. One of them: is we thoroughly endorse the SOC with 

Deputy Secretary England and Deputy Secretary Mansfield. But, 

we also believe that there are some specific areas where additional 

oversight may be needed and we suggested that the Congress may 

wish to establish an oversight group or committee to keep up with 

these many, many recommendations from all these groups, to make 

sure that none of the important ones fall in the cracks. We don’t 

want to find ourselves all back here in 2 years saying, well, gee, 

we talked about this before but nothing ever happened. 

So, taking nothing away from the two departments and taking 

nothing away from the Senior Oversight Council, it seems to us 

that in some of these areas, oversight—you can call it independent 

oversight or you could call it another level of oversight—might be 

valuable to make sure that some of these things don’t just go away. 

That was the intent of the recommendation, ma’am. 

Senator MURRAY. OK. Thank you very much for that. 

Secretary Dunne, the Senate has acted on legislation. We came 

together—the VA and the DOD Committee. We put together the 

Dignified Treatment of Wounded Warriors Act. It has passed out 

of the Senate. Has the administration taken a position on that legislation? 

Admiral DUNNE. Senator, I think the best way I can describe reaction to the legislation is based on my experience of the past 7 

months and looking at the comprehensive plan that the Senior 

Oversight Committee is putting in place right now to address such 

activities as the TBI, PTSD, case management, et cetera, and creating a Center of Excellence—putting that into action already on 

PTSD and TBI. 

My best understanding is with the legislation which I participated in drafting, which was sent over here yesterday, to reflect 

the recommendations of the Dole-Shalala Commission, and what I 

have learned as a member of the Senior Oversight Committee. I 

think that I would say, that is the best legislative approach to take. 

Senator MURRAY. So, they are not commenting, or they are commenting in opposition to it? 

Admiral DUNNE. I don’t believe that we have an administrative 

position right now. 

Senator MURRAY. OK. One other quick question. All of the other 

task forces emphasized and talked about family support except for 

the President’s Task Force. I understand you were limited in your 

scope. The President said he didn’t want to spend any new money, 

90 

so you were not looking to expand anything. I know that put a big 

damper on it. But, can you tell me what the VA’s recommendations 

are on family support programs? 

Admiral DUNNE. Well, one of our key assets is using the Vet Centers, which we have over 200 of them throughout the country, and 

they are available, legislatively have been made available to families and dependents, as well as servicemembers, for counseling; 

dealing with the challenges of deployments; et cetera; and also, 

where necessary, bereavement counseling for the families. 

Senator MURRAY. I am sure you have seen the other reports. 

They focus a lot on what the real stresses for families today in the 

current military are and how families are the support groups, and 

all the issues from health care to being there for someone who is 

critically ill for a long period of time. Did your task force not look 

at all at some of this extra support, additional support, needed support, for those families? 

Admiral DUNNE. The task force responded to the request that we 

received from the different information sources we sought, including our Web site, e-mails coming in, et cetera, and—— 

Senator MURRAY. That sounds so bureaucratic. I am just asking 

you, don’t you think that there are a lot of families out there who, 

in today’s world, really need additional services? 

Admiral DUNNE. I absolutely do, and one of the ways we are 

dealing with that is with the Transition Patient Advocates, who 

have the ability to communicate with the family and determine 

where there is a need, where there is a special circumstance, et 

cetera, and for them to find an answer to that special circumstance 

anywhere within VA—that they need to go to get the answer. 

Senator MURRAY. Well, don’t you think a lot of them are getting 

lost today because they don’t know where to go? 

Admiral DUNNE. I am confident that my fellow workers at VA 

are doing their utmost to make sure that nobody falls through the 

cracks. 

Senator MURRAY. And you wouldn’t think that the VA needs 

today to look differently at veterans’ families than they have in the 

past? 

Admiral DUNNE. We need to continue to emphasize that the family is a very essential element to the recovery of our veterans and 

active duty personnel and we need to work with them to make sure 

that they can focus on recovery and not on administrative procedures. 

Senator MURRAY. Mr. Chairman, my time has expired, but I do 

think in today’s world, with what we are asking of our men and 

women who serve us and the fact that many of them have families 

today, they end up being the caregivers. That is something we have 

to really focus on. Thank you very much, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Murray. 

I want to thank this panel very much for your testimony, your 

responses, as well as your recommendations. It will be helpful to 

our Committee as we proceed here. In case we receive any further 

questions, we will be submitting them to you for the record. So, 

thank you again, and thank you to the rest of the Commissioners 

who are here for your service to our country. 

91 

I now welcome our third and final panel and want to extend our 

welcome to each of you. 

I extend a welcome and aloha to Ms. Ariana Del Negro, the wife 

of an Army Ranger who suffered a Traumatic Brain Injury while 

serving in Iraq in 2006. Ms. Del Negro traveled all the way from 

my home State of Hawaii to testify before the Committee today. 

Ms. Del Negro also testified at a field hearing I held this August 

in Honolulu where she shared the challenges that she and her husband have faced in obtaining proper medical care for his injuries. 

I thank Ms. Del Negro for traveling a great distance to share her 

and her husband’s experience with us and for the record. 

Also testifying on the third panel are Colonel Peter Duffy, who 

is the Deputy Director of Legislative Programs for the National 

Guard Association of the United States; Gerald Manar, the Deputy 

Director of VFW’s National Veterans Service, who is representing 

the views of the Independent Budget; Meredith Beck, National Policy Director of the Wounded Warrior Project; and Colonel Steve 

Strobridge, Director of Government Relations for the Military Officers Association of America. 

I thank all of you for being here today and look forward to hearing your perspectives on the proposals and recommendations put 

forth in the reports of those who appeared on today’s earlier panels. Of course, your full statements will appear in the record of the 

hearing. 

May I ask Ms. Del Negro to begin with your statement. 

STATEMENT OF ARIANA DEL NEGRO, 

WIFE OF 1LT CHARLES GATLIN 

Ms. DEL NEGRO. Thank you very much. As you mentioned, my 

name is Ariana Del Negro and I am here representing most of the 

families who are entering the awkward transition stage between 

active duty and veteran status. 

As Chairman Akaka mentioned, my husband, Charles Gatlin, a 

First Lieutenant and scout platoon leader of his infantry battalion, 

was wounded September 28, 2006, after a vehicle-born improvised 

explosive device detonated less than 20 yards from where he was 

standing. My husband is a very accomplished soldier. His prior 

service was in the Old Guard. He deserved better care when he 

came home. 

He was subsequently returned to Hawaii approximately 4 weeks 

after his injury. It was immediately frustrating. At our first doctor’s appointment they didn’t know what a VB–IED was; they also 

took no initiative to get him the care he needed. My husband, an 

Army Ranger, a 200-pound man who was responsible for collecting 

intelligence to ensure the safety of his fellow soldiers, admitted he 

was having anxiety at his first neurologist appointment. The response from the neurologist, ‘‘See me in 2 weeks,’’ was inappropriate—absolutely inappropriate. 

My husband could not drive when he came home. He had severe 

vertigo. He leaned to the left. He had hand and facial tics and he 

couldn’t keep eye contact when speaking. My husband used to work 

in the Pentagon in the public tour program. There was no room for 

error with speech. He developed a stutter and it significantly compromised his communication abilities. I had to act on his behalf as 

92 

his agent. He was unable to follow conversations. He did not receive any education about his injury. 

I work in the health care field and made sure to familiarize myself with the complexities of the injury and the required standard 

of care that should be delivered. Throughout this process, initially 

at Tripler Army Medical Center, that standard of care was not administered. There was no coordination of care. There was no communication between providers. And the providers we were able to 

see, and only able to see after we demanded that those appointments be made, did not have any consensus between them. 

Subsequently—this was January of 2007—we finally had a meeting with my husband’s providers. They still did not have a coordinated care plan established, and it was at that time that we continued with our insistence that he be referred to the Defense and Veterans Brain Injury Center in San Diego for treatment. Our request 

for referral was finally granted January 31, 2007, 5 days before the 

Washington Post articles were released. 

Our experience represents exactly what those articles captured. 

It was humbling to see that we were not an exception but more the 

rule, and it was very sad. I am from Bethesda, Maryland. I work 

in the health care industry for a very large online health care resource. We have no children and I telecommute to New York for 

work. The responsibilities that me and my husband were asked of 

were not fair. If they were not fair for us, who were more independent and capable, what does that mean for these other families, 

for those whose husbands return far worse off than my husband, 

for those with children who have to work to supplement the family’s income and who don’t know that the care they are receiving 

is not what they need? 

I urge you to continue to support these families, specifically by 

extending resources to them. I would not have known about the 

Defense and Veterans Brain Injury Center had I not done extensive research and actively reached out to those providers. 

I must mention that we received care at the Sharp Rehabilitation 

Program, which coordinated with Balboa Naval Medical Center. 

The treatment at Sharp was impeccable. It represented the complete antithesis of the treatment we received at Tripler and my 

husband came home a husband. I am no longer a caregiver, I am 

a wife. Because of Sharp, which was a civilian program—because 

they had 20 years of experience, we managed to survive as a family. That is the bottom line. That is the most important message. 

We can sit here all day and discuss the importance of policy, but 

unless some of these things are implemented immediately, we will 

continue to fall through the cracks. 

Thank you. 

[The prepared statement of Ms. Del Negro follows:] 

PREPARED STATEMENT OF ARIANA DEL NEGRO, WIFE OF 1LT CHARLES GATLIN

Mr. Chairman, Committee Members, thank you for allowing me the opportunity 

to participate in this vital forum on the issue of providing coordinated care to 

servicemembers, veterans, and their families. My name is Ariana Del Negro and I 

represent one of the many families with a loved one injured in Iraq or Afghanistan 

who are now entering the awkward and unfamiliar transition phase between active 

duty and veteran status. I am here today not only to tell you about the numerous 

obstacles my husband and I faced when he first returned home from Iraq, but also 

to describe the excellent care he ultimately received for his Traumatic Brain Injury 

93 

(TBI). My husband and I believe that there is much work to be done and hope that 

sharing our experiences will help create a model of care for servicemembers and veterans with TBI and their families that establishes: (1) strong support networks and 

access to information; (2) timely, comprehensive, and coordinated care; and (3) appropriate funding for the continued research and training required to provide a high 

standard of long-term care to the ever-increasing numbers of warriors suffering from 

TBI. 

The wounds suffered from these injuries extend beyond the soldier; the frustrations with gaps in care and lack of support also wound the families fighting for their 

loved ones. These servicemembers, veterans, and families need our help, and the responsibility to provide them with that help falls on the Nation for whom these warriors bravely fought. 

OUR STORY

My husband, 1LT Charles Gatlin was the Scout/Sniper Platoon Leader of his Infantry Battalion. He was honored to hold this highly coveted position, one which 

was reserved for the ‘‘best’’ lieutenant in the Battalion. He took pride in having the 

degree of skill and professionalism required for the position, particularly because his 

work gathering intelligence helped both to ensure the safety of his fellow soldiers 

and to meet the larger objective of unifying a politically and religiously diverse area. 

My husband commands deep respect from his soldiers and continues to perform his 

job (albeit in a different capacity) with the highest degree of excellence and professionalism. 

On September 28, 2006 in Kirkuk, Iraq, my husband suffered a closed-head TBI 

after a very large vehicular-borne improvised explosive device (VBIED) detonated 

less than 20 yards from where he was standing. He was exposed to three concussive 

forces: first, the explosion; then the engine block from the vehicle which struck him 

on the back of the head as he was thrown into the air; and finally when he hit his 

head again after falling to the ground on his back, where he remained unconscious 

for at least 10 minutes. 

The screening and care my husband received in the battlefield and in the theater 

was excellent, proficient, and per protocol. Within 1 hour of his injury, my husband 

was medevaced to Balad Medical Hospital where he was admitted in serious condition. After 3 days in the intensive care ward, he was eventually discharged from 

the hospital and returned to his base in Kirkuk in hopes that his initial TBI symptoms would subside enough that he could return to the field of combat within a few 

weeks. I believe that my husband was returned to his base in Kirkuk instead of 

being medevaced to Landstuhl Regional Medical Center in Germany because of his 

insistence that he be back with his men in the field. During the 4 weeks my husband spent back in Kirkuk, he had to depend on his medic and roommate, CPL 

Joshua Harmon. CPL Harmon tended to him, helped him dress, assisted him when 

moving from room to room, and checked his pupils each night. (Sadly, on August 

22, 2007, CPL Harmon and nine of his fellow Scout platoon members died in a helicopter crash outside of Kirkuk, Iraq. To CPL Harmon and his family, and to the 

families of his fallen comrades, thank you.) 

After spending approximately 4 weeks in Kirkuk without resolution of his symptoms, my husband was returned back to his home base in Hawaii. He could barely 

keep his balance, let alone figure out where he was supposed to go and whom he 

was supposed to see for his medical care. Unfortunately, the system he reported to, 

Tripler Army Medical Center, did not know either. 

My husband had sustained what is now known as the ‘‘signature wound’’ of the 

Global War on Terror. However, he was injured before this phrase was coined and 

before the full implications of the injury were recognized. The general lack of awareness of TBI at the time of his injury, coupled with its ‘‘silent’’ symptoms, were significant barriers when my husband first sought medical treatment upon his return 

from Iraq. 

A closed-head TBI is literally a hidden injury; an injury with the potential for subtle yet devastating symptoms that go unnoticed by those who are unfamiliar with 

the individual’s functioning prior to his or her injury. Health care professionals are 

used to having physical evidence of an injury, but mild, closed-head TBIs typically 

do not show up on brain scans and referrals for treatment must be made on the 

basis of neurological exams, self- and family-reported symptoms, and the results of 

neuropsychological testing. 

When he first returned home from Iraq, my husband complained of debilitating 

headaches, chronic vertigo, memory lapses, anxiety, and hearing loss. He leaned to 

the left, developed hand and facial tics, and could not maintain eye contact when 

speaking. Two weeks later, as some symptoms worsened, new symptoms emerged. 

94 

He developed a significant stutter, had difficulty recalling words, and frequently 

dropped objects. Unable to drive, this fiercely independent man lost his autonomy 

and was forced to depend upon others for his basic needs. It was also at this time 

that he began to withdraw socially, avoiding public and busy areas. His time was 

mostly spent sitting, staring blankly. Watching my husband, an exceptionally accomplished and strong man, struggle with such simple tasks was very difficult. 

EARLY DISAPPOINTMENTS

The phrase ‘‘twice wounded,’’ often used to describe the struggles wounded warriors face when seeking care in the military health care system may seem cliche ́d, 

but it is exactly what my husband experienced after he returned from Iraq. He describes the struggles we encountered at Tripler as being as painful as sustaining 

the injury itself. 

Treating TBI requires a multidisciplinary approach from as many as nine specialists. However, the single most important component of treatment is effective communication and coordination among these providers. Although Tripler had the resources required to effectively treat TBI, they lacked that crucial coordination. Coupled with Tripler’s lack of experience managing TBI and post-concussive syndrome 

(a diagnosis made when a patient continues to exhibit symptoms from TBI beyond 

1 month), this lack of coordination compromised and slowed my husband’s recovery. 

Despite his worsening symptoms, we had to fight for every referral he needed— 

audiology, vestibular testing, ophthalmology, speech therapy, etc. And, even after we 

were referred to and met with these specialists, no two specialists agreed about 

what my husband needed; we spent our days shuttling from one appointment to the 

next, only to discover that the recommendations made by one provider were deemed 

unnecessary by another. 

Many of the providers we saw had little or no experience with blast-related TBI. 

When my husband told the doctors treating him at Tripler that his injury was 

caused by a VBIED, they asked him what a VBIED was. Likewise, when my husband—the brave infantryman who had insisted on remaining in Kirkuk after his injury—actually summoned up the courage to acknowledge to his neurologist that he 

was experiencing anxiety, his neurologist simply responded: ‘‘See me in 2 weeks.’’ 

Had this neurologist instead taken the time to find out what my husband’s responsibilities were in Iraq and what he witnessed, he would perhaps have realized that 

exposure to these stressors meant my husband was at increased risk for depression, 

anxiety, and other psychological issues. In my husband’s case, these risks were exponentially compounded by the fact that several symptoms associated with post-concussive syndrome secondary to TBI are psychological in nature. Whether due to a 

lack of combat experience, poor training, or overwhelming caseloads, these doctors 

simply did not have the knowledge or skills to treat my husband’s injuries. 

Similarly, because doctors cannot see physical evidence of TBI, they sometimes 

wrongly conclude that servicemembers suffering from TBI are malingering and trying to shirk their duties and avoid returning to Iraq or Afghanistan. One of the physicians treating my husband in Hawaii made exactly this kind of accusation against 

my husband, which added salt to an already open wound. 

My husband was unable to drive, which placed responsibility for taking him to 

each and every one of his appointments and to and from work on me, his lone caregiver. Because of the adverse cognitive and communication effects of his injury, I 

also had to act as his representative, speaking and processing information on his 

behalf. But the system at Tripler was far from encouraging and supportive of my 

efforts. Many of the people we encountered seemed to be less than pleased with a 

wife who was outspoken, informed, and persistent. One physician even went so far 

as to suggest that my husband was receiving poor care because of my outspokenness. 

Finally, after 14 long and frustrating weeks of struggling with the system to get 

my husband the care he needed, our request for referral to the Defense and Veterans Brain Injury Center (DVBIC) at Balboa Naval Medical Center in San Diego, 

CA, for thorough evaluation and comprehensive treatment was granted. After waiting another 6 weeks for the paperwork to be finalized, we finally arrived in San 

Diego. All told, it took us more than 5 months to get access to this excellent level 

of specialized health care. These were five valuable months lost in the crucially important acute rehabilitation stage of TBI. 

