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LEGISLATIVE HEARING ON H.R. 3051, 

H.R. 6153, AND H.R. 6629 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

SEPTEMBER 9, 2008 

Serial No. 110–102 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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ii 

COMMITTEE ON VETERANS’ AFFAIRS 

BOB FILNER, California, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

MICHAEL H. MICHAUD, Maine 

STEPHANIE HERSETH SANDLIN, South 

Dakota 

HARRY E. MITCHELL, Arizona 

JOHN J. HALL, New York 

PHIL HARE, Illinois 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

DONALD J. CAZAYOUX, JR., Louisiana 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

GINNY BROWN-WAITE, Florida 

MICHAEL R. TURNER, Ohio 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

STEVE SCALISE, Louisiana 

MALCOM A. SHORTER, Staff Director 

SUBCOMMITTEE ON HEALTH 

MICHAEL H. MICHAUD, Maine, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

PHIL HARE, Illinois 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

DONALD J. CAZAYOUX, JR., Louisiana 

JEFF MILLER, Florida, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

HENRY E. BROWN, JR., South Carolina 

VERN BUCHANAN, Florida 

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

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

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

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

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

is further refined. 

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iii 

C O N T E N T S 

September 9, 2008 

Page 

Legislative Hearing on H.R. 3051, H.R. 6153, and H.R. 6629 ............................. 1 

OPENING STATEMENTS 

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

Prepared statement of Chairman Michaud .................................................... 29 

Hon. Jeff Miller, Ranking Republican Member, prepared statement ................. 29 

Hon. Phil Hare ......................................................................................................... 1 

Prepared statement of Congressman Hare .................................................... 29 

WITNESSES 

U.S. Department of Veterans Affairs, Gerald M. Cross, M.D., FAAFP, Principal Deputy Under Secretary for Health, Veterans Health Administration .. 18 

Prepared statement of Dr. Cross ..................................................................... 40 

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

Rehabilitation Commission ................................................................................. 11 

Prepared statement of Mr. Wilson .................................................................. 38 

Disabled American Veterans, Joy J. Ilem, Assistant National Legislative Director ..................................................................................................................... 9 

Prepared statement of Ms. Ilem ...................................................................... 32 

Johnson, Hon. Eddie Bernice, a Representative in Congress from the State 

of Texas ................................................................................................................. 3 

Prepared statement of Congresswoman Johnson .......................................... 30 

Salazar, Hon. John T., a Representative in Congress from the State of Colorado ....................................................................................................................... 4 

Prepared statement of Congressman Salazar ................................................ 31 

Shea-Porter, Hon. Carol, a Representative in Congress from the State of 

New Hampshire .................................................................................................... 6 

Prepared statement of Congresswoman Shea-Porter .................................... 31 

Vietnam Veterans of America, Thomas J. Berger, Ph.D., Senior Analyst for 

Veterans’ Benefits and Mental Health Issues ................................................... 13 

Prepared statement of Dr. Berger ................................................................... 39 

SUBMISSIONS FOR THE RECORD 

American Veterans (AMVETS), Raymond C. Kelly, National Legislative Director, statement ....................................................................................................... 49 

Brain Injury Association of America, Susan H. Conners, President/Chief Executive Officer, statement ....................................................................................... 50 

Hodes, Hon. Paul W., a Representative in Congress from the State of New 

Hampshire ............................................................................................................ 51 

National Military Family Association, Inc., Barbara Cohoon, Deputy Director, 

Government Relations, statement ...................................................................... 51 

Paralyzed Veterans of America, statement ........................................................... 54 

Schraa, James C., Psy.D., Neuropsychologist, Licensed Psychologist, State 

of Colorado, Craig Hospital, Englewood, CO ..................................................... 57 

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

Legislative Associate, National Legislative Service, statement ....................... 58 

Wounded Warrior Project, Anna Frese, Family Outreach Coordinator for 

Brain Injury, statement ....................................................................................... 59 

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(1) 

LEGISLATIVE HEARING ON H.R. 3051, 

H.R. 6153, AND H.R. 6629 

TUESDAY, SEPTEMBER 9, 2008 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON HEALTH, 

Washington, DC. 