FINE EXAMPLE OF EXCELLENT CARE AND INVALUABLE EDUCATION

The care in San Diego represented the complete antithesis of what we received 

in Hawaii. The DVBIC at Balboa coordinates its care with the Community Re-Entry 

Program at Sharp Rehabilitation Center, a center with more than 20 years of expeVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00098 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
95 

rience in rehabilitative care. The providers at Sharp and at Balboa addressed all 

of my husband’s needs (physical, occupational, and speech therapy), integrated our 

requests into their rehab program, and provided amazing support to both of us. My 

husband finally received the care he should have received all along. He underwent 

intensive rehabilitation 7 hours a day, 4 days a week. We had biweekly coordination 

meetings with all of my husband’s providers who met with us to discuss his 

progress, make suggestions, and ask for feedback. 

The care my husband received in San Diego represented what we should have 

been receiving all along. I use the term ‘‘we’’ because the caregiver and family unit 

are integral to a successful rehabilitative process. In stark contrast to the care in 

Hawaii, where my involvement was discouraged, the program in San Diego integrated the caregiver into the rehabilitative process. 

And, importantly, they educated us. We learned that our situation was not unique 

and that many closed-head TBI patients face similar obstacles and frustrations that 

compound their symptoms. Shortly after coming home from Iraq, for example, my 

husband commented that because he was not missing a limb and/or did not have 

scars on his head or body, he questioned whether he was as seriously wounded as 

those with visible injuries; a question reinforced by his experiences with some of the 

doctors he encountered at Tripler. The education we received at the DVBIC and 

Sharp provided affirmation to my husband that he was seriously injured and deserved the best care possible. They explained that the adverse effects of his injury 

would have resolved faster had some of the frustration with his medical care been 

avoided. They also explained that my husband probably would have made greater 

progress during rehabilitation had he been referred earlier in the treatment process. 

Although he likely would have recovered to the same degree, he would have done 

so at a much faster rate. Importantly, they also explained that there may be some 

symptoms that will never resolve and that the success of his rehabilitative therapy 

depends on our ability to set reasonable goals and maintain realistic expectations. 

My husband left San Diego a changed man. He regained his ability to accomplish 

complex tasks, his speech was fluid, he was able to run, and he passed a driving 

evaluation. He was able to regain his autonomy, enabling me to (semi-) retire from 

my roles of caregiver and chauffeur. Now I can be a wife and he can be a husband. 

He has since returned to duty in an administrative capacity as his Battalion’s RearDetachment Executive Officer in Hawaii. Although he still suffers from intermittent 

headaches, vertigo, fine motor skill deficits, and some memory problems, they are 

less intense than when he first came home. He has applied the lessons we learned 

in San Diego and is learning to accept and compensate for his limitations. 

Throughout this process, my husband and I have done our best to keep a sense 

of perspective, returning time and time again to our sense that we are one of the 

lucky families. My husband and I are both well-educated and make a good living. 

Working in the health care industry, I have been able to rely upon my medical background to find appropriate resources. My husband was also fortunate to receive remarkable support from his Command. His Commander, MAJ William J. O’Brien, in 

the spirit of a true Infantryman, dedicated a significant amount of time and effort 

to ensure that my husband received the care he rightly deserved. Without MAJ 

O’Brien’s support, and the support of the 25th Infantry Division, it’s likely that I 

would be sharing a different story with you today. 

However, if it has been this difficult for my husband and me, we cannot imagine 

what it must be like for the other families—those with warriors who return far 

worse off than my husband; families with children; families with mothers who have 

to work outside the home to help support their families; and those who do not know 

that the care they are receiving is far inferior to what they need and, importantly, 

deserve. 

SUPPORT FOR FAMILIES AT ALL STAGES IN THE RECOVERY PROCESS

The success we had at Sharp Rehabilitation demonstrated that in addition to providing adequate funding and training, it is important that systems be created to 

provide support for servicemembers, veterans, and their families. Our frustrations 

with my husband’s initial care alienated us; we had nothing to compare our own 

experience with, and had no communication with other families in similar situations. Less than 1 week after our request for referral to the DVBIC was honored, 

The Washington Post published the first in its series of articles on Walter Reed, 

chronicling the frustrations wounded servicemembers, and their families faced trying to navigate through a complicated and bureaucratic system. The Washington 

Post articles were bittersweet: the sweet of knowing we were not alone coupled with 

the bitter of knowing we were not an exception. These articles also validated my 

belief that it is not just the individual servicemember who bears the brunt of injury. 

96 

The unrealistic expectations that the system places on the caregiver add further 

burden to an already stressful and taxing situation. 

It is critically important that servicemembers and their families are proactively 

made aware of the resources that are available to them; they should not have to 

seek them out. I would not have known about the DVBIC unless I had actively 

sought out information and made contact with both Walter Reed and San Diego. I 

would not have known that my husband was not getting the appropriate standard 

of care if I did not have a medical background and if I hadn’t done extensive research to educate myself on TBI. I made sure that I was armed with knowledge for 

each doctor’s appointment and I did the best I could to educate my husband. What 

is clear from our own experience is that there are many families in need. These families need immediate access to resources, they need advocates, and they need support. It is one thing to develop resources but it is another to actually utilize them. 

If the families do not know that these resources exist, they are unlikely to ever be 

able to reap benefits from those programs. 

I am pleased that the reports from The President’s Commission on Care for America’s Returning Wounded Warriors (commonly referred to as the Dole-Shalala Commission), as well as the Veterans Disability Benefits Commission, recognize the pivotal role of family in the treatment process and I strongly advocate for an amendment to the Family Medical Leave Act, extending unpaid leave from 12 weeks to 

6 months for caregivers tending to the needs of a servicemember. I believe, however, 

that the legislation should go one step further to include those tending to the needs 

of wounded veterans, particularly since many of the diagnoses for TBI and PTSD 

are made after servicemembers are separated from active duty. 

THE IMPORTANCE OF TIMELY AND COORDINATED CARE

Our success with Sharp’s Community Re-entry Program was the result of receiving excellent individualized care and education from a multidisciplinary group of 

providers who worked well together and integrated the family unit into the decisionmaking process; in essence, they practiced ‘‘relationship-based health care’’. This 

medical model is outlined in pending legislation, such as the Veterans Traumatic 

Brain Injury Rehabilitation Act of 2007 (S. 1233). 

My husband was very high-functioning after his injury and was not an injured 

servicemember for whom the military typically considered intensive rehabilitation 

necessary. However, the increasing awareness of the deleterious and long-term consequences of TBI—namely through the adoption of the DVBICs across the country— 

my husband was finally properly identified as someone who could benefit from such 

care. 

Our experience at the Sharp Rehabilitation Center also demonstrates the importance of extending civilian health care services to servicemembers and veterans. 

Programs such as the one at Sharp have experience with these types of injuries, 

have an effective program in place, and clearly yield excellent results. More initiatives need to be taken to institute similar programs partnering military, veteran, 

and civilian health care services. In addition, consideration must be given to properly pairing the offerings of a rehabilitation center with the specific needs of a 

servicemember/veteran with TBI. Employing the valuable resources of these non-Department facilities could help reduce the heavy burden on the Department of Veterans’ Affairs (VA)—a burden likely to grow in parallel with the number of wounded. 

STAFFING SHORTAGES AND LACK OF TRAINING COMPROMISE CARE

As noted in Dole-Shalala Commission Report, the chances of recovery from TBI 

are greatest when prompt and correct care is administered. Communicating this 

message to health care providers is pivotal to ensure that all servicemembers and 

veterans have immediate access to care. Meeting this objective, however, is contingent on providing appropriate, timely, and comprehensive training to health care 

professionals, with an emphasis on the signs and symptoms of TBI and PTSD. It 

is also dependent upon adequate long-term funding. 

This also speaks to the staffing shortages of health care providers in the military 

and VA systems. Tripler Army Medical Center is the largest military medical treatment facility in the entire Pacific Basin, covering an eligible population of 400,000 

servicemembers, veterans, and their families. Yet, when my husband first arrived 

at Tripler for care, there were only three neurologists in the entire hospital. Furthermore, there was only one full-time neuropsychologist, a provider described in a 

Veterans Health Initiative as ‘‘the key player in diagnosing cognitive impairments’’ 

in patients with post-concussive syndrome. Neuropsychological testing is a labor-intensive process and the results of the testing require careful and detailed analysis 

97 

to ensure a fair assessment. Given the recent findings of the Neurocognition Deployment Health Study that deployment to Iraq increases the risk of neurological compromise, the caseload for these neuropsychologists will undoubtedly increase. 

MORE RESEARCH IS NEEDED! 

There is little doubt that more research on blast-related TBI is needed, particularly as it relates to the effects of exposure to multiple primary blasts and long-term 

outcomes. TBI in a combat environment is a complex injury. A thorough understanding of the nuances of the injury, whether physically evident or otherwise, is 

absolutely essential to identify effective therapies and maximize outcomes. Currently, much of the evidence on blast-related TBIs is derived from animal studies, 

which have helped researchers understand the pathophysiologic effects of the injury; 

however, the implications of these findings in the clinical setting have not been well 

studied. As the number of closed-head TBI wounds increase, so too does the need 

for allocated funding to support clinical research and new practice guidelines. 

For example, much of the data on TBI are largely based on older studies, evaluating outcomes of patients who sustained a TBI in an automobile accident, a fall, 

or a sports injury. These studies do not take into consideration that a blast-related 

TBI may injure cells at a more severe, microscopic, sub-cellular level. Injury to this 

fine of a degree may influence outcomes and possibly require longer periods for maximum recovery than TBIs suffered in a non-combat setting. 

Although much has been learned about the recovery and treatment process for 

TBI, much remains unknown, particularly about the long-term effects of these injuries. For example, how long should care be administered? When is a patient considered fully recovered? What will the long-term consequences of closed-head TBI be— 

epilepsy? Parkinson’s? Alzheimer’s? Answers to these questions remain ambiguous 

at best. Applying the tragic lessons learned from exposure to Agent Orange, we 

should prepare for the likelihood of long-term adverse effects from this conflict as 

well. 

TRANSITIONING FROM ACTIVE DUTY TO VETERAN STATUS—ACTION IS NEEDED

Although my husband is still on active duty, our experience represents what 

many young veterans suffering TBI have had to face before being discharged from 

the service. We fear that without major reform, the obstacles and frustrations we 

faced within the Army’s medical system will not be significantly different from those 

we may encounter when we enter the VA health care system. Although the VA and 

Department of Defense (DOD) systems are separate entities, the two departments 

share similar bureaucratic problems. We need to learn from the experiences of 

servicemembers and families such as ours in order to avoid similar obstacles within 

the VA system. The continuum of care must begin on the battlefield, move to the 

military health care system, and continue through the VA. 

We are encouraged by recent initiatives proposed by Congress, the DOD and the 

VA to improve the care and support for servicemembers, veterans, and their families, particularly as it relates to developing a strong collaboration between the two 

departments to streamline the transition process. There is little doubt that the systems to accomplish these goals are in place; however, they are still in the early 

stages of implementation and, as with any natural process, it will take time for 

them to mature to the degree desired. While the development of these initiatives 

are imperative for the future, we must not lose focus and overlook the fact that today’s servicemembers and veterans continue to face a number of obstacles and hardships. Unless immediate action is taken, these individuals will continue to fall 

through the large cracks borne of years of neglect and empty promises. 

CONCLUSION

Although The Washington Post articles in February 2007 have turned much-needed public attention to the hardships that both servicemembers and veterans face, 

they were hardly the first warnings about these problems. For years, the Government Accountablity Office has issued reports documenting the significant backlog in 

the VA disability system, the outdated nature of the VA Schedule for Rating Disabilities, and the incompatibility of electronic health records between the VA and 

DOD systems. Concerns regarding blast-related TBIs were also addressed prior to 

The Washington Post articles. On August 11, 2006, the Armed Forces Epidemiology 

Board presented its findings on the acute and long-term health implications of TBI 

in military servicemembers to the Assistant Secretary of Defense for Health Affairs. 

The Board’s recommendations closely mirror those made in the Dole-Shalala Commission Report. 

98 

I ask of you: why did it take a series of articles in The Washington Post for these 

concerns to suddenly be regarded as serious? And, if only little progress has been 

made in response to reports over the course of the past few years, why should we 

believe that recommendations in the new reports will suddenly transform the status 

quo? Reform has been needed for years and some of the recommendations made in 

these reports will take still more years to implement. Where does that leave today’s 

and tomorrow’s generation of veterans? 

I am aware that this continues to be an ongoing learning process, but I also believe that measures need to be put in place to ensure that these changes are made, 

to assess the efficacy of these programs, and to set specific benchmarks. Thus far, 

we have a wealth of data and an abundance of recommendations. However, until 

these recommendations are actually integrated into the existing system and successfully applied, they will remain nothing more than notes on a page. 

In the end, my husband and I hope that you and your colleagues will work to 

make other returning servicemembers and veterans just as fortunate by implementing systems that: (1) provide family members with support and assistance navigating the system; (2) that facilitate coordinated care; and (3) that fund further 

long-term research of the devastating injuries of TBI and PTSD. It is time that the 

excellence that these servicemembers and veterans dedicated and displayed in the 

field of combat be matched by the system for which they sacrificed. 

Chairman AKAKA. Thank you very much, Ms. Del Negro. 

Colonel Duffy? 

STATEMENT OF COL. PETER J. DUFFY, USAR (RET.), DEPUTY 

DIRECTOR OF LEGISLATIVE AFFAIRS, NATIONAL GUARD ASSOCIATION OF THE UNITED STATES 

Colonel DUFFY. Chairman Akaka, Ranking Member Burr, and 

Members of the Committee, it is my distinct pleasure to appear before you on behalf of the National Guard Association of the United 

States (NGAUS), to address certain recommendations of particular 

concern to the welfare and benefit of our wounded National Guard 

members and their families, as set forth in the report of the President’s Commission on Care for America’s Returning Wounded Warriors, hereinafter referred to as the report. 

This brief submission will address four recommendations of the 

report relative to improving care for our wounded members. 

NGAUS supports all recommendations of the report with additional 

recommendations of its own to improve the subject care. NGAUS 

urges this Committee to continue to differentiate between the medical needs of our active duty members and our veterans, particularly with respect to geographical barriers. 

It is important to note that National Guard members returning 

from deployment can be extended on active duty for treatment by 

military treatment facilities before being discharged. In most cases, 

our members, upon returning from deployment, are quickly discharged from active duty and then eligible as veterans for care at 

the Department of Veterans Affairs health facilities. Once discharged, most of our members continue in the Selected Reserve 

and, as such, are eligible to enroll in TRICARE Reserve Select beyond the six-month Transitional Assistance Management Program. 

However, once discharged, our members are no longer eligible for 

treatment at military treatment facilities. 

Report recommendation one.—Immediately create comprehensive 

recovery plans to provide the right care and support at the right 

time in the right place. The needs of our wounded National Guard 

members and their families are geographically spread across the 

full area of our country, its Commonwealths and Territories. Once 

released from medical hold, our wounded members return to their 

99 

civilian communities, not to military installations. These communities are often in areas isolated from a Department of Veterans 

Affairs treatment facility. Obtaining continuing treatment at a 

DVA facility for many of our veterans will mean having to travel 

significant distances. This travel may require the veteran and possibly an accompanying family member to take time off from work, 

thereby further straining an employer-employee relationship already stressed by previous deployments. 

Although perhaps most often associated with States west of the 

Mississippi, geographical barriers to treatment can occur in States 

as small as Rhode Island and as far East as Maine. Maine Representative Michael Michaud, Chairman of the Health Subcommittee of the House Veterans Affairs Committee, indicated this 

session at a hearing of his Subcommittee that some of his veterans 

in the State of Maine must travel 9 hours to be treated at facilities 

in Boston. In recommending the creation of Comprehensive Recovery Plans to provide the right care and support at the right time, 

in the right place, the report speaks to the need to expand DVA 

treatment for our National Guard members in their communities. 

If necessary, this may mean authorizing DVA to contract with civilian health care providers and other facilities to remove the geographical barriers peculiar to the National Guard veterans. Our 

members and their families deserve no less. 

Report recommendation three.—Aggressively prevent and treat 

Post Traumatic Stress Disorder and Traumatic Brain Injury. Without a shifting of care to the communities, the geographical barriers 

to treatment may be insurmountable for the psychologically wounded and for those suffering from Traumatic Brain Injuries (TBI). Experts have written that individuals experiencing moderate to severe brain injuries require a continuum of care that, at some point, 

will involve community-integrated rehabilitation that will include 

neurobehavioral programs, residential programs, and home-based 

programs. 

For those requiring behavioral readjustment or treatment for 

Post Traumatic Stress Disorder and willing to seek the same, 

eliminating time and distance factors will intuitively expedite and 

ease the transition from non-recognition to treatment. Physicians 

say that the sooner these behavioral conditions can be recognized 

and treated, the more successful and mitigating the treatment will 

be. DVA needs to have access to all available behavioral health 

care resources in communities throughout the country to provide 

the care our National Guard veterans and their families are requiring in a convenient location. 

In addition to removing geographical barriers for psychological 

health, it is essential that mandatory cognitive screening both preand post-deployment be implemented to establish a baseline 

against which any delta in cognitive functioning occurring during 

deployment can be determined for purposes of expeditiously diagnosing and treating TBI and possibly PTSD conditions. The screening technology exists and needs to be implemented immediately. 

Report recommendation four.—Significantly strengthen support 

for families. NGAUS strongly supports amending the Family and 

Medical Care Leave Act as recommended in the report to authorize 

family caregivers for our wounded members to take leave from emVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00103 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
100 

ployment for up to 6 months. A visit to Walter Reed will quickly 

show that our seriously wounded National Guard members are actively attended by family members for extended periods. These 

family members should not be penalized with the loss of employment for attending to the needs of our heroes with their care and 

support. 

Under current law, an employee would only be allowed a total of 

12 weeks during a 12-month period to provide such care. In too 

many cases, the serious injuries suffered in the Global War on Terror are requiring far more than 12 weeks of treatment. As our 

members convalesce in military treatment facilities or in their communities over these extended periods, the care of their loved ones 

is an irreplaceable comfort to them and an immeasurable aid in the 

recovery process. Extending the 12-week period to 26 weeks under 

the FMLA would provide the caring family members with the assurance that he or she will not be terminated from reemployment 

during that extended period of care should it be needed. 

Report recommendation five.—Rapidly transfer patient information between DOD and VA. The recommendation that DOD and the 

VA must move quickly to transfer clinical and benefit data to users 

will require interoperability of the AHLTA and VISTA electronic 

recordkeeping systems used by DOD and DVA, respectively. Although this moment of interoperability is reported by DOD’s contractors to be close at hand, the medical needs of our National 

Guard members have been overlooked with this effort that does not 

require the records of civilian health care providers treating our 

members to be entered into the DOD AHLTA database. 

Currently, although the technology exists, there is no mandate 

from DOD to scan or otherwise enter hard copies of our National 

Guard members’ medical records from their civilian health care 

providers into the DOD AHLTA database. Please keep in mind that 

our National Guard members in a non-deployed status do not receive their medical care from military treatment facilities but from 

civilian physicians. 

Failure to scan National Guard members’ civilian treatment 

records into the AHLTA database will continue to keep military 

physicians in the dark when treating our members relative to preexisting conditions and medication histories found in their civilian 

medical records. Lack of ready access to this information in emergency treatment situations during deployments puts the National 

Guard patient at risk while being treated by military physicians. 

The recommendation of the report needs to go further to include 

the mandatory transfer of all MTF treatment records for National 

Guard members into the DOD and DVA electronic records system. 

If these records were required to be entered into the AHLTA system, then they would also be accessible to the DVA once interoperability of the DOD and DVA systems is attained. 

In conclusion, we at NGAUS hope that we have both reinforced 

and amplified, where needed, the recommendations of the report of 

the President’s Commission on Care for America’s Returning 

Wounded Warriors relative to the needs of the National Guard. 

Thank you again for this opportunity to address this Committee 

and for all that you do for our Nation’s veterans. Thank you. 

[The prepared statement of Col. Duffy follows:] 

101 

PREPARED STATEMENT OF COL. PETER J. DUFFY, USAR (RET), DEPUTY DIRECTOR OF

LEGISLATIVE AFFAIRS, NATIONAL GUARD ASSOCIATION OF THE UNITED STATES

Chairman Akaka, Ranking Member Craig, and Members of the Committee, it is 

my distinct pleasure to appear before you on behalf of the National Guard Association of the United States (NGAUS) to address certain recommendations of particular 

concern to the welfare and benefit of our wounded National Guard members and 

their families as set forth in the Report of the President’s Commission on the Care 

for America’s Returning Wounded Warriors (hereinafter referred to as the Report). 

This brief submission will address four recommendations of the Report relative to 

improving care for our wounded members. NGAUS supports all recommendations 

of the Report with additional recommendations of its own to improve the subject 

care. NGAUS urges this Committee to continue to differentiate between the medical 

needs of our active duty members and our veterans particularly with respect to geographical barriers. 

It is important to note that National Guard members returning from deployment 

can be extended on active duty for treatment at Military Treatment Facilities before 

being discharged. In most cases our members upon returning from deployment are 

quickly discharged from active duty and then eligible as veterans for care at the Department of Veterans’ Affairs health facilities. Once discharged, most of our members continue in the Selected Reserve and as such are eligible to enroll in TRICARE 

Reserve Select beyond the 6 month Transitional Assistance Management Program 

(TAMP). However, once discharged, our members are no longer eligible for treatment at Military Treatment Facilities 

REPORT RECOMMENDATION 1—IMMEDIATELY CREATE COMPREHENSIVE RECOVERY

PLANS TO PROVIDE THE RIGHT CARE AND SUPPORT AT THE RIGHT TIME IN THE RIGHT

PLACE

The needs of our wounded National Guard members and their families are geographically spread across the full area of our country, its Commonwealths and territories. Once released from medical hold, our wounded members return to their civilian communities not to military installations. These communities are often in areas 

isolated from a Department of Veterans Affairs (DVA) treatment facility. Obtaining 

continuing treatment at a DVA facility for many of our veterans will mean having 

to travel significant distances. This travel may require the veteran and possibly an 

accompanying family member to take time off from work thereby further straining 

an employer/employee relationship already stressed by previous deployments. 

Although perhaps most often associated with states west of the Mississippi, geographical barriers to treatment can occur in states as small as Rhode Island and 

as far east as Maine. Maine Representative Michael Michaud, Chairman of the 

Health Subcommittee of the House Veterans’ Affairs Committee, indicated this session at a hearing of his Subcommittee that some of his veterans in the state of 

Maine must travel 9 hours to be treated at facilities in Boston. 

In recommending the creation of comprehensive recovery plans to provide the 

right care and support at the right time in the right place, the Report speaks to 

the need to expand DVA treatment for our National Guard members in their communities. If necessary, this may mean authorizing VA to contract with civilian 

heath care providers and other facilities to remove the geographical barriers peculiar to the National Guard veteran. Our members and their families deserve no less. 

REPORT RECOMMENDATION 3—AGGRESSIVELY PREVENT AND TREAT POST TRAUMATIC

STRESS DISORDER AND TRAUMATIC BRAIN INJURY

Without a shifting of care to the communities, the geographical barriers to treatment may be insurmountable for the psychologically wounded and for those suffering from Traumatic Brain Injuries (TBI). 

Experts have written that individuals experiencing moderate to severe brain injuries require a continuum of care that at some point will involve community integrated rehabilitation that will include neurobehavioral programs, residential programs, residential programs and home based programs. 

For those requiring behavioral readjustment or treatment for Post Traumatic 

Stress Disorder and willing to seek the same, eliminating time and distance factors 

will intuitively only expedite and ease the transition from non recognition to treatment. Physicians say that the sooner these behavioral conditions can be recognized 

and treated, the more successful and mitigating the treatment will be. DVA needs 

to have access to all available behavioral health care resources in communities 

throughout the country to provide the care our National Guard veterans and their 

families are requiring in a convenient location. 

102 

In addition to removing geographical barriers for psychological health care, it is 

essential that mandatory cognitive screening both pre and post deployment be implemented to establish a baseline against which any delta in cognitive functioning 

occurring during deployment can be determined for purposes of expeditiously diagnosing and treating TBI and possibly PTSD conditions. The screening technology exists and needs to be implemented immediately. 

REPORT RECOMMENDATION 4—SIGNIFICANTLY STRENGTHEN SUPPORT FOR FAMILIES

NGAUS strongly supports amending the Family and Medical Leave Act (FMLA) 

as recommended in the Report to authorize family care givers for our wounded 

members to take leave from employment for up to 6 months. A visit to Walter Reed 

will quickly show that our seriously wounded National Guard members are actively 

attended by family members for extended periods. These family members should not 

be penalized with the loss of employment or attending to the needs of our heroes 

with their care and support. 

Under current law an employee would only be allowed a total of 12 weeks during 

a 12 month period to provide such care. In too many cases the serious injuries suffered in the Global War on Terror are requiring far more than 12 weeks of treatment. As our members convalesce in military treatment facilities or in their communities over these extended periods, the care of their loved ones is an irreplaceable 

comfort to them and an immeasurable aid in the recovery process. Extending the 

12 week period to 26 weeks under the FMLA would provide the caring family member with the assurance that he or she will not be terminated from reemployment 

during that extended period of care should it be needed. 

REPORT RECOMMENDATION 5—RAPIDLY TRANSFER PATIENT INFORMATION BETWEEN

DOD AND VA. 

The recommendation that DOD and the VA must move quickly to transfer clinical 

and benefit data to users will require interoperability of the AHLTA and VISTA 

electronic recordkeeping systems used by DOD and DVA respectively. Although this 

moment of interoperability is reported by DOD’s contractors to be close at hand, the 

medical needs of our National Guard members have been overlooked with this effort 

that does not require the records of civilian health care providers treating our members to be entered into the DOD AHLTA database. 

Currently, although the technology exists, there is no mandate from DOD to scan 

or otherwise enter hard copies of our National Guard members’ medical records 

from their civilian health care providers into the DOD AHLTA database. Please 

keep in mind that National Guard members in a non deployed status do not receive 

their medical care from Military Treatment Facilities (MTF) but from civilian physicians. Failure to scan National Guard members’ civilian treatment records into the 

AHLTA database will continue to keep military physicians in the dark when treating our members relative to pre existing conditions and medication histories found 

in their civilian medical records. Lack of ready access to this information in emergency treatment situations during deployments puts the National Guard patient at 

risk while being treated by military physicians. 

This recommendation of the Report needs to go further to include the mandatory 

transfer of all non MTF treatment records of our National Guard members into the 

DOD and DVA electronic record systems. If these records were required to be entered into the AHLTA system, then they would also be accessible to the DVA once 

interoperability of the DOD and DVA systems is attained. 

In conclusion, we at NGAUS hope that we have both reinforced and amplified, 

where needed, the recommendations of the Report of the President’s Commissions 

on Care for America’s Returning Wounded Warriors relative to the needs of the National Guard. 

Thank you again for the opportunity to address this Committee and for all that 

you do for our Nation’s veterans. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO COL. 

PETER J. DUFFY, USAR (RET.), DEPUTY DIRECTOR OF LEGISLATIVE AFFAIRS, NATIONAL GUARD ASSOCIATION OF THE UNITED STATES

Dear Chairman Akaka, Ranking Member Burr and Members of the Committee, 

thank you for the opportunity to respond to the following question: 

103 

MENTAL HEALTH CONTRACTING

Question. The Dole-Shalala report very broadly notes that ‘‘Congress should enable all veterans deployed in Afghanistan and Iraq who need PTSD care to receive 

it from VA.’’ While the Dole-Shalala report did not include specifics on this recommendation, your organization believes this should take the form of contracting 

with outside providers. In your view, are there other options, such as bringing on 

more mental health providers and positioning them in communities that would address this concern? 

Response. PTSD among our Reserve Component veteran population has reached 

alarming levels. A JAMA article released November 14, 2007 entitled, ‘‘Longitudinal 

Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning from the Iraq War’’ identified 42 percent of Reserve component veterans of Operation Iraqi Freedom (OIF) and 20.3 percent of active duty personnel 

as requiring mental health treatment based upon their responses to the Post Deployment Health Re-Assessment completed 3–6 months after return from deployment. 

The medical community says that PTSD is treatable but stresses that early recognition and treatment offer the best opportunities for success. Although veterans 

suffering from PTSD can receive 2 years of care from the VA, many face geographical barriers in rural areas that delay and even frustrate their efforts to obtain 

the same. In serious cases of PTSD, this delay can prove fatal. The most desirable 

option for successfully treating veterans suffering from PTSD is the supplemental 

mental health contracting afforded by S. 38 that would allow veterans under the 

auspices of the VA to be treated conveniently and expeditiously in or near their 

communities by qualified mental health care providers within and without the VA. 

According to a roster compiled by the VHA Office of Public Health and Environmental Hazards, 751,273 Operation Enduring Freedom (OEF) and Operation Iraqi 

Freedom (OIF) veterans with out-of-theater dates through May 2007, have left active duty and have become eligible for VA health care. According to the subject roster, 389,036 of these new veterans (52 percent) are from the ranks of our Reserves 

and National Guard while 362,237 (48 percent) are from the ranks of our active 

forces. 

Applying the percentages from the JAMA study, 42 percent of the population of 

389,036 OIF and OEF Reserve Component veterans (163,395) and 20.3 percent of 

the population of 362,237 OIF and OEF active duty veterans (73,737) are arguably 

requiring or have required mental health treatment from the VA through May 2007. 

The treatment needs of this growing new veteran group and the mental health care 

needs of the pre-2002 veteran population have overwhelmed mental health care facilities of the VA. They will continue to do so unless all mental health care providers 

in the country can be engaged in treating our veteran population. 

The need for the rapid delivery of mental health care in the widely scattered communities of our surging veteran population is urgent. Unfortunately, the VA does 

not and will not have that capability without mobilizing all mental health providers 

in every community with a nearby veteran population. Because it is impractical for 

the VA to hire all mental health providers or to build clinics in every community, 

the solution must lie in authorizing the VA to contract, when necessary, with mental health care providers in remote areas having a veteran population in need of 

mental health care. This is what S. 38 would provide for veterans and their families. 

S. 38 is modeled after similar programs operating in Montana, Washington and 

South Dakota where the VA has been contracting successfully with Community 

Mental Health Centers in delivering behavioral health care to our members in those 

expanded geographically areas. Because the mental health contracting program has 

been proven effective, it should be made available to all areas of the country where 

it is needed. The pilot program proposed by S. 2162 is appreciated but it will only 

serve to delay nationwide implementation of a necessary program that has already 

been successfully piloted. 

Please note that S. 38 already builds into its matrix the features of the proposed 

pilot program of S. 2162. If the civilian provider effectively addresses the needs of 

our members, the VA will continue to use that provider, but only as long as the 

need persists. Any decision to contract with outside mental health care providers 

would be driven by need recognized by the VA. Each regional VA facility would be 

able to evaluate the effectiveness of any contracted behavioral care provider. The 

VA would retain oversight and control of the process. 

Five years into this war, the geographically dispersed behavioral needs of our 

members and families are not being met by the VA. Those needs cannot endure another pilot program in ten regions. Veterans in rural areas outside the pilot areas 

would still be neglected. Denying those veterans and their families outside of the 

104 

ten pilot regions the same treatment options as those within the ten regions is neglectful and unfair. Moreover, without participation across the country, information 

on the availability of the pilot programs will be difficult to disseminate. For the VA 

to claim that it alone can address these needs in house is admirable, but ultimately 

neglectful of our veterans’ mental health needs. 

The question may arise within the Committee that if the contracting programs 

in Montana, Washington and South Dakota have worked work so well, why have 

they been they limited to those states? The answer to that question lies in the reluctance of the VA to contract with local care providers, not in the lack of quality care 

available in the civilian community. The Committee should recall the testimony of 

Tammy Duckworth on this point. 

This Committee heard testimony from witnesses on November 6 about the difficulty the VA has had in finding qualified physicians in the remote area of Marion, 

Illinois. Ms. Duckworth, Director of the Illinois Department of Veterans’ Affairs, testified about a lack of health care consistency across the VA especially in rural communities. She criticized the reluctance of the VA to access local physicians despite 

having the authority to do so. S. 38 would send a clear message that it may be necessary for the VA to care for the behavioral needs of our veterans by contracting 

with mental health care providers in the civilian community. 

Contracting with local health care providers will not toll the death knell for the 

VA. S. 38 does not seek to tear down the brick and mortar of the VA but to offer 

an affordable and viable alternative in addressing the historical surge of PTSD 

cases in our veteran population. Using civilian providers in remote areas when necessary will save the VA the costs of hiring staff and acquiring space in remote areas 

not otherwise having a large veteran population. 

Using local civilian providers when necessary would also give the veteran consumer a closer and more immediate choice once he or she overcomes the reluctance 

to recognize the need for treatment. That reluctance, once overcome, could return 

to the detriment of the veteran if time and distance barriers delay treatment. A distant VA facility might also require the veteran and family members to take time 

off from work which would only further stress an employment relationship already 

stressed by a previous deployment. Local treatment would avoid leaving the veteran 

and family member the choice of distant treatment for a poorly understood illness 

or continued employment. It is in the best interest of the veteran to remove the time 

and distance barriers to make mental health treatment as convenient as possible. 

It is important to reemphasize that S. 38 does not require the DVA to contract 

with civilian providers. It only authorizes the VA to do so with the force of a statute 

that breaks internal and perhaps regional adhesions that are blocking innovation 

and response in this crisis. 

The downside risk posed by S. 38 is minimal. PTSD is not unique to the military. 

Licensed civilian psychiatrists are fully capable of recognizing and treating PTSD 

without having to enter an employment relationship with the VA to do so. To require them to be employed with the VA as a condition to treat our veterans at government expense would waste a needed capability. 

There is a sense that the VA and some veteran support organizations are pushing 

back against this legislation out of fear that it would diminish the VA when the contrary would be true. S. 38 would expand the outreach of the VA throughout a state 

in a qualitative and cost-effective manner that would inure to the benefit of our veterans and their families. Insistence on the VA’s paternal model of delivering health 

care, although very effective in most cases, should yield, in this instance, to the behavioral health care needs of our veterans and families who need the geographical 

outreach in mental health treatment that S. 38 would provide. 

NGAUS is and will remain a staunch supporter of the Department of Veterans 

Affairs (DVA). The DVA is and will remain the backbone of service and benefits to 

our veterans. NGAUS is committed to a robust DVA that would only be made more 

robust by authorizing it to engage all available behavioral health care providers 

within and without DVA to enable it to provide the necessary surge capacity in 

meeting the burgeoning behavioral health care needs of our veterans and their families. 