The Committee met, pursuant to notice, at 10:00 a.m., in Room 

334, Cannon House Office Building, Hon. Michael Michaud [Chairman of the Subcommittee] presiding. 

Present: Representatives Michaud, Snyder, Hare, Berkley, 

Salazar, Miller, and Brown of South Carolina. 

OPENING STATEMENT OF CHAIRMAN MICHAUD 

Mr. MICHAUD. I would like to call this hearing to order. And I 

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

hearing is an opportunity for Members of Congress, veterans service organizations (VSOs), the U.S. Department of Veterans Affairs 

(VA), and other interested parties to provide their views and discussion on the legislation that has been introduced within the Subcommittee’s jurisdiction. I do not necessarily agree or disagree with 

these bills before us today, but I believe that this is an important 

part of the legislative process that will encourage frank discussion 

of new ideas. 

We have three bills before us today. Congressman Salazar’s bill, 

H.R. 3051, the ‘‘Heroes at Home Act of 2007,’’ H.R. 6153, Congresswoman Johnson’s bill, the ‘‘Veterans’ Medical Personnel Recruitment and Retention Act of 2008,’’ and H.R. 6629, Congresswoman 

Shea-Porter’s bill, the ‘‘Veterans Health Equity Act of 2008.’’ I look 

forward to hearing the views of our witnesses on these bills before 

us. Due to the late inclusion of H.R. 6629 we do not expect to have 

written testimony today. However, I would ask the witnesses if 

they would submit their views in writing on H.R. 6629 within ten 

legislative days after the ending of this hearing. 

[The prepared statement of Chairman Michaud appears on 

p. 29.] 

Mr. MICHAUD. I would like to ask Mr. Hare if he has an opening 

statement. 

OPENING STATEMENT OF HON. PHIL HARE 

Mr. HARE. I do. Thank you, Mr. Chairman. First, let me thank 

you and Ranking Member Miller for holding this hearing today. 

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The three bills before us today address important issues, all of 

which have huge impacts on the welfare of our Nation’s veterans. 

Secondly, I would like to thank the sponsors of these bills, the 

three Members that are testifying before the Subcommittee today. 

Mr. Salazar is a fellow Committee Member and I know from sitting 

next to him over the past 2 years that he is a tireless advocate for 

veterans, especially the many rural veterans that live in his large 

district in the State of Colorado. His bill addresses family caregivers of veterans suffering from Traumatic Brain Injuries (TBI), 

and also telehealth services. These are crucial matters that are directly in line with Mr. Salazar’s passion for improving the lives of 

veterans and their families. 

Ms. Johnson is also a big supporter for veterans. For fifteen 

years she worked at the Dallas VA Medical Center (VAMC) as a 

medical and psychiatric nurse. Appropriately, her bill aims to help 

VA recruit and retain more nurses and other healthcare professionals. 

Ms. Shea-Porter and I came into Congress at the same time, and 

I know without a doubt that there is nobody more dedicated to 

serving our veterans than she is. It is a paradox then that her 

home State, the great State of New Hampshire, does not have a VA 

Medical Center. Her bill attempts to resolve this injustice. 

Third, I would like to thank all of our witnesses for testifying 

today, including Dr. Cross of the VA, and each representative of 

the three VSOs present. I would also like to congratulate the Disabled American Veterans (DAV) for recently electing Raymond 

Dempsey, a fellow Illinoisan, as National Commander. Speaking on 

behalf of this great State of Illinois I take pride in knowing that 

such a well respected organization is under the leadership of Mr. 

Dempsey. 

Mr. Chairman, thank you again for holding this important hearing. I look forward to our witnesses testifying this morning. Thank 

you. 

[The prepared statement of Congressman Hare appears on p. 29.] 

Mr. MICHAUD. Thank you very much, Mr. Hare, for your opening 

statement. Mr. Miller. 

Mr. MILLER. Thank you very much, Mr. Chairman. I apologize 

for being late. I would like to just submit my opening statement 

for the record. 

[The prepared statement of Congressman Miller appears on 

p. 29.] 

Mr. MICHAUD. Without objection so ordered. 