Chairman AKAKA. Thank you very much, Colonel Duffy. 

Mr. Manar? 

105 

STATEMENT OF GERALD T. MANAR, DEPUTY DIRECTOR, NATIONAL VETERANS SERVICE, VETERANS OF FOREIGN WARS 

OF THE UNITED STATES, ON BEHALF OF THE MEMBERS OF 

THE INDEPENDENT BUDGET 

Mr. MANAR. Mr. Chairman and Members of the Committee, 

thank you for the opportunity to speak with you about transition 

issues affecting the men and women who serve our Nation with 

perseverance, courage, and honor. 

For more than 20 years, the members of the Independent Budget—AMVETS, Paralyzed Veterans of America, the Disabled American Veterans, and the Veterans of Foreign Wars—have annually 

assessed the state of the VA and made recommendations to Congress, which would, if adopted, better help the Department of Veterans Affairs help veterans. Interestingly, in recent years, many of 

our recommendations on the VA budget, health care, construction, 

and other issues have been closer to VA’s actual needs than were 

reflected in the budgets submitted to Congress. We are not new to 

this work. Our organizations have been working with and serving 

America’s veterans for more than 100 years. 

With this as background, I would like to take a few minutes to 

discuss the recommendations of the President’s Commission on 

Care for America’s Returning Wounded Warriors, and in contrast, 

the recommendations of the Veterans Disability Benefits Commission. 

The President’s Commission was created in March 2007 and 

ended its work in July 2007. They did a significant amount of work 

in a little over 4 months. Where they were strongest was in those 

areas of their principal interest—care for injured servicemembers 

at the end of their military service and their transition from active 

duty to civilian life. Where they were weakest, in our view, is in 

the area of reforming the VA compensation program. 

Our written testimony outlines in great detail those transition 

recommendations we believe are most effective, and most likely to 

help disabled servicemembers. We would like to use our short time 

this morning discussing some of the problems we note with the 

President’s Commission and the alternatives provided by the Disability Commission. 

The President’s Commission recommends creation of a two-tiered 

system of benefits, one for combat veterans and one for all other 

veterans. We find this an unacceptable distinction, one which is not 

supported in history, law, or the veteran community. 

We are all veterans equally. This is not a new concept. The Bradley Commission adopted a guiding principle in April 1956, which 

said, in part, that providing compensation on a uniform basis to 

people with equal handicaps is the best possible way to discharge 

our obligation to them. Fair and equal treatment of all veterans, 

disabled and non-disabled, according to their service-connected 

needs should be the guiding principle in all our programs. 

The Veterans Disability Benefits Commission, in their Guiding 

Principle Three, stated that compensation must be based on severity of disability and not where or how it was incurred, and Congress, no less, supports this principle since it eliminated separate 

compensation for disabilities incurred in combat with legislation in 

1972. 

106 

This does not mean that distinctions cannot be made among veterans. In fact, the opposite is true, and this is a theme that runs 

through the Disability Commission report—that the more seriously 

disabled a veteran is, the more treatment, support, and benefits he 

or she should receive. 

The President’s Commission recommends the creation of transition payments, and with this we concur—not necessarily in the 

form that they propose, but rather as a separate benefit, totally unrelated to compensation. All of us in this room who are veterans 

have had the opportunity to be released from active duty, and after 

the first joy of the moment has passed, we wonder what we are 

going to do. Now, some of us have planned ahead and we have 

lined up jobs, but many veterans come home, they take a break, 

and then they start looking for work. 

There is every reason to support a recommendation that Congress create a specific transition benefit, unrelated to compensation. The idea that was proposed by the President’s Commission to 

have a transition benefit for 3 months in lieu of compensation from 

VA for service-connected disabilities is unacceptable to us; but a 

transition benefit focused on helping bridge the few months following service is certainly within the realm of our support. 

In addition, the President’s Commission, their proposals, if 

adopted, would require a new rating schedule—a new rating schedule which, in their view, could be done in 6 months. I submit to 

you that I could sit down and in a matter of a week or two come 

up with a new rating schedule. That doesn’t necessarily mean that 

it is better, it would simply be different. 

The Veterans Disability Benefits Commission, on the other hand, 

has provided in their report an ordered and deliberate process for 

evolving and reforming the ratings schedule that the VA currently 

uses, and we commend their recommendations for your consideration. 

In addition, the President’s Commission would, under their new 

separate program for compensating our future veterans, create a 

new rate schedule. It is totally devoid of any suggestion of what 

this rate schedule would look like or how it would be made up. 

Finally, there are so many other things that the VA does, and 

should be looked at from time to time, that the President’s Commission has not even addressed. For instance, the Veterans Disability Benefits Commission, with the help of the Institute of Medicine, has come up with a plan, a scheme, for regularizing, if you 

will, the designation of disabilities that are presumptively related 

to service. Although we don’t agree with the entire proposal, the 

point is that they come up with a process for reform, for evolving 

into something which is better than what currently exists, and that 

is what we support. 

If we adopt—if you adopt—the President’s Commission’s recommendation to create a second separate disability compensation 

program, what you are forcing the VA to do is to run two disability 

compensation programs for at least the next 70 years. Imagine 

that, two separate programs with a workforce either required on an 

individual basis to master both programs or to separate the workforce to deal with both. This is an unnecessary imposition on the 

VA and on America’s veterans. 

107 

1http://icasualties.org/oif/; October 12, 2007. 

I would like to leave you with this thought. The President’s Commission served 41⁄2 months to arrive at their recommendations. In 

our view, nearly all of the recommendations dealing with VA compensation are mere bullets. They are hollow. They lack substance 

and definition. If their program is simple, it is because the things 

that make a compensation program work have not been added to 

it yet. 

On the other hand, the Veterans Commission served, studied, argued, and decided everything in public for 30 months. They did the 

heavy lifting necessary to support their recommendations with substance and process. Its report has been described today as 600 

pages of band-aids. Well, this 544-page document lays a solid foundation and a clear path forward for reform of the VA compensation 

program. We do not agree with all the recommendations, but we 

can say, conclusively, that we agree with the framework that they 

have laid down to effect change in an ordered, evolutionary way. 

Thank you for your time this afternoon and I will take questions 

when you have them. 

[The prepared statement of Mr. Manar follows:] 

PREPARED STATEMENT OF GERALD T. MANAR, DEPUTY DIRECTOR, NATIONAL

VETERANS SERVICE, VETERANS OF FOREIGN WARS OF THE U.S. 

Thank you for this opportunity to provide the views of the members of the Independent Budget—AMVETS, Disabled American Veterans, Paralyzed Veterans of 

America and the Veterans of Foreign Wars of the United States—on VA and DOD 

collaboration, the Report of the President’s Commission on Care For America’s Returning Wounded Warriors, the Report of the Veterans Disability Benefit Commission and other related reports. 

It seems that every few years another study is commissioned to examine some of 

the problems involving benefits and delivery of benefits available to service disabled 

veterans. With the Veterans Disability Benefits Commission (VDBC), a pattern has 

emerged that our Nation requires a more comprehensive review every 50 years or 

so to help us all refocus on the entire system of benefits, note the things that are 

working well and devise solutions to those that no longer fully address the needs 

of the men and women who stood ready in both peace and war to defend our Nation, 

even at the possible cost to themselves of disability or death. 

Six years after terrorists attacked us on American soil, we remain deeply embroiled in armed conflict in both Iraq and Afghanistan. Over 3,800 men and women 

have been killed and nearly 28,000 wounded. Another 29,000 were treated for diseases and injuries not arising from combat, disabilities so debilitating that they required air transport from the region in order to receive appropriate medical treatment.1 There is no accounting for the thousands of other service men and women 

who were treated and returned to duty in that troubled region of the world. 

Thousands of soldiers, Marines, sailors and airmen have returned home with catastrophic injuries. It was their difficulty in obtaining treatment, proper housing, adequate benefits and services, as well as basic help in the transition from military 

service to civilian life that caught our attention earlier this year. What was most 

disturbing was that the problems coming to light in 2007, while perhaps exacerbated by the current conflict, have existed to some extent for decades. The Presidents Commission on Care for America’s Returning Wounded Warriors (PCCWW), 

created in March 2007 and reporting 4 months later, examined how the Armed 

Services treat those with serious injuries and help them through discharge from 

service and transfer to the Department of Veterans Affairs. 

While this testimony will focus primarily on the recommendations of the PCCWW 

and VDBC on transition issues, we will also address the recommendations of both 

commissions on benefits provided by the Department of Veterans Affairs for disabilities arising while performing military service. 

You have before you enough ideas, suggestions and recommendations to create another title in the U.S. Code and keep regulation writers at both the Department of 

Defense and the Department of Veterans Affairs busy for the next 10 years. It is 

108 

little wonder that you have asked those of us at this table to help you parse the 

cornucopia of proposals and make coherent the competing voices. 

There are many good things presented in these reports: some are simple, others 

complex beyond imagination. Some will help DOD and VA help service men, women 

and veterans while others would create more problems. Some are inexpensive while 

others will place additional burdens on the Treasury. 

We offer you our views, not to make your task easier, but rather, to help make 

the correct path more visible. 

THEY ARE ALL VETERANS EQUALLY

One of the Guiding Principals adopted by the VDBC was that benefits should be 

awarded based on the severity of the service-connected disability and not on the circumstance under which it was acquired. This principle is not new. At one time VA 

paid higher benefits to veterans with service connected disabilities incurred in combat. However, Congress recognized the inequity of paying veterans with identical 

disabilities different amounts of compensation solely because one received his injury 

in combat and the other did not; as a consequence, Congress equalized the rates for 

all veterans in 1972. 

The Veteran Service Organizations we represent today endorse the current government policy and completely reject the notion that injuries acquired in combat are 

any more disabling, any more worthy of compensation, than those incurred elsewhere in service to our country. We agree with the VDBC that benefits should be 

based only on the severity of disability. 

TRANSITION

Care for seriously disabled servicemembers.—We support the PCCWW recommendations which would: 

• Develop integrated care teams 

• Create individualized recovery plans 

• Develop and assign Recovery Coordinators 

• However, we oppose the idea that Recovery Coordinators should be Public 

Health Service employees. We believe that properly trained VA employees, with substantial support from both DOD and VA, can be effective in supporting seriously disabled servicemembers and veterans. 

We believe that these services should be provided to all seriously disabled servicemembers regardless of where their disabilities were acquired. A soldier paralyzed 

from the neck down from an accident in Germany or Korea is no less deserving of 

these services than is someone who was paralyzed by an IED in Iraq. 

Transfer of patient information across systems.—We support the PCCWW recommendations that would: 

• Make patient information available to all personnel who need it 

• Continue efforts for a fully interoperable information system between DOD and 

VA 

• Provide internet access to personal treatment records and health care information through secure Web sites for servicemembers and veterans. 

Strengthen support for families of seriously disabled servicemembers and veterans.—We support the PCCWW recommendations that would: 

• Expand eligibility for TRICARE respite care and aid and attendance 

• Expand caregiver training for families 

• Cover family members under the Family Medical Leave Act (FMLA) 

• However, TRICARE, caregiver training and expanded coverage under the 

FMLA should be available to all seriously disabled servicemembers and not just 

OIF/OEF servicemembers. 

Improve care for servicemembers with Post Traumatic Stress Disorder (PTSD) 

and Traumatic Brain Injury (TBI).—We support the PCCWW recommendations that 

would: 

• Address the shortage of mental health professionals in both DOD and VA 

• Establish and expand networks of experts in PTSD and TBI 

• Improve dissemination of clinical practice guidelines 

• Increase availability of treatment for PTSD for Iraq and Afghanistan veterans 

from the VA 

• While we support increased availability of mental health providers through the 

VA for veterans suffering from PTSD, the PCCWW recommendation that ‘‘all Iraqi 

and Afghanistan veterans who need PTSD care [should] receive it from VA’’ is problematic. First, all veterans who are discharged today may receive free treatment for 

109 

virtually any problem within 2 years of discharge. In addition, this recommendation 

would allow any new veteran, regardless of the source of PTSD (e.g. pre-service car 

wreck) to move ahead of veterans with service related PTSD. Further, we are already receiving complaints from older veterans who believe that they are being 

forced to wait longer for appointments because of priorities given to newer veterans. 

We believe the better approach would be to vastly increase the numbers of mental 

health professionals at VA to provide better and timelier service to all veterans with 

PTSD. While increasing mental health staff, VA should use its fee-basis authority 

whenever old or young veterans must receive care immediately. 

Finally, VA should improve its ability to triage veterans with mental health symptoms to ensure that those who might be a danger to themselves or others are seen 

immediately and by an appropriate professional. 

Again, we believe that every disabled servicemember should be eligible for every 

benefit and service required by the severity of the disability they have and not by 

the place or circumstance under which it was incurred. 

Enhance the Joint Executive Council (JEC).—We support the recommendation of 

the VDBC to: 

• Develop a strategic plan with specific milestones 

• Designate lead officials responsible for each milestone 

• Include DOL and SSA in the JEC 

VA and DOD should develop a joint intensive case management program for severely disabled veterans with an identifiable lead agent.—We support the recommendation of the VDBC. 

Congress should adequately fund and mandate the Transition Assistance program 

DOD-wide.—We support the recommendation of the VDBC. 

Benefits Delivery at Discharge (BDD) should be available to all disabled servicemembers including Guard, Reserve and medical hold patients.—We support the recommendation of the VDBC. 

DOD should mandate separation examinations for all servicemembers; the examination should conform with VA protocols and directives.—We support the recommendations of the VDBC. 

DOD should provide TRICARE free of charge for severely injured servicemembers 

and their families.—We support the recommendation of the VDBC. 

We commend the other recommendations from the VDBC dealing with transition 

issues to you for consideration. 

POST SERVICE TRANSITION

Both the PCCWW and the VDBC understand the need to ensure that services and 

benefits do not stop as disabled servicemembers make the transition to civilian life. 

Too often, the only ‘‘transition’’ disabled servicemembers received was a Transition 

Assistance Program briefing or a bit of counseling from the VA or a veteran service 

officer at a BDD site. The recommendations discussed earlier, if adopted, should 

make the transition process much better for disabled servicemembers. 

However, most veterans are not seriously disabled at discharge and are not processed through the Disability Evaluation System. While they know what their education benefit eligibility might be, they have little knowledge of vocational rehabilitation, home loan guarantees and the like from VA. 

Vocational rehabilitation.—Both the PCCWW and the VDBC recommended 

changes in vocational rehabilitation which, in our view, should be seriously considered for implementation. 

• Veterans with service connected disabilities causing employment handicaps 

should be encouraged to undertake and complete training that will help them find 

not just gainful employment but a career for life. 

• Further, vocational rehabilitation should not be a one-time benefit. Disabilities 

often worsen throughout life and some veterans may need vocational rehabilitation 

services a second time. Helping a disabled veteran remain productively employed 

should be a goal of VA. We believe that a disabled veteran should be able to utilize 

vocational rehabilitation more than once. 

• Vocational rehabilitation subsistence allowance rates are inadequate to support 

veterans as they obtain the training needed to help them adjust to the employment 

handicap caused by their service-connected disabilities. We support increases in subsistence allowance rates. 

Transition payments.—As the claims backlogs have increased at the VA, it seems 

that a growing number of people, including some Members of Congress, have voiced 

the opinion that these veterans should not be made to wait for VA to decide their 

claims for benefits. Their greatest concern has been for the recently discharged vetVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00113 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
110 

2Public Law 108–136, Section 1502. See also, http://www.vetscommission.org/index.asp. 

Charter. 

eran who often has little income, perhaps some disability and no job. In the last 

year, some have even suggested that VA should simply pay the veteran whatever 

it is they claim. 

We oppose the use of the disability compensation program to pay what amounts 

to a transition benefit or bonus. We do, however, support the idea of a transition 

payment independent of VA compensation. We urge Congress to consider creating 

such a payment, a form of deferred compensation, independent and separate from 

VA compensation, to help men and women during the initial few months following 

their discharge from service. 

REENGINEERING VA DISABILITY COMPENSATION—REVOLUTION OR EVOLUTION?

In 2004 the Congress enacted legislation creating the Veterans Disability Benefits 

Commission: 

‘‘The purpose of the Veterans’ Disability Benefits Commission is to carry 

out a study of the benefits under the laws of the United States that are 

provided to compensate and assist veterans and their survivors for disabilities and deaths attributable to military service, and to produce a report on 

the study.’’ 2

The first few meetings of the Veterans Disability Benefits Commission (VDBC) 

(starting in May 2005) were met with skepticism and wariness by some of us in the 

veteran community. We were well aware of the forces which led to the creation of 

that commission and were deeply concerned that at least some Commissioners harbored secret agendas which, if adopted, would lead to the dismantling of programs 

designed to help treat and compensate veterans for the residuals of disabilities incurred or aggravated while in service to our country. 

During the 28 public sessions spanning 55 days of public hearings, it became apparent that Commissioners were willing to work hard to learn about compensation 

benefits: what they are; how the program evolved to where it is today; and what 

problems exist. Further, we were gratified to note that Commissioners were willing 

to reconsider their opinions as facts were brought to light by the Center for Naval 

Analyses and the Institute of Medicine. We watched extensive fact gathering and 

more extensive debates on issues that were critical to the establishment of a foundation for later decisions. 

While we have disagreed with some decisions made by the commission we could 

tell the veterans we represent that the commission was well on the way to producing a thoughtful and constructive report which addressed many problems without harming veterans. 

A few weeks ago the VDBC released its final report. Of the commission’s 114 recommendations, fully 83 percent deal with compensation benefits or factors related 

to compensation benefits. Even when the commission drifted a little afield and made 

recommendations dealing with transition issues, it is clear that most deal with ensuring that VA has the information it needs as soon as possible to process claims 

from veterans. 

The President’s Commission on Care for America’s Returning Wounded Warriors, 

on the other hand, was created in March 2007 and delivered its report less than 

four and a half months later. It produced 24 recommendations; 8 of the 24 recommendations were focused on discarding the current compensation program and 

substituting a new program requiring a new rating schedule, new rates for disability benefits, new theories of what could be service connected, how long compensation payments would continue and so on. 

While there are a few ideas presented by the PCCWW that may have merit, the 

discussion, below, describes those that are most objectionable. 

• Two-tiered system.—The PCCWW recommends the creation of a two-tiered system of compensation for service connected disabilities, one for combat injured veterans and one for all others. Under their proposal, combat injured veterans would 

be eligible for quality of life payments while those not injured in combat would be 

denied. This means the paralyzed veterans mentioned earlier in this paper would 

receive substantially disparate compensation even though their quality of life would 

be the same. 

• Delay of compensation.—The PCCWW would delay compensation benefits for a 

minimum of 3 months and possibly for years while the veteran receives ‘‘transition’’ 

payments. In our view, it is for Congress to decide whether newly discharged veterans should be granted a transition benefit for a short period following service. 

111 

3PCCWW Report, pg. 109. 

4 38 U.S.C. 1155. 

Since the transition benefit is not based on disability but would be, in fact, available 

to all new veterans, it should not replace compensation paid for disability incurred 

or aggravated while in military service. If Congress agrees that vocational rehabilitation rates are too low and do not encourage veterans to remain in vocational rehabilitation, then it should raise those rates to appropriate levels. 

• Average impairment of earnings capacity.—In its report, the PCCWW says that: 

‘‘Congress has directed that the VA disability compensation system should 

replace lost civilian earnings.’’ 3

What the law actually says is: 

‘‘The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations.’’ 4

The seemingly subtle difference between ‘‘earnings’’ and ‘‘average impairment of 

earning capacity’’ is significant. We commend to you the discussion in the VDBC report on this topic. We can say, however, that this focus on earnings rather than average impairment of earning capacity opens the door for some of the draconian recommendations by the PCCWW discussed below. What the commission recommends 

is nothing short of throwing out a compensation program, designed, refined and 

tested over 70 years to pay disabled veterans based on the average impairment of 

earnings capacity to one based solely on loss of earnings. This, in turn, opens the 

door for means testing, taxing and curtailing compensation. • Means testing compensation.—The PCCWW would substitute a payment 

scheme that is means tested in place of the current compensation program 

(‘‘. . . the amount would be recalculated periodically as veterans’ condition or earnings change.’’ Figure 11) (‘‘. . . once transition payments end, disabled veterans 

should receive earnings-loss payments—to make up for any lower earning capacity 

remaining after training.’’ Draft, page 6). This means that veterans with identical 

disabilities would receive different benefits or, in some cases, no compensation at 

all. The commission suggests that the DOD disability annuity payment, as well as 

the quality of life payment, would continue for life. However, only about 10 percent 

of all veterans (those discharged through the DES) would receive the annuity. While 

not all veterans have service-connected disabilities for which they receive compensation, a significant percentage of those receiving compensation today would not be 

eligible for the annuity. 

Further, since the PCCWW proposes that only combat injured veterans would be 

potentially eligible for quality of life payments, those non-combat injured veterans 

no longer eligible for compensation because of means testing would receive nothing 

at all. 

• Taxing compensation.—The PCCWW would tax disability compensation payments to veterans. In a word, we find this proposal to be outrageous. We are speaking of men and women who sacrificed not only their time and energy in defense of 

our Nation but who continue to suffer from the residuals of injury or disease incurred during that service. Under this proposal, veterans would be taxed to marginally mitigate a reduction of their benefits when they can no longer work. Outrageous. 

• Termination at retirement.—The PCCWW proposes the termination of compensation benefits at ‘‘retirement’’ to be followed by Social Security. A recent article 

in the Washington Post showed that more people work past ‘‘retirement’’ than ever 

before; and the trend is increasing. Further, a Center for Naval Analysis study conducted for the VDBC shows that current compensation rates generally replace lost 

earnings if paid over a veteran’s lifetime. If the PCCWW recommendation is adopted, veterans will not have earnings replaced by compensation prior to ‘‘retirement’’ 

unless compensation rates are substantially increased. 

• Abuse of reexamination process.—The PCCWW recommends that veterans be 

recalled for examination every 3 years throughout their lifetime to determine whether their disability has worsened or improved. VA already has the authority to reexamine veterans whose disabilities could improve. This authority has existed for 

many decades. If it is not often used now it is more a function of VA trying to manage its workload by reducing review examinations in the face of extremely high 

backlogs than it is anything else. 

Further, this proposal is a transparent attempt to not just identify those individuals whose disabilities may improve over time but to harass those veterans whose 

disabilities are static. And since failure to report for an examination is a basis for 

112 

terminating compensation, this practice would, if adopted, result in the termination 

of benefits to many veterans whose disabilities are either static or worsened primarily because they do not always notify the VA when they move. 

For these reasons, and others, we strenuously object to the proposals by the 

PCCWW to throw out the current compensation program and put in its place a program which will be harmful to the vast number of men and women who have volunteered to serve our Nation, and who are fighting even now in Iraq and Afghanistan. 

The Veterans Disability Benefits Commission has exhaustively examined the current compensation program, affirmed its strengths and pushed forward many 

thoughtful and constructive recommendations for evolving it into a mechanism to 

better serve America’s new generations of veterans. Their approach is to retain the 

best parts of the disability compensation program and create a process for measured 

and deliberate reform and improvement. We urge you to carefully consider their recommendations. 

We trust that this is the first of several hearings on these reports and other proposals affecting the transition of servicemembers from warrior to respected veteran. 

We appreciate the opportunity you have afforded us today. 

I will be happy to answer any questions you may have for me. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO GERALD

T. MANAR, DEPUTY DIRECTOR, NATIONAL VETERANS SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED STATES, ON BEHALF OF THE MEMBERS OF THE INDEPENDENT BUDGET

EASY ACCESS TO CARE

Question. The Dole-Shalala Commission recommends that veterans with PTSD 

have immediate access to VA evaluations and treatment. You noted in your testimony that such an opportunity does, in fact, exist now in the two year window of 

easy access to VA care and treatment following release from active duty. In your 

view, how well is this two-year authority working? 

Response. According to VA, by the end of FY 2007 nearly 800,000 OIF and OEF 

veterans left active duty and became eligible for VA health care since FY 2002. 

Nearly 300,000 (37 percent) of those veterans obtained VA health care since their 

discharge. Further, slightly more than 120,000 veterans (40.1 percent of those seeking treatment) were seen for complaints of a mental disorder. Finally, half of those 

seen for mental health issues were diagnosed with PTSD. 

Clearly, OIF and OEF veterans know that health care is readily available from 

VA as demonstrated by the 37 percent who obtain it. Further, they know that they 

can receive free health care for virtually any condition without the need to demonstrate a connection with their military service. 

While some observers may be concerned that more OIF/OEF veterans have not 

sought treatment from VA, we must be mindful of the fact that most of these men 

and women are in the prime of their lives when it is significantly less likely that 

they will have medical or psychological conditions requiring treatment. 

We believe that the current law opening up VA health care to all OIF/OEF veterans for 5 years following discharge is working and no additional legislation will 

likely result in greater participation by these men and women. 

If Congress is concerned that this group of veterans is underutilizing VA health 

care opportunities, it could provide an increase in funds for advertising and outreach. 

Chairman AKAKA. Thank you very much, Mr. Manar. 

Ms. Beck? 

STATEMENT OF MEREDITH BECK, NATIONAL POLICY 

DIRECTOR, WOUNDED WARRIOR PROJECT (WWP) 

Ms. BECK. Thank you, sir. Mr. Chairman, thank you for the opportunity to testify today regarding the various reports, commissions, and task forces completed to date addressing the needs of 

our Nation’s wounded servicemembers. The Wounded Warrior 

Project has direct daily contact with these wounded warriors and 

we have a unique perspective on their needs and the obstacles they 

face as they attempt to reintegrate into their communities. With reVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00116 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
113 

spect to the reform of the Disability Evaluation System, the 

Wounded Warrior Project strongly supports the spirit and intent 

for which the Dole-Shalala and the Veterans Disability Benefits 

Commissions were established. WWP agrees with the finding of 

both reports that the current benefits system places too little emphasis on veterans’ recovery, rehabilitation, and reintegration into 

the community. For those who are able, incentives to participate in 

vocational rehabilitation programs, educational opportunities, and 

reintegration to the workforce could lead to a better, healthier life. 

In addition, under the current system, individual unemployability 

ratings are necessary for some, but others are often burdened at a 

young age to choose between potentially beneficial vocational experience and needed compensation. 

Periodic evaluation, gradual reduction in compensation rather 

than abrupt termination, and improvements in the compensation 

structure for warriors with PTSD or TBI would result in a more 

effective system that enables wounded warriors to successfully reintegrate to civilian life. WWP believes these principles must be 

taken into consideration during discussions on modernizing the 

current disability compensation system and any significant changes 

should require ultimate Congressional approval. 

WWP also strongly supports removing the Department of Defense from the disability ratings process. DOD and the VA ratings 

systems are currently confusing and overly-burdensome. Currently, 

DOD assesses the veteran’s fitness for duty. Following this determination, the VA performs yet another physical to rate the veteran 

for all service-connected injuries. Unfortunately, these ratings are 

not assigned in a vacuum. Lost records, lack of resources, ineffective training, and inconsistencies in the interpretation of regulations by both agencies are often cited as reasons for the extended 

period of time required to assign a disability rating. A system such 

as that proposed by the Commissions would encourage a more efficient and fair evaluation and remove one of the most frustrating 

aspects of an already difficult process. 

WWP agrees that comprehensive changes are needed within the 

compensation and benefits delivery system. However, we are deeply 

concerned that the inclusion of provisions to overhaul the existing 

veterans disability compensation system in the same package as 

health and transition-related recommendations would be a distraction from these important health proposals. Any legislation implementing compensation-related recommendations must be carefully 

crafted through a thoughtful and deliberate process to ensure the 

most beneficial outcome for those who have sacrificed in service to 

this country. 

However, as many of us recognize, the current disability ratings 

system suffers from significant shortcomings which have become 

more apparent with the passage of time. We must use our passion 

to encourage honest discussion to resolve these issues. 

WWP is very pleased that the Dole-Shalala panel recognized the 

need for education and training of family members. Specifically for 

the family members of those with severe TBI, who often have to 

leave their jobs. WWP also supports payments to caregivers similar 

to those already in place in the San Diego VA Medical Center for 

Spinal Cord Injury patients. This program offers training and 

114 

makes eligible for payment those family members who have become 

certified as personal care attendants. This often removes at least 

part of the financial burden incurred by those with severe injuries. 

WWP also strongly supports the Dole-Shalala recommendation to 

implement a recovery plan that promotes prompt care in, quote, 

‘‘the most appropriate facility.’’ With respect to Traumatic Brain Injury, legislation currently exists to facilitate such a recommendation. Section 203 of the Senate version of H.R. 1538, the Dignified 

Treatment of Wounded Warriors Act, would allow the Secretary of 

the VA to refer patients to non-department facilities if the Secretary is unable to provide the required treatment or, even more 

importantly, when the Secretary determines that such a referral is 

optimal for recovery and rehabilitation. In order to comply with our 

obligation to offer these wounded warriors the best care possible for 

their respective injuries, these facilities must be readily available 

as an option for their care. 

With respect to DOD–VA collaboration, there are still many 

issues to address, but WWP has been very impressed with the level 

of involvement of the leadership of both DOD and VA in the Senior 

Oversight Committee formed to address these issues. As recommended by the Dole-Shalala Commission, the SOC is in the 

process of improving the case management process through the creation of a Recovery Coordinator. However, the Recovery Coordinator can only be successful if he or she has the authority to break 

through the current barriers within both agencies. 

Part of that authority would have to include the overlap of benefits and services about which WWP and other organizations have 

previously testified and which is included in the Senate version of 

H.R. 1538, as well. An overlap would allow the Recovery Coordinator to access DOD and VA systems necessary to ensure the proper care and rehabilitation of severely injured servicemembers. Each 

agency has its own strengths. Why would we base their access to 

care on the status of the servicemember as active duty or retired, 

rather than on his medical condition? 

The skills and previous experience of the Recovery Coordinator 

are extremely important to their success. In the past, both agencies 

have based their hiring criteria for similar positions solely on education level. WWP is concerned that the agencies will once again 

rely on education level alone and exclude eminently qualified candidates with good problem-solving skills and institutional knowledge. 

It is not only DOD and VA who need to cooperate more fully or 

collaborate more fully. Others, such as the Social Security Administration, Medicare, and the Department of Labor and private entities need to be included more fully in these discussions. For example, an injured servicemember recently contacted WWP because he 

was understandably confused. He had been rated as unemployable 

by the VA, but was told he did not qualify for Social Security disability benefits because he was able to work. Additionally, the Social Security Administration has had a difficult time accessing 

DOD records necessary to evaluate his claim. These agencies must 

work together to resolve inconsistencies in their policies, or the 

often-stated goal of seamless transition will never be achieved. 

115 

Finally, it is imperative that a joint permanent structure be in 

place to evaluate changes, monitor systems, and make further recommendations for process improvement. This office must be structured to minimize bureaucracy and must have a clearly defined 

mission with the appropriate authority to make necessary changes 

or recommendations as warranted. With the passage of time, as 

veterans’ issues fade from the national spotlight, it will be necessary to have that joint structure in place to ensure the future 

agency coordination. 

Thank you, and I look forward to your questions. 

[The prepared statement of Ms. Beck follows:] 

PREPARED STATEMENT OF MEREDITH BECK, NATIONAL POLICY DIRECTOR, THE

WOUNDED WARRIOR PROJECT (WWP) 

Mr. Chairman, Senator Burr, Members of the Committee, thank you for the opportunity to testify today regarding the various reports, commissions, and task 

forces completed to date addressing the needs of our Nation’s wounded servicemembers. My name is Meredith Beck, and I am the National Policy Director for the 

Wounded Warrior Project (WWP), a non-profit, non-partisan organization dedicated 

to assisting the men and women of the U.S. Armed Forces who have been injured 

during the current conflicts around the world. As a result of our direct, daily contact 

with these wounded warriors, we have a unique perspective on their needs and the 

obstacles they face as they attempt to reintegrate into communities across America. 

Due to the broad range of topics covered by this hearing, I would like to limit my 

comments to those that WWP finds most pressing. 

COMMISSION REPORTS: 

With respect to the reform of the disability evaluation system, the Wounded Warrior Project strongly supports the spirit and intent for which the Dole-Shalala and 

Veterans Disability Benefits Commissions were established. WWP agrees with the 

finding of both reports that the current benefits system places too little emphasis 

on veterans’ recovery, rehabilitation, and reintegration into the community. For 

those who are able, incentives to participate in Vocational Rehabilitation programs, 

educational opportunities, and reintegration into the workforce could lead to a better, healthier life. In addition, under the current system, Individual Unemployability ratings are necessary for some, but others are often burdened at a young age 

to choose between a potentially beneficial vocational experience and needed compensation. Periodic evaluation; gradual reduction in compensation rather than abrupt termination; and improvements in the compensation structure for warriors 

with Post Traumatic Stress Disorder (PTSD) or Traumatic Brain Injury (TBI) would 

result in a more effective system that enables wounded warriors to successfully reintegrate to civilian life. WWP believes these principles must be taken into consideration during discussions on modernizing the current disability compensation system. 

Any significant changes should require ultimate Congressional approval. 

WWP also strongly supports removing the Department of Defense (DOD) from the 

disability rating process. DOD and the Department of Veterans Affairs rating systems are currently confusing and overly burdensome. Currently, the Department of 

Defense assesses a servicemember’s fitness for duty and then assigns a rating based 

on the injury that made him/her unfit. Following this determination, the Department of Veterans Affairs performs yet another physical examination to rate the veteran for all service-connected injuries, and, depending on the rating level, the veteran could then become eligible for a myriad of benefits. Unfortunately, ratings are 

not assigned in a vacuum—lost records, lack of resources, ineffective training, and 

inconsistencies in the interpretation of regulations by both agencies are often cited 

as reasons for the extended period of time required to assign a disability rating. A 

system such as the ones proposed by the Commissions would encourage a more efficient and fair evaluation and remove one of the most frustrating aspects of an already difficult process. 

WWP would like to make another recommendation. A servicemember should not 

be retired until he or she has a VA rating in place. This would prevent severely 

injured servicemembers from experiencing a long gap between their military retirement and eventual receipt of VA compensation. Additionally, as DOD would be responsible for paying servicemembers until their retirement, DOD would be encouraged to quickly share medical records to expedite the process. 