Now I would like to thank our first panel for coming here this 

morning. I look forward to your testimony. We will start off, in the 

order that you arrived, with Congresswoman Johnson of Texas to 

introduce her piece of legislation first. Thank you. 

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STATEMENTS OF HON. EDDIE BERNICE JOHNSON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS; 

HON. JOHN T. SALAZAR, A REPRESENTATIVE IN CONGRESS 

FROM THE STATE OF COLORADO; AND HON. CAROL SHEAPORTER, A REPRESENTATIVE IN CONGRESS FROM THE 

STATE OF NEW HAMPSHIRE 

STATEMENT OF HON. EDDIE BERNICE JOHNSON 

Ms. JOHNSON. Thank you very much, Mr. Chairman, and other 

distinguished members of the panel. I will submit my written 

statement and try to summarize. 

As has been said, I worked as a professional psychiatric nurse at 

the Veterans Administration Hospital for fifteen years before entering public office, and I opened the psychiatric unit. And I know 

how important the psychiatric unit became day after day as veterans started coming back from active wars. Recently there were 

four suicides of psychiatric patients at the VA hospital that made 

the front page of the paper. The VA hospital is in my district so 

I went to visit to see what the problem was. And they explained 

that the real problem is they are not attracting enough professional 

nurses to do what they need done to observe psychiatric patients. 

As you know, psychiatric patients are supposed to be observed at 

least every fifteen minutes. It is also very important for consistency. It is important that they develop a relationship with the 

nurses. And the nurses remain the profession with the most trust 

of the public. 

They are using part-time nurses because the work in the VA hospital for nurses is a little more stringent than in other facilities. 

And they identified their problem as not having nurses in the Medical Personnel Recruitment and Retention Act. And it actually 

came out because nurses were so tight, there was such a shortage, 

that they thought that this would give more even distribution of 

nurses to other facilities as well. But they found that they lost 

many, many nurses because of the work. It is just hard in facilities 

like the VA. 

It does not take much to observe that. You can go into a private 

facility and if you find a professional nurse they are usually seated 

at the desk. You go into a VA hospital and they are usually walking, taking care of patients. So it is really a difference, and I can 

tell you that from experience. 

So I came back to see what I could do. They specifically asked 

for this type of legislation. And I saw where Senator Akaka had introduced a bill, it is Senate Bill 2969, that address the same problem. And so this simply is a companion bill to his. It is an urgent 

need. Very early I put an amendment on one of the bills to see that 

when patients were admitted to psych, admitted, coming directly 

from war, that they got a psychiatric evaluation by professionals 

right away because most of them come back with post traumatic 

stress disorder (PTSD) even if they do not have head injuries, and 

many are coming back with head injuries. The earlier they are diagnosed, the earlier the intervention, the better the outcome. 

When I worked at the VA hospital, there were long-term patients 

because at the time the modality was not experienced enough to 

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have very early intervention. Consequently, we had a number of 

long-time, chronic patients. The approach has changed now. But in 

order to make it successful, the professionals must be available. 

And this legislation directly addresses that issue by placing nurses 

in the same category of physicians and dentists, and other therapists, so that their pay rate pays them back into it. So that their 

pay will be on the scale that it had been on the professional level. 

I know that this is asking for additional money, probably not 

right away but in the scale as it comes. But if we want to give the 

appropriate attention to those people that have given much of their 

lives in defending this country, I think it is only right to make sure 

that they have adequate care, and a large enough and professionally qualified staff; especially nurses, who spend more time 

with the patient than any other professional. They are in their 

care, they are there 24 hours. And especially on a psychiatric ward 

you cannot depend on people coming in part-time, hitting it one 

time this week and another time next month. You have got to have 

consistency. 

I see that my time is up and I will be available for any questions. 

[The prepared statement of Congresswoman Johnson appears on 

p. 30.] 

Mr. MICHAUD. Thank you very much, Congresswoman. Congressman Salazar, thank you for introducing your piece of legislation 

and for your ongoing commitment to our veterans. I open it up for 

your comments. 