116 

WWP believes that a comprehensive review of the disability compensation and 

benefits delivery system is needed. However, we are deeply concerned that the inclusion of provisions to overhaul the existing veterans’ disability compensation system 

in the same package as health and transition-related recommendations is an unnecessary distraction from these important health and transition proposals. Any legislation implementing compensation-related recommendations must be carefully crafted 

to ensure the most beneficial outcome for those who have sacrificed in service to this 

country. However, as many of us recognize that the current disability ratings system suffers from significant shortcomings, which have become more apparent with 

the passage of time, we must use our passion to encourage honest discussion to resolve these issues. Veterans deserve a thoughtful and deliberate process for reform 

of the disability compensation system, with appropriate Congressional oversight. 

WWP is very pleased that the Dole-Shalala panel recognized the need for education and training of the family members. Specifically for the family members of 

those with severe TBI who often have to leave their jobs. WWP also supports payments to caregivers similar to those already in place at the San Diego VA Medical 

Center for Spinal Cord Injury patients. This program offers training and makes eligible for payment those family members who become certified as personal care attendants. This often removes at least part of the financial burden incurred by those 

with severe injuries. 

WWP also strongly supports the Dole-Shalala recommendation to implement a recovery plan that promotes ‘‘prompt’’ care in ‘‘the most appropriate facility.’’ With respect to Traumatic Brain Injury, legislation currently exists to facilitate such a recommendation. Section 203 of the Senate version of HR. 1538 would allow the Secretary of the VA to refer patients to non-department facilities if the Secretary is unable to provide the required treatment, OR, even more importantly, for whom the 

Secretary determines that such a referral is optimal for their recovery and rehabilitation. In order to comply with our obligation to offer these wounded warriors the 

best care possible for their respective injuries, these facilities must be readily available as an option for their care. 

DOD/VA COLLABORATION

With respect to DOD/VA collaboration, while there are still many issues to address, WWP has been very impressed with the level of involvement of the leadership 

of both DOD and the VA in the Senior Oversight Committee (SOC), formed to address these issues. As recommended by the Dole-Shalala Commission, the SOC is 

in the process of improving the case management process through the creation of 

a recovery coordinator. However, the recovery coordinator can only be successful if 

he/she has the authority to break through the current barriers within both agencies. 

Part of that authority would have to include the overlap of benefits and services 

about which WWP has previously testified, and which is included in the Senate 

version of H.R. 1538, The Dignified Treatment of Wounded Warriors Act. An overlap 

would allow the recovery coordinator to access DOD and VA systems necessary to 

ensure the proper care and rehabilitation of severely injured servicemembers. Each 

agency has its own strengths. Why base access to care on the status of a servicemember as active duty or retired, rather than on the medical condition? 

The skills and previous experience of the Recovery Coordinator are extremely important to their success. In the past, both agencies have based their hiring criteria 

for similar positions solely on education level. WWP is concerned that the agencies 

will, once again, rely on education level alone and exclude eminently qualified candidates with good problem solving skills and institutional knowledge. 

It is not only DOD and VA who need to collaborate more fully. Others such as 

the Social Security Administration, Medicare, the Department of Labor, and private 

entities need to be included in these discussions. For example, an injured servicemember recently contacted WWP because he was understandably confused. He had 

been rated as unemployable by the VA, but was told he did not qualify for Social 

Security Disability benefits because he was able to work. Additionally, the Social Security Administration had a difficult time accessing DOD records necessary to 

evaluate his claim. These agencies must work together to resolve inconsistencies in 

their policies or the often stated goal of ‘‘seamless transition’’ will never be achieved. 

Finally, it is imperative that a joint, permanent structure be in place to evaluate 

changes, monitor systems, and make further recommendations for process improvement. This office must be structured to minimize bureaucracy and must have a 

clearly defined mission with the appropriate authority to make necessary changes 

or recommendations as warranted. With the passage of time, as veterans issues fade 

from the national spotlight, it will be necessary to have a joint structure in place 

to ensure future agency coordination. 

117 

Mr. Chairman, thank you again for the opportunity to testify before you today, 

and I look forward to answering your questions. 

Chairman AKAKA. Thank you very much, Ms. Beck. 

Now we will hear from Colonel Strobridge. Colonel? 

STATEMENT OF COL. STEVEN P. STROBRIDGE, USAF (RET.), DIRECTOR, GOVERNMENT RELATIONS, MILITARY OFFICERS 

ASSOCIATION OF AMERICA 

Colonel STROBRIDGE. Thank you, Mr. Chairman, Ranking Member Burr, and distinguished Members of the Committee. Thank you 

for this opportunity to present the Military Officers Association’s 

views on the needs of America’s returning warriors. 

I would start by recognizing the tremendous efforts by this Committee and by the Armed Services Committee, as well, to ensure 

that we do the right thing by these veterans. Senior DOD and VA 

leaders also deserve great credit for their unprecedented cooperation in working to address the many serious problems encountered 

by these members and their families. 

As you know, most of the problems aren’t new. They have been 

identified in multiple previous studies. What is different now is the 

degree of leadership involvement and commitment to finding fixes. 

That kind of top-down leadership is the only way to break down 

the barriers of departmental parochialism, and it is gratifying to us 

to see it happening. 

But, we are concerned about ensuring continuity of those efforts 

into next year and beyond, when most of the leaders who have 

been driving those efforts will be departing. Often, a new administration faces a lag in installing new leaders and many new appointees face a significant learning curve. That raises the potential 

for the change process to lose momentum during the transition. For 

that reason, the continuing leadership and oversight of this Committee will be crucial to sustaining long-term success. 

The Committee has seen the findings of all the various study 

groups on the wounded warrior issues and MOAA thinks they have 

been pretty much on target with most of their recommendations. 

We strongly endorse the use of a single DOD and VA separation 

physical and reform of the Military Disability Retirement System 

as recommended by the Veterans Disability Benefits Commission. 

In that regard, we very much support the pilot program now being 

implemented by DOD and VA under which the services determine 

fitness for continued service, the VA is the single agency assigning 

disability ratings, and DOD must accept those ratings for military 

disability retirement purposes. 

We strongly agree with the findings of all the panels on case 

management needs, the importance of TBI and PTSD screening assessments, care and rehabilitation, and updating the VA ratings 

system to more appropriately reflect those conditions’ effect on veterans and their families. 

We are concerned that there are a number of gaps, as Meredith 

mentioned, in coverage between DOD active duty retired and VA 

health programs. Some of the examples are: cognitive therapy; and 

per diem for caregivers, which ceases when a member is retired 

and is not available from the VA. Those significantly detract from 

disabled veterans’ continuity of care. Rather than trying to chase 

118 

down all the individual shortfalls, we think it is essential to authorize temporary overlap of both coverages. To us, that means 

continuing active duty-level TRICARE coverage for at least 3 years 

for all service-disabled personnel and their families and also authorizing VA care for active duty wounded warriors. 

As the Committee considers possible benefit adjustments or recommends against creating a differential benefit system for members who are disabled in combat versus other service-connected 

causes, I think you have heard the different panel members. I 

think we have all kind of said the same things—that there is a little bit of confusion, I think, in terms of what some people mean 

when they say, ‘‘combat disabled.’’ When we have asked people, everybody has pretty much said, anything that is service-connected 

should be compensated. If a member becomes a quadriplegic in 

service, the effect on the member’s life is the same whether that 

was caused by a bullet or a military vehicle or a slip on an icy 

street. Similarly, we should sustain the longstanding principle that 

military service is 24/7 duty that we discussed earlier for the purposes of determining service connection in disabilities. 

Like Meredith said, we believe it will be particularly important 

to establish a Joint Seamless Transition Office, permanently 

staffed with full-time personnel from both DOD and VA to oversee 

development, fielding, and sustainment of initiatives such as the 

Electronic Medical Record and the Electronic Separation Document. It is ironic that when I worked in DOD in 1988, I was initiating action for a joint DD Form 214. I got promoted and left the 

office a year later, called back and said, what is the status, and the 

answer was, ‘‘huh?’’ That is the problem that you have. We have 

to build a structure of responsibility that won’t evaporate with the 

departure of the incumbent or the departure of the incumbent’s 

boss. 

Finally, we urge the leaders of the Veterans Affairs Committees 

and Armed Services Committees to continue that example of topdown leadership collaboration in addition to the recent efforts in 

the Executive Branch. We know all of the committees and staffs 

are working hard to do the right thing, but we also know that frustration with past joint efforts and some of their lack of success can 

foster skepticism about the future, and that is a big concern. A renewed commitment by committee leaders to bipartisan, bicameral 

collaboration would establish an important guideline for the difficult road ahead. 

We appreciate this opportunity to offer our comments and pledge 

our continued support on all of these issues to ensure the Nation 

completes its obligations to our wounded warriors and their families. Thank you. 

[The prepared statement of Col. Strobridge follows:] 

PREPARED STATEMENT OF COL. STEVEN P. STROBRIDGE, USAF (RET.), DIRECTOR, 

GOVERNMENT RELATIONS, MILITARY OFFICERS ASSOCIATION OF AMERICA

Mr. Chairman and distinguished Members of the Committee, I am honored to appear before you today on behalf of the Military Officers Association of America 

(MOAA), to present our views on various Commission recommendations on the 

wounded warrior care, transition support, the disability evaluation process and related matters. 

MOAA does not receive any grants or contracts from the Federal Government. 

119 

EXECUTIVE SUMMARY

Urgency of Joint Congressional Action and Oversight.—Military and VA systems 

have been caught unprepared for the large wave of wounded and traumatized veterans returning from Iraq and Afghanistan, and these veterans’ needs will only 

grow in the future. Sustained bipartisan, bicameral congressional leadership focus 

and cooperation will be vital to successfully address continuing problems, especially 

with a change of leadership coming soon in the Executive Branch, and attendant 

introduction of new DOD and VA leaders who will be far less sensitized to the urgency of leadership-driven changes currently underway or contemplated. 

VA–DOD Disability Evaluation Reform.—MOAA strongly endorses the recommendation of the Veterans’ Disability Benefits Commission (VDBC) that DOD 

and VA should realign the disability evaluation process so that the Services determine fitness for duty, and servicemembers who are found unfit are referred to VA 

for the disability rating. 

All conditions that are identified as part of a single, comprehensive medical exam 

should be rated and compensated. In revamping the DES, the Services must include 

all unfitting conditions as rated by the VA in assessing whether the servicemember 

is to be medically retired or separated. (See Items 6, 12 and 46 in the attached matrix.) 

MOAA does not support elimination of the military disability retired pay system, 

as some would interpret the Dole-Shalala recommendations as implying. Rather, we 

support DOD’s acceptance of VA-determined disability percentages in calculating 

military disability retired pay. 

Traumatic Brain Injury/PTSD Care, Treatment and Service Connection.—MOAA 

strongly supports the recommendations of the Dole-Shalala Commission and other 

panels on TBI/PTSD care, coordination and rehabilitation. (See Items 3, 4, 15, 22, 

23, 33, 37 and 38 in the matrix.) 

Establish Joint Seamless Transition Agency/Office.—MOAA strongly supports establishment of a separate, joint DOD–VA Seamless Transition Agency staffed with 

full-time DOD and VA professionals to oversee the development, fielding, completion 

and assessment of seamless transition imperatives. (See Item 50 in the matrix.) 

Overlap in Active Duty and VA Health Coverage.—MOAA strongly recommends 

authorization of at least 3 years of eligibility for active duty TRICARE benefits for 

wounded warriors after leaving service. This will protect them from loss of urgently 

needed services—such as cognitive therapy and caregiver per diem—that now terminate when they leave active duty. (See Item 34 in the matrix.) 

Caregiver Support and Case Management.—MOAA strongly endorses the recommendations of the commissions and task forces on caregiver support/assistance 

and case management for wounded warriors. (See Items 2, 10, 13, 21, 29, and 34 

in the matrix.) 

Reaffirmation of the ‘‘24–7’’ Principle in Assessing Service-Connection of Disabilities.—MOAA strongly recommends the Committee reaffirm its longstanding commitment to the principle that all service men and women who are disabled in the 

line of duty—the ‘‘24/7’’ rule—are entitled to service-connected compensation, or if 

eligible, military retirement, if the disability did not result from misconduct. 

Collaboration and Oversight of Congressional Committees.—MOAA notes that parochial departmental concerns in the past have extended beyond the executive 

branch, and strongly recommends that leaders of the Committees on Veterans Affairs and Armed Services make a concerted effort with their House counterparts to 

develop a more collaborative framework to assess, oversee, prioritize, and fund 

cross-jurisdictional issues affecting wounded warriors and their families who are 

having such unacceptable difficulties getting fair and effective outcomes from DOD 

and VA bureaucracies. 

INTRODUCTION

Last February, a series of articles in the Washington Post titled ‘‘The Other Walter Reed’’ profiled shocking cases of wounded servicemembers who became lost in 

military health care and administrative systems upon being transferred to outpatient rehabilitative care. 

Subsequently, the national media were flooded with stories of seriously wounded 

troops warehoused in substandard quarters, waiting weeks and months for medical 

appointments and evaluation board results, confused by a maze of benefit and disability rules, and lowballed into disability separations rather than being awarded 

the higher benefits of military disability retirement. 

There were interviews with family members—spouses, children, and parents— 

who quit their jobs and virtually lived at military hospitals to become caregivers to 

seriously wounded troops. Left with diminishing resources and unfamiliar with miliVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00123 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
120 

tary benefit and disability rules, they were severely disadvantaged in trying to represent the interests of their wounded spouses and children who couldn’t stand up 

for themselves. 

These issues drew the attention of the President and Congress, leading to the appointment of special commissions and task forces charged with investigating the 

problems and identifying needed solutions. The details of sorting out the multiple 

overlapping proposals to fix the bureaucratic snafus among multiple Federal departments can be mind-numbing, whether you’re a legislator, a lobbyist, a Federal administrator, or an average citizen. 

The key to success will be to stay focused on the top priorities, and recognize that 

the government must bear responsibility for these long-term costs of war. 

MOAA is very grateful for the work of the Dole-Shalala Commission, the Veterans 

Disability Benefits Commission, the Marsh-West Independent Review Group, VA 

Interagency Task Force on Returning Veterans, and the Mental Health Task Force. 

Attached to this statement is a summary of the major recommendations of these 

panels and MOAA’s positions and recommendations on them. We are very pleased 

to say that with relatively few exceptions, as noted, MOAA endorses the vast majority of these groups’ recommendations. 

URGENCY OF JOINT CONGRESSIONAL ACTION AND OVERSIGHT

Military and VA systems have been caught unprepared for the large wave of 

wounded and traumatized veterans returning from Iraq and Afghanistan, and these 

veterans’ needs will only grow in the future. 

Sustained bipartisan, bicameral congressional leadership focus and cooperation 

will be vital to successfully address continuing intra- and inter-agency problems. 

With a change of leadership coming soon in the Executive Branch, and attendant 

introduction of new DOD and VA leaders who have not been a party to developing 

urgent leadership-driven changes currently underway or contemplated, the importance of congressional oversight cannot be overstated. 

DISABILITY EVALUATION SYSTEM (DES) REFORM

Current gross disability rating disparities between the services and between DOD 

and the VA must be resolved. The Independent Review Group appointed by the Secretary of Defense found huge disparities between the disability retirement (vs. separation) statistics between the services for returning veterans. The percentage of returning veterans who received military disability ratings of 30 percent or higher 

(and thus qualified for lifetime retirement benefits) was far lower among the Army 

and Marine Corps, who had the greatest exposure to combat injuries. The disability 

retirement rate for the Navy was nearly three times higher than the Army’s, feeding 

perceptions that seriously combat-wounded soldiers were being ‘‘low-balled’’ to save 

the government money, as shown on the following chart. 

DISABILITY RETIREMENT DISPARITY

Percent of disabled members awarded disability retirement (30+ percent DOD disability rating) 

Army 13% 

Navy 36% 

USMC 18% 

USAF 27% 

MOAA believes strongly that members with significant, lifelong, service-caused 

disabilities should be retired rather than separated with no military benefits. There 

must be a common rating standard that accounts for all service-connected disabilities and provides fair compensation and benefit packages commensurate with the 

level of disability. Wounded members should be retained on active duty until the 

disabling condition is stabilized, rather than expediting separation and shifting care 

responsibility to the VA. 

Further, the process of assigning fair and consistent disability ratings is too important to be left to five independent agencies (four services and the VA). While the 

services need to be the arbiters of what conditions render a soldier, sailor, airman 

or Marine unfit for continued service, the percentage disability rating should be determined by the VA, and the VA system must be made as uniform as possible across 

the country. (In this regard, MOAA is concerned at studies that have shown large 

disparities in disability ratings by VA offices in different states/regions.) 

MOAA strongly endorses the recommendation of the Veterans’ Disability Benefits 

Commission (VDBC): that DOD and VA should realign the disability evaluation 

121 

process so that the Services determine fitness for duty; and servicemembers who are 

found unfit are referred to VA for the disability rating. 

All conditions that are identified as part of a single, comprehensive medical exam 

should be rated and compensated. MOAA strongly recommends that in revamping 

the DES, the Services must include all unfitting conditions as rated by the VA in 

assessing whether the servicemember is to be medically retired or separated. (See 

Items 6, 12 and 46 in the attached matrix.) 

MOAA does not support elimination of the military disability retired pay system, 

as some would interpret the Dole-Shalala recommendations as implying. Rather, we 

support DOD’s acceptance of VA-determined disability percentages in calculating 

military disability retired pay. 

WOUNDED WARRIOR CARE AND TREATMENT: FOCUS ON TRAUMATIC BRAIN INJURY (TBI)

AND POST TRAUMATIC STRESS DISORDER (PTSD)

TBI and PTSD affect 25% to 50% of returning veterans, according to a number 

of government and other studies. And the percentage rises with prolonged and repeated exposure through multiple and extended deployments. But reluctance to disclose mental health conditions deters many members and families from testing and 

treatment. 