STATEMENT OF HON. JOHN T. SALAZAR 

Mr. SALAZAR. Well, thank you Mr. Chairman, Ranking Member 

Miller, and Members of the Subcommittee. I surely enjoy being a 

Member of this wonderful Committee and all the work that we all 

do for veterans. I appreciate the trip that we took to Iraq. That was 

a very enlightening trip. 

Mr. Chairman and Ranking Member Miller, first I would like to 

thank Dr. Jim Schraa, a neuropsychologist at Craig Hospital, and 

Anna Frese, with the Wounded Warrior Project, who submitted testimony for the record on the bill that I introduced, H.R. 3051, the 

‘‘Heroes at Home Act,’’ on July 17, 2007. 

The purpose of this bill is to improve the diagnosis and treatment of traumatic brain injury in current and former members of 

the Armed Forces. The program will be located in VA healthcare 

centers across the Nation. This is especially important in rural districts like mine where making healthcare accessible is a constant 

challenge. H.R. 3051 addresses the needs for access to care by expanding the U.S. Department of Defense (DoD) and VA telehealth, 

and telemental health programs. Ultimately the bill will ease the 

burden on our veterans suffering from TBI and the families who 

care for them. 

Our Committee has heard testimony from many veterans, VSOs, 

and the VA on mounting cases of TBI, PTSD, and other invisible 

wounds of war. I think that many of us agree that veterans are 

often worse off with those unseen injuries than those with visible, 

physical injuries. Unlike injuries that can heal, brain injuries are 

often permanently disabling. In addition, TBI can sometimes take 

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years to develop and diagnose. Even when discovered, the road to 

recovery is long and is borne by families of our brave men and 

women in uniform. 

We have also heard of the link between TBI and other mental 

conditions such as epilepsy. A DoD study after Vietnam found that 

15 percent of soldiers with a penetrating TBI developed epilepsy 

soon after their injury. H.R. 3051 creates a program to train family 

members of the TBI patients to become their personal care attendants. Participants going through the program would also become 

certified and receive compensation from the VA so that they can 

focus their energy on caring for their loved one. 

By taking place at home with family, the healing process is made 

more comfortable for our veterans. The cost to the VA for having 

someone cared for at home is less than having them at a medical 

facility and allows the VA to allocate the resources they have to 

serve more veterans. We have soldiers in Iraq and Afghanistan 

spending longer periods of time in harm’s way and away from their 

families, and with this in mind we need to ensure that there are 

programs in place to care for them when they return home. 

A program that provides quality care for our veterans and a financial benefit for the family seems appropriate for the difficult 

economic times our country is facing. Most importantly, the bill 

will help us reach our goal of ensuring our veterans the best care. 

Mr. Chairman, I still have 2 minutes and I anticipated some of 

the questions that you might have. If you do not mind, I would like 

to address some of those. I know that one of the questions is how 

much is this going to cost? The Congressional Budget Office has 

not scored this bill. However, the cost of having someone cared for 

at home is much less than having them at a medical institution. 

In fiscal year 2006, San Diego VAMC spent $825,000 for Personal 

Care Attendants (PCA) services for 52 veterans. This year they expect the service’s cost to be $1 million. They are currently providing home care services to 56 individuals. I believe that it is 

much less expensive to take care of these veterans at home with 

family members. We must keep in mind that a family member rate 

is less than $16 per hour versus a professional at a medical facility 

that may be charging $30 or more. 

The training will actually take place at home. Currently the Department operates a similar PCA training and certification program for the spinal cord injury (SCI), SCI population out of San 

Diego. Senate Bill 3421, the ‘‘Veterans Benefits Healthcare and Information Technology Act of 2006,’’ includes a provision which, in 

section 214, requires the establishment of a pilot program to improve caregiver assistance. I think that the language specifically 

mentions caregiver training and certification as part of the pilot 

and authorizes $10 million over the next 2 years. 

With that, Mr. Chairman, I think my time is up. I do appreciate 

your time. 

[The prepared statement of Congressman Salazar appears on 

p. 31.] 

Mr. MICHAUD. Thank you very much, Mr. Salazar. Ms. Shea-Porter, I want to thank you for coming this morning and presenting 

your piece of legislation, and thank you for fighting for our veterans as well. 