Traditional military ‘‘can-do’’ and ‘‘tough-it-out’’ attitudes that are the pride of the 

warrior ethos actually work against the future well-being of the warrior who doesn’t 

understand the potential long-term consequences of failing to at least find someone 

to talk to. Officers and senior NCOs who fear that acknowledgement of such conditions may affect their security clearances or future leadership opportunities are particularly vulnerable through such reluctance. 

Even less visible and likely to go unidentified are the secondary effects on family 

members who also suffer the long-term effects of living with victims of war-related 

stress. 

We must get a better handle on cause and effect, starting with crash efforts to 

destigmatize mental health conditions and publicize opportunities for confidential 

discussions. 

We also must dramatically improve diagnosis and treatment capacity and methodology. One key is to dramatically improve testing for the effects of Traumatic Brain 

Injury, including routine baseline pre- and post-deployment neurocognitive assessments; and testing as soon as possible after any exposure to high-risk blast or concussive events. 

MOAA strongly endorses the recommendations of the commissions/task forces on 

Traumatic Brain Injury and PTSD care and rehabilitation. (See Items 3, 4, 15, 22, 

23, 33, 37 and 38 in the matrix.) 

JOINT SEAMLESS TRANSITION AGENCY NEEDED

Widely reported breakdowns in the management of care at Walter Reed Army 

Medical Center reflect the fact that policies and administrative procedures for the 

care, rehabilitation, outprocessing and transitioning of our wounded warriors are 

not working ‘‘seamlessly’’ for them and their families. 

DOD and VA have critical, complementary roles in the transition process. The 

pace of the two departments’ collaborative and cooperative efforts continues to be 

hampered by bureaucratic and parochial barriers. 

The key, we believe, is a coordinated top-down strategy which engages both departments’ leadership from a single point of attack. Recent leadership initiatives 

generated at the secretarial level have had galvanizing effects on the two agencies’ 

staffs, and there has been unprecedented cooperation and progress in recent 

months. 

However, MOAA is very concerned for the viability of these newly energized efforts beyond the next 15 months, given the inevitable leadership turnover that will 

attend any new administration. 

The JEC does not appear to have the authority to direct change in both departments, only to forge broad agreements and report to Congress. We are into the fifth 

year of the war on terror, and the hand-off between the departments for those who 

are in the greatest need is far from seamless, despite recent, more strenuous leadership efforts. 

This effort is too important to be someone else’s part-time job. MOAA believes 

strongly that there is an overriding need to establish a permanent joint office, with 

permanently assigned staff from both departments, whose full-time mission is to devise, implement, oversee and sustain the joint mission of serving our warriors rather 

than serving their respective departments’ bureaucratic prerogatives. 

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Acting Secretary of Veterans Affairs, Gordon Mansfield, a distinguished disabled 

Vietnam veteran, endorsed a joint transition agency in testimony before the House 

Veterans’ Affairs Committee on 28 September 2006. 

Some elements of seamless transition oversight and implementation that should 

come under this office include: 

• Bi-Directional Electronic Medical Records • A Single Separation Physical and Electronic Separation Document (DD–214) • Coordination of Policy/Procedures for Special Needs Health Care, including implementation of a case management system and patient-centered recovery plan program • Coordination of multiple agency inititiatives on Traumatic Brain Injury (TBI) 

and PTSD diagnosis, treatment and Rehabilitation • Expansion of Joint DOD–VA Research • Improvement and Expansion of the Benefits Delivery at Discharge program. 

Joint Bi-Directional Electronic Health Record 

MOAA and our colleagues in The Military Coalition recently were briefed on efforts underway to improve the transfer of medical records between DOD and the 

VA. There are significant signs of progress, in our view, on this complex issue. However, we are concerned that full electronic record ‘‘jointness’’ won’t be completed 

until 2012 at best. That is just too long to wait. MOAA strongly endorses accelerated completion of this critical seamless transition function. 

Joint DOD–VA Physical 

A ‘‘one stop’’ separation physical supported by an electronic separation document 

(DD–214) is a cost-saving initiative that is an essential component of the seamless 

transition model. Although prototypes exist in some facilities, one has yet to be accepted as a standard throughout the two departments. It must become the ‘‘gold 

standard’’ of effective and efficient transitions. 

Polytrauma Centers and Traumatic Brain Injury 

TBI is the signature injury of OIF/OEF—its impact on combat veterans ranges 

from mild to severe. Developing best practices for identification and treatment is essential, including research on the long-term consequences of mild TBI. The goal of 

achieving optimal function of each individual TBI patient requires improved interagency coordination between VA and DOD. 

MOAA is pleased to note that the VA is establishing a fifth Level One polytrauma 

center. The new center and the four existing VA Polytrauma Rehabilitation Centers 

require special attention in order to ensure the needed resources are available, to 

include specialized staff, technical equipment and adequate bed space in order to ensure top-quality care for severely injured servicemembers and veterans. 

MOAA strongly supports establishment of a separate, joint DOD–VA Seamless 

Transition Agency to oversee the development, fielding, completion and assessment 

of seamless transition imperatives. (See Item 50 in the matrix.) 

ASSISTANCE FOR FAMILY CAREGIVERS

The unprecedented quality and rapid delivery of battlefield health care, along 

with widespread use of body armor and other protective equipment, means that unprecedented numbers of warriors who would have died of their wounds in previous 

wars are surviving to return to their families. Unfortunately, many of these heroes 

face long and arduous recovery periods, and many require significant levels of care 

for months or years, and some, for the rest of their lives. 

In this tragic situation, many spouses, parents, siblings, and other family members find themselves having to take on roles as full-time caregivers and representatives of severely injured/disabled personnel who are unable to navigate military and 

VA personnel and compensation bureaucracies on their own. Many give up their 

jobs and careers to care for a loved one, in come cases having to rely on the goodwill 

of charities and communities to meet various necessities of their loved ones’ new 

lives. 

MOAA believes strongly that the government has an obligation to change this situation and develop new programs to meet the extreme needs of these special cases. 

There must be institutionalized outreach programs to provide information and navigation assistance on administrative proceedings, appeal options, and benefit programs. In the more severe cases, compensation is appropriate and essential to recognize family members’ sacrifice of their own incomes and careers to care for servicedisabled members. 

For the longer term, the VA needs to establish fair compensation for caregivers 

forced into hardship situations. For the short term, MOAA strongly recommends auVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00126 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
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thorization of at least 3 years of eligibility for active duty TRICARE benefits for 

wounded warriors after leaving service. This will protect them from loss of urgently 

needed services—such as cognitive therapy and caregiver per diem—that now terminate when they leave active duty. (See Item 34 in the matrix.) 

MOAA strongly endorses the recommendations of the commissions and task forces 

on caregiver support/assistance and case management for wounded warriors. (See 

Items 2, 10, 13, 21, 29, and 34 in the matrix.) 

RETROACTIVE CASE REVIEW

In addition to making more sensitive decisions in the future, equity demands a 

review of discharge and retirement cases already completed for warriors wounded 

or otherwise disabled in Iraq or Afghanistan, while their case histories are still 

fresh. Multiple examples of severely disabled soldiers whose separation with zero 

disability ratings created the pressure for change, but that change can’t just be prospective. It must include retroactive review and re-adjudication for those whose examples brought the inequities to public attention. 

In the same vein, an even more sensitive situation is coming to light. There are 

numerous cases of exemplary soldiers and marines who, after multiple tours in Iraq 

or Afghanistan, became ‘‘changed men’’—disciplinary cases who experienced demotion, incarceration, and adverse separation characterizations that now bar them 

from eligibility for VA treatment, compensation and rehabilitation for conditions 

many would not have incurred if not for their wartime service. 

LENGTHY CLAIMS PROCESSING DELAYS ARE INTOLERABLE AND MUST BE FIXED

The workload and complexity of VA disability claims continues to increase. As of 

mid-February 2007, there was a backlog of 626,429 claims. VA projects that by the 

close of this year there will be at least 800,000 claims in the system. Moreover, disability claims processing time rose to nearly 6 months (177 days) on pending claims 

in 2006 against an original performance goal of 100 days. It’s our understanding 

that VA has moved the goalposts and its new performance goal for completing initial claims is 125 days. 

MOAA endorses the VDBC’s recommendation on improving the VA claims processing system. (See Item 48.) MOAA recommends that the Committee work with its 

Armed Services Committee counterparts to ensure this review is completed as soon 

as possible. (See Item 8 in the matrix.) 

MOAA CONCERNS

MOAA applauds the work of the commissions and task forces that have examined 

wounded warrior care, treatment, transition, and services. As indicated elsewhere 

in this statement, MOAA endorses most of the major recommendations of these panels. We do, however, have some concerns about certain recommendations, while recognizing that in some cases a commission’s recommendation was limited by its charter and time. 

MILITARY SERVICE IS A ‘‘24/7’’ ENTERPRISE, AND IS SUBSTANTIVELY DIFFERENT FROM

CIVILIAN EMPLOYMENT

Under current law, the term ‘‘service-connected’’ means generally, ‘‘with respect 

to disability or death, that such disability was incurred or aggravated, or that the 

death resulted from a disability incurred or aggravated, in the line of duty in the 

active military, naval, or air service.’’ (38 U.S.C. § 101(16)) An injury or disease incurred ‘‘during’’ military service ‘‘will be deemed to have been incurred in the line 

of duty’’ unless the disability was caused by the veteran’s own misconduct or abuse 

of alcohol or drugs, or was incurred while absent without permission or while confined by military or civilian authorities for serious crimes.’’ (38 U.S.C. § 105) 

This statutory framework has withstood the test of time and thorough past reviews. MOAA is confident that the statutes reflect the will of Congress and the 

American people regarding the unique nature and the inherent sacrifices involved 

in military service. 

Disability and survivor benefits should continue to reflect the unique nature of 

that service in defense of the Nation. 

MOAA understands that the Dole-Shalala Commission was empowered to examine only wounded warrior issues. However, we cannot support establishment of separate disability evaluation processes and benefit differentials for combat or operations-related disabilities vs. other service-connected disabilities. (See Items 6, 30 

and 46 in the matrix.) 

124 

MOAA strongly recommends that the Committee reaffirm its longstanding commitment to the principle that all service men and women who are disabled in the 

line of duty—the ‘‘24/7’’ rule—are entitled to service connected compensation, or, if 

eligible, military retirement, unless the disability was a result of misconduct. 

COLLABORATIVE CONGRESSIONAL LEADERSHIP NEEDED

MOAA was pleased to note that a rare joint hearing was held earlier this year 

between the Senate Veterans Affairs and the Armed Services Committees to receive 

the views and preliminary recommendations of the Veterans Disability Benefits 

Commission. In the House, there have been joint hearings on educational benefits 

under the Montgomery GI Bill. 

But it’s no secret that on some issues, jurisdictional firewalls in the Legislative 

Branch as well as the Executive Branch inhibit effective collaboration on some of 

the core issues affecting VA and DOD interaction. In this regard, we have been dismayed on many occasions at the continuing skepticism of Veterans Affairs and 

Armed Services Committee staffs in both chambers about the extent of joint cooperation between the committees that’s likely or feasible on various topics of common interest. 

We recognize the enormous challenges involved in crafting and revising public 

laws that cross jurisdictional lines. We also can appreciate the budgetary and political histories that have arisen from difficult interactions over multiple past congresses. 

But MOAA believes strongly that there is bipartisan, bicameral agreement among 

all of the committees on the need for far greater communication and collaboration 

between DOD and VA to achieve positive outcomes for wounded veterans in such 

great need. 

We’ve been extremely encouraged by the personal efforts of the Secretaries of Veterans Affairs and Defense, demonstrating that determined leadership initiative can, 

in fact, cut through longstanding parochial red tape and generate a genuine cooperative effort among staffs whose main experience has been colored by ‘‘stove-piped’’ 

perspectives. 

But those efforts can be undermined in the longer term if there is not decisive, 

determined, top-down congressional leadership direction to develop joint congressional staff consensus on priorities, policy direction, and funding responsibilities on 

these vital matters. 

MOAA strongly recommends that leaders of the Senate Committees on Veterans 

Affairs and Armed Services make a concerted effort with their House counterparts 

to develop a more collaborative framework to assess, oversee, prioritize, and fund 

cross-jurisdictional issues affecting wounded warriors and their families who are 

having such unacceptable difficulties getting fair and effective outcomes from DOD 

and VA bureaucracies. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO COLONEL STEVEN P. STROBRIDGE, USAF (RET.), DIRECTOR, GOVERNMENT RELATIONS, 

MILITARY OFFICERS ASSOCIATION OF AMERICA

RETROACTIVE REVIEW OF DOD RATINGS

Question. The Disability Benefits Commission report suggests that many servicemembers may have been given low ratings by the DOD Physical Disability Evaluation System to save DOD from having to pay them medical retirement benefits. 

Your testimony supports retroactive case review for certain veterans who are dissatisfied with the rating assigned them by DOD. What criteria would you suggest be 

used to determine who is eligible for a reevaluation? 

Response. At a minimum, we believe there should be a retroactive review of all 

medical separations since Oct. 7, 2001—that is, servicemembers who had servicecaused or service-aggravated medical conditions that precluded further service and 

whose disabilities were rated by the service as less than 30 percent disabling. This 

would catch the most egregious situations in which a member was wrongly denied 

a medical retirement and the attendant annuity, health coverage and other benefits 

associated with military retirement. 

Other members who were medically retired with less than 20 years of service 

should be notified of their right to appeal to their service Board for Correction of 

Military Records if they believe the physical disability evaluation by their parent 

service inappropriately denied consideration of any service-caused condition(s) that 

also would have precluded their continued service in uniform. 

125 

Chairman AKAKA. Thank you very much, Colonel. 

I have a question for all of our panelists. If the VA disability system is revised from the current form, should different consideration 

be given to those veterans whose disability was incurred in a combat zone versus those who were disabled elsewhere? Let me start 

with Ms. Del Negro. 

Ms. DEL NEGRO. I have conflicting feelings about that. During 

the initiation of the MEB process for my husband, we were in a 

room. Actually, the first time he showed up for Part I of his physical, the soldiers were sitting on the floor. They didn’t even take 

them into the back. Some of them were combat-wounded soliders. 

It was very appalling to my husband to see these gentlemen sitting 

on the floor. 

At the same time, however, while I would like to think that combat-related injuries would receive greater compensation, I think 

that creating a second line of differentiation between veterans will 

create even more bureaucratic obstacles, slowing down the process. 

By virtue of that, I would say that I would discourage the making 

differences between combat and non-combat injuries. Perhaps a caveat to that would be that if one is a Purple Heart recipient, that 

there would be some sort of additional severance associated with 

it, but that it would not influence health care benefits. 

Chairman AKAKA. Thank you. Colonel Duffy? 

Colonel DUFFY. Yes, sir. I agree with Ariana. I thought that was 

very well said. In creating another category that the veteran has 

to prove, you are creating more work for the veteran, more work 

for the administration in judging a claim. A servicemember is 

under the care and custody of the military 24/7. Any injury that 

occurs during that period should be compensated. 

In the civilian world, if an employee is hurt at work, there is a 

Workers’ Compensation system that covers that employee as a 

work-related injury. Anything that happens during the day is 

work-related for a servicemember and should be compensated. 

Chairman AKAKA. Thank you. Mr. Manar? 

Mr. MANAR. Simply said, ditto. I have talked about this. We have 

all, I think, arrived at the same conclusion—that the distinction 

here should be based on the severity of disability, the level of disability, not where or how it was incurred. If someone spends a year 

in Iraq and comes back with Post Traumatic Stress, are they any 

more or less deserving of treatment than the female soldier who 

was raped in Germany or Japan? If someone steps on an IED and 

has a leg amputated below the knee in Falujah, are they any more 

or less worthy of compensation and benefits and care than someone 

who has their leg amputated because of diabetes in the U.S. or because of an automobile accident while they were serving in Japan? 

So, our view is that there is no distinction. The distinction is on 

the level of severity. With greater severity of disabilities, then they 

should receive greater compensation, greater care, of course, for 

their service-connected disabilities. 

Chairman AKAKA. Thank you, Mr. Manar. 

Ms. Beck? 

Ms. BECK. My brother is a Marine Corps helicopter pilot, and 

whether he is deployed or at home with his children, they still 

share the same fear and anxiety of when he would be deployed or 

126 

a possible accident whether he is deployed or not in combat. As a 

result, as General Scott said, if you are covered by the UCMJ, you 

should be covered by the good things, too. 

Chairman AKAKA. Colonel Strobridge? 

Colonel STROBRIDGE. Sir, we very strongly believe there should 

be a single system. Let me give you one example of a real case of 

a person to show how good intentions can go awry. This individual 

was disabled preparing for a combat mission out on the wing of an 

airplane doing pre-flight, slipped off the wing, fell on a piece of 

equipment, broke his back, became a paraplegic. When he applied 

for combat-related special compensation under this new program, 

it was denied. Even though he was preparing for a combat mission, 

the determination was the reason he broke his back was the ice, 

so it was weather, not combat, that caused the disability. 

I don’t think that was ever envisioned when Congress established 

combat-related special compensation, but that is what can happen 

to these kinds of determinations. And to us, it is to avoid that kind 

of hair-splitting that it is very important to say it is the disability, 

not how you got it. As long as it was service-connected: if it was 

service-connected, you deserve the same compensation. 

Chairman AKAKA. Ms. Del Negro, are there any issues that were 

not addressed by today’s other witnesses that you think merit attention? 

Ms. DEL NEGRO. Do you have a few minutes? No, I am just kidding. [Laughter.] 

There are a number of issues, and I will do my best to keep this 

brief. As I said, my husband and I endured this process before the 

Washington Post articles came out, which seemed to bring the onslaught of all these reports and recommendations, even though the 

same reports and the same recommendations had been around for 

a decade. 

However, when my husband is released from active duty, the recommendations that are made in this report—given the amount of 

time they will take to implement—will not be available to my husband because he will have already been separated from active duty. 

So, I would like to see that some of these changes be made retroactive to affect and benefit some of those recently separated. 

In addition, the Recovery Coordinator plan proposed by the DoleShalala Commission report is difficult because you are already 

dealing with staffing shortages, as documented by a GAO report 

dated September 27, showing that over 50 percent of the Warrior 

Transition Units that are being employed by the Army have less 

than—or are missing—two or one of the critical triad positions, including case managers. So, if you can’t even fill slots of case managers, how are you proposing to fill slots of Recovery Coordinators 

that are also going to require training? 

Furthermore, I would like to reiterate previous comments regarding the Family Medical Leave Act. I think it is absolutely imperative that it be extended. I had the opportunity to meet with President Bush, my husband and I both, in Hawaii; and he was generous enough to ask how he could help, and my response was that 

he could sign that amendment when it graced his desk. I emphasized that that was one way he could help servicemembers and 

their families. However, I also think it will benefit the veterans 

127 

and their families in the long-term. We do not know the long-term 

implications of the injuries sustained in this conflict. 

Traumatic Brain Injury, the focus today primarily mentions moderate to severe brain injury. We don’t know the implications of mild 

Traumatic Brain Injury, particularly as it is related to blast injuries. The basis of conclusions so far on mild Traumatic Brain Injury 

are based on pre-clinical studies evaluating rats. We need more 

data before we can conclude that those individuals are not going 

to require long-term care. 

In addition, there is no definition of severely injured. What is severely injured? If you are admitted to a military hospital or classified as SI, does that mean that you will get all these benefits? I 

think that that really places us in a precarious situation, to define 

what severely injured is. 

Lastly, the integration of the data between the DOD and VA systems, no one mentioned today the security of the data. In the last 

few years, there have been reports about problems with the VA and 

release of data, and while developing an e-benefits page and whatnot may help, it does not address the security issues. Thank you. 

Chairman AKAKA. Thank you very much. 

I am going to now call on Senator Burr. I may have a second 

round, but Senator Burr? 

Senator BURR. Thank you, Mr. Chairman. We may both have 

second rounds, but I know we have kept our witnesses here too 

long and let me thank all of you. 

Ms. Del Negro, thank you for your family’s sacrifice, your husband’s service to the country. How is he doing? 

Ms. DEL NEGRO. He is doing fantastic. 

Senator BURR. Great. 

Ms. DEL NEGRO. Absolutely great. 

Senator BURR. I apologize that you have had to weave your way 

through and navigate through a system that took some time getting the right degree of benefit. I can only say that we are learning. 

The Committee is well aware of the progress that needs to be made 

and we are committed to work with the Veterans Administration. 

Armed Services is committed to work with the Department of Defense, which seems to be the area that your husband was in 

through his transition. 

To try to understand that it is a little different today and that 

we are dealing with different injuries; that we have got to have the 

right responses; let me ask you just to expand on one thing that 

I didn’t quite understand—the distinction of seriously injured. 

When we have an injured veteran, there is no difference in the 

treatment, the health care that is delivered to them. What was the 

purpose of highlighting seriously injured? 

Ms. DEL NEGRO. I believe the Veterans Commission report identified that basis of service, as Mr. Manar addressed, should not be 

based on whether or not the injury was combat or not combat-related, but it should be related to—— 

Senator BURR. OK. I just wanted to make sure I hadn’t missed 

something relative to—— 

Ms. DEL NEGRO. Sorry. 

Senator BURR. Colonel Duffy, thank you for being here. Your testimony regarding unique issues surrounding the seamless transfer 

128 

of medical records for Guard and Reserves has intrigued me. I 

went to your testimony and I will read from it, ‘‘Although this moment of interoperability is reported by DOD contractors to be close 

at hand, the medical needs of our Guard members have been overlooked with this effort that does not require the records of civilian 

health care providers treating our members to be entered into the 

DOD AHLTA database.’’ Is that a HIPAA problem that we have? 

Is there a privacy health insurance, health privacy issue? 

Colonel DUFFY. There is potentially a HIPAA problem with any 

medical record, but to overcome a HIPAA problem, the patient only 

needs to consent—and the military could certainly require that consent—for a soldier to be deployable. 

Senator BURR. So could this—— 

Colonel DUFFY. They would need to know all the medical information on that servicemember. 

Senator BURR [continuing]. Could this be as simple as we are not 

asking Guard and Reserves to sign a release on their health care 

privacy, or is it—go ahead. 

Colonel DUFFY. It is at least a two-fold issue. Yes, any HIPAA 

issue would have to be overcome with an authorization, which 

could be voluntarily given, or, in the case of a servicemember, I 

suppose involuntarily, required to be given. 

But, there is also the technology. The contractor who runs the 

AHLTA program, Northrop Grumman, has informed us the technology is there. They have just not been asked to do it. Civilian 

medical records—and there is some concern that any treatment 

within the Guard is not being scanned into the DOD AHLTA system—not just civilian medical records, but should any treatment be 

given at a Guard medical installation. The technology is there. 

They are just lacking the mandate. Tell us to do it and we will do 

it. 

Senator BURR. You have triggered the right degree of fault. So, 

let us take it from here and see what we can do to try to find a 

solution to something that I would think would be extremely helpful, not only to Guard and Reservists, but on the back end of the 

system—to have within DOD, within VA, the complete records of 

individuals that will end up back in the system. 

Colonel DUFFY. Absolutely. And sir, may I say just one thing. I 

think at a hearing earlier this year, you had patients at Walter 

Reed come, one of whom testified that when he was sent from Iraq 

to Walter Reed, his medical records were placed on his stomach. I 

think we all heard that. And then they were not there when he returned Stateside—a big concern if he is later filing a disability 

claim with the Veterans Administration and doesn’t have those 

records. 

Senator BURR. We share your concern. 

Mr. Manar, let me say from the start, I have looked at all these 

proposals on disability changes and I am, hopefully like the Chairman, I am in neutral. I am in the middle somewhere still trying 

to assess them. But, you made a statement that I have just got to 

ask you some questions on. If the President’s Commission recommendations were adopted, the VA would have to run a dual system for 70 years, and you alluded to the fact that they couldn’t do 

that. Did I—— 

129 

Mr. MANAR. They are having difficulty running the current program. 

Senator BURR [continuing]. Let me just say this. If a dual system 

is better for future veterans, which has not been determined yet, 

but were it, would you object to a dual system? If you were convinced that it would benefit the next generation? 

Mr. MANAR. First, let me answer that by saying I will be speaking for myself here. If it could be shown to me, proven, if you will, 

that a new system is better for future veterans, then I wouldn’t oppose it. But, I would also ask, why not make it available to all veterans? 

Senator BURR. That is certainly something the Dole-Shalala 

Commission threw out within the organizations and felt that there 

was enough push-back, according to Senator Dole, that they would 

make it available to the future generations and an option to the 

past. I agree with you. If it is better, then everybody ought to be 

offered it. 

But let me just share with you, 13 years ago when I got to Washington, we have this—government employees all have an opportunity for their retirement funds in the TSP, whatever that stands 

for, and it had three options as far as I can invest in. I remember 

the first day I asked, why are there not more options, and they 

said, well, that is what there has always been. [Laughter.] 

And they made a change in the head of the TSP and we now 

have, Colonel, nine or something different options—international 

funds and all this—and now Federal employees are actually in better shape about their retirement funding because of the additional 

options that were added to the Thrift Savings Plan. 

I only point that out to you because what we have is a unique 

opportunity, a unique opportunity to look at the population that is 

the most affected right now and figure out how do we integrate 

them through the system? How do we deliver the best quality of 

care and learn what we have been doing wrong and transition it 

for the ones that are still in the system? How do we look at the 

disability process and try to figure out, is there a better way to do 

it? Is there a way that is fairer? Is there a way that is more efficient? And that we take the opportunity to make that transition. 

I wish I could tell you how many man hours my office spends 

with veterans on disability claims because nobody understands how 

the process happens. And its usually on the close calls, which requires a call from me, or a call from the Senator from Hawaii, and 

if I fail, I am going to get the Senator from Hawaii to call on my 

behalf. 

But it shouldn’t happen like that. It is pretty clear cut. Clearly, 

when you have got two different entities making disability determinations, one has to look at it and say, how can two different entities come up with two different conclusions? Because they are judging two different things. We understand that now. Is that right? 

Probably not for the future. Colonel, I was glad to hear you say, 

one is great. 

Ms. Beck, let me ask you, you support the idea of Recovery Coordinators. As you know, these coordinators hopefully would overcome the barriers of DOD and VA. The Commission’s recommendation is that these coordinators be employees of an independent PubVerDate Aug 31 2005 10:46 Sep 15, 2008 Jkt 000000 PO 00000 Frm 00133 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\39934.TXT SVETS PsN: PAULIN
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lic Health Service, but the decision has now been made that the coordinators are to actually be VA employees. 

One, what do you feel about Recovery Coordinators? Two, what 

do you feel about them as a VA employee versus an independent 

entity, and would they be able to exert a sufficient amount of authority over DOD employees if they are VA employees? 

Ms. BECK. Regarding the Public Health Service question—in an 

ideal world, that might work; but in the real world, having a Marine going to a Public Health servant before he can go to another 

Marine—it is not going to happen. So, the idea of having them be 

a VA employee and their authority would actually probably rely on, 

one, as I mentioned, that overlap of benefits to be able to legally 

access both sides. We can talk about it all day, but if they have 

legal obstacles to doing that, then they are not going to be able to 

do it. 

The other issue is, that Steve and I have discussed, is the option 

to allow to have that oversight structure in place—to ensure that 

they have the ability to maneuver within the Department of Defense and within the VA; and honestly, within the Social Security 

Administration, Medicare, and the Department of Labor. So, you 

are going to have to have those entities in place because these 

problems are going to happen. We all know they are going to happen. And, without some sort of ability to address those problems 

in the future, we are going to find ourself in the same place 5 years 

from now. 

So yes, we do support the idea of a Recovery Coordinator. You 

are going to have to find someone who has the ability and the initiative and problem solving skills to do this because it is not easy. 

Sarah, as you mentioned, she is her husband’s recovery coordinator 

and that is not fair. She is his wife and she should be. So, that 

would be our one concern—that they not be able to have that buyin from the other agencies. 

Senator BURR. I thank you for that. I also thank you for the fact 

that it was clear from your testimony, you are focused on outcome 

and not process. I am not sure that we can say that enough up 

here, because this is about outcome. It is not about whether we follow what the process is. It is about what comes out on the other 

end. And I think there is a tendency that we look at things from 

the wrong end. Maybe it is time we work backwards a little bit and 

say, what is the optimum outcome that we want and how do we 

get it? 

I actually think we are going through that process on a lot of 

things right now. It is difficult to absorb it all. I know it is for all 

of us who are asked to play a part in it. So, I implore all of you 

to stick with it, because anything short of attempting to do this, 

somebody will lose. 

Colonel, let me ask you one last thing. You raised, I think, a very 

important issue and that is without some type of permanent 

transitioning structure, how can any of us leave the jobs we are in 

and believe that: (1) a task will be completed, or (2) it will continue 

to evolve into what it should over time. Let me ask it from another 

side. Do you have any worry that creating a new bureaucracy within this difficult hand-off between DOD and VA will impede our 

ability to actually make this transition? 

131 

Colonel STROBRIDGE. Well, sir, I guess the only thing you can go 

by is based on experience, and not having one doesn’t work. So, 

having been in OSD and looking at the structures now and talking 

with the folks there, you have some folks for whom this is a parttime job—they have other things to do, and you never know when 

something else is going to crop up that pulls them away from this. 

Right now, there is a lot of leadership emphasis on making sure 

this gets done. 

Senator BURR. How quick would this have to happen from your 

standpoint? What is the time line that it would have to happen 

where you would say, you know what? It has happened. We don’t 

need another bureaucracy. 

Colonel STROBRIDGE. Well, there is a provision in the Senate 

version of the defense authorization bill that would establish a 

joint office specifically to oversee the Joint Medical Record, which 

we certainly think is a good start. There would be some other 

things that probably ought to come under that, not the least of 

which is the Transition Coordinators. 

One of the issues that you have right now, you can have the 

greatest person in DOD who is assisting these folks through the 

DOD system; then, they hand them over to the VA and they are 

done; and now somebody picks them up at the VA who doesn’t have 

the background. So, to us, part of that office’s responsibility should 

be saying, what do we need to do to get them through—not just to 

the point of VA—but until they are stable in the VA system. 

Senator BURR. Well, as somebody said, we are hopeful that Gordon and Gordon are actually mapping out all the transitional 

things that need to exist, and then it is an implementation and an 

oversight function. 

Colonel STROBRIDGE. And a maintenance, yes, sir. 

Ms. BECK. Sir, can I make one point on that? It would be imperative that if you create such a structure, and to avoid the bureaucracy that you are talking about, that you actually absorb the functions of all the little offices that have popped up throughout the 

Department of Defense and the VA. Because right now, the VA 

doesn’t normally know where to go when they have a problem within the Department of Defense, because there are so many different 

areas where they could try to resolve their problems. 

Senator BURR. Nor do we sometimes. Thank you. 

Chairman AKAKA. Thank you very much, Senator Burr. 

I have more questions, but at this point, I just looked at the time 

and I want to praise all of you for your patience today. In a few 

minutes, it will be 4 hours that we have been here, and thanks so 

much for all of that. I am going to submit my questions for the 

record. 

Again, thank you so much for your time, for traveling this far. 

All of your testimonies and your responses will be helpful to this 

Committee and what we will be doing in the future and I thank 

you very much. I thank all the witnesses today. It is not every 

hearing that we get to hear from so many distinguished guests like 

you. 

I want you to know that we really appreciate you taking the time 

to give us a better understanding of the recommendations of the 

various groups so that we have a clearer sense of what is needed 

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to move closer to making the transition back to civilian life as 

seamless as possible. You have been a big help in doing this. 

With all of that and just about 4 hours, this hearing is now adjourned. 

[Whereupon, at 1:25 p.m., the Committee was adjourned.] 

(133) 

A P P E N D I X 

PREPARED STATEMENT OF HON. BARACK OBAMA, U.S. SENATOR FROM ILLINOIS

Mr. Chairman, I want to thank you as well as Ranking Member Burr for holding 

this important hearing today. I also want to welcome and thank distinguished Members of the various commissions as well as our partners and friends in the VSO community. 

While there are different views in Congress about the war in Iraq, there should 

be no disagreement about the tremendous sacrifice being made by the men and 

women who are serving in Iraq and Afghanistan. They have performed valiantly 

under exceedingly difficult circumstances. They have done everything that we have 

asked of them. And when they come home, they should be able to expect the care 

and benefits they so richly deserve. Our military families and recovering servicemembers should not have to wage a second war at home to get that next doctor’s 

appointment or receive that first disability check. 

Like most Americans, I was outraged to learn of the disgraceful conditions and 

obstacles confronting those who have served us with honor. That is why I am proud 

to have introduced bipartisan legislation, the Dignity for Wounded Warriors Act of 

2007 (S.713), to address both the immediate and systematic problems uncovered in 

a recent Washington Post series about Walter Reed Army Medical Center. 

This comprehensive legislation addresses problems not only at Walter Reed but 

throughout the military medical system. The bill sets new standards for all outpatient medical facilities—including a ‘‘zero tolerance’’ policy for pest infestations 

and overdue work orders; streamlines the paperwork and red tape currently imposed on servicemembers and their families—especially with regard to the disability 

review process; increases caseworker ratios to provide extra support to servicemembers and their families; increases access to mental health services, including a 

new 24-hour hotline; and provides important new protections for family members, 

including health care and mental health services while on invitational job orders— 

as well as Federal employment protections for their jobs. In my view, a mother 

should never have to choose between caring for an injured son and keeping her job. 

I am proud that many of these provisions passed the Senate recently in a larger 

package focused on helping our wounded warriors, and I hope the House and Senate 

will complete its conference soon and submit this legislation for the President’s signature. But more action is needed. The pace of change is too slow within the Pentagon and VA, and we have to consider other fundamental reforms that will help 

ensure our wounded warriors and our veterans are getting the care and benefits 

they deserve. 

I look forward to hearing from the panelists, especially the recommendations from 

the President’s Commission on Care For America’s Returning Wounded Warriors 

and the Veterans Disability Benefit Commission. I think we can all agree on the 

need to pursue some of these recommendations, such as the Dole-Shalala commission’s call for better prevention and treatment of PTSD and TBI; and for providing 

much more robust support for our recovering warriors as they transition from the 

military to the VA. But Congress must also avoid ceding its important role in revising other complicated policies, such as the current disability rating system within 

the military and the VA. I share the Chairman’s concerns, for example, over any 

proposal that would effectively cut Congress out of this important work. 

134 

Mr. Chairman, we owe it to our returning servicemembers and veterans to get 

this right. I look forward to working with you and our panelists to consider the 

range of options and find the best approach to giving these heroes what they deserve. 

Thank you. 

Æ