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STATEMENT OF HON. CAROL SHEA-PORTER 

Ms. SHEA-PORTER. Mr. Chairman, thank you for the opportunity 

to speak to your Subcommittee about a critical inequity facing New 

Hampshire veterans, the lack of full service in State healthcare. 

New Hampshire has not had a full-service veterans hospital since 

2001. New Hampshire is the only State without a full-service VA 

hospital or comparable facility. Veterans in Alaska and Hawaii receive care at military hospitals on base. While New Hampshire 

may be a small State, it has a veteran population of 130,000. Unlike many New England States whose populations are declining for 

veterans, New Hampshire’s veterans population is projected to 

grow over the next 10 years. 

Because New Hampshire does not have a full-service veterans 

hospital, our veterans are forced to travel out of State for some 

medical care. Veterans traveling from the most northern parts of 

the State can travel for 3 hours to Manchester and then be forced 

to travel another hour to Boston if referred there for care. Then 

they have to wait while everybody on that van receives their care. 

So we are sending our sickest and our most vulnerable to Boston 

to wait all day after traveling several hours to get to the central 

meeting point. This routinely happens. In 2007, 704 of our veterans 

were transferred out of State for acute care. Three-hundred fortysix of those veterans were sent to Boston. 

I have been calling for the VA to either restore the Manchester 

facility to full-service hospital care, or allow New Hampshire vets 

to receive care locally since I came to Congress. I have been working with both the VA and my colleagues to realize that goal. Chairman Filner visited the Manchester facility earlier this year and 

held a series of events, including a round table hearing in which 

we heard about the serious burdens placed on the New Hampshire 

veterans and their families simply because we do not have a fullservice hospital. And again, I would like to emphasize, the only 

State in the country. 

Despite these efforts, the administration refuses to either provide 

local access to care or restore the full-service hospital care to New 

Hampshire. I met with Secretary Peake at the Manchester VA 

Medical Center in June to express my interest in working with him 

to either restore the facility to a full-service hospital or provide 

local access. Unfortunately, after our meeting, Secretary Peake told 

the local press that there would be no full-service hospital in Manchester. 

The administration’s failure to act is just unacceptable. New 

Hampshire veterans deserve the best care possible and the current 

system is not delivering that. That is why I introduced H.R. 6629, 

the ‘‘Veterans Health Equity Act of 2008.’’ This legislation will ensure that veterans have access to at least one full-service VA hospital, or that they can receive care locally. That would mean that 

the VA would have to do one of two things, either restore the facility to a full-service hospital or provide more local care providers. 

The men and women in our local VA facility have done a herculean 

job caring for these vets despite the limits placed on them. The administration has recently shown some willingness to allow radiation therapy to be provided locally, but this is not enough. Our 

veterans, regardless of whether they need radiation therapy, menwwoods2 on PRODPC68 with HEARING

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tal health services, acute care, or anything else, need and deserve 

the care their counterparts in every other State receive. It is unconscionable that we deny them this full-service care and instead 

we offer ad hoc services. 

Mr. Chairman, I appreciate your leadership in providing the best 

healthcare for our Nation’s veterans. I am sure you and other 

members of your Subcommittee appreciate the challenges created 

by the lack of the full-service hospital. I look forward to working 

with you and the Subcommittee to address these challenges. Again, 

thank you for the opportunity to come and speak to you about this 

important issue and I look forward to answering any questions that 

you might have. Thank you. 

[The prepared statement of Congresswoman Shea-Porter appears 

on p. 31.] 

Mr. MICHAUD. Thank you very much, Congresswoman. And once 

again I would like to thank our first panel for your willingness to 

come before us this morning. Mr. Miller. 

Mr. MILLER. Thank you, Mr. Chairman. Ms. Shea-Porter, you 

only talk about the 48 contiguous States and you do not talk about 

Alaska. You talk about Hawaii, but what about the territories as 

well? Is there a reason—— 

Ms. SHEA-PORTER. Well my understanding, and again we were 

just looking at the ones coming from our States, but they can receive access at military bases. And so when we looked at just the 

50 States, and because that was the best comparison that we could 

make, we are the only State without it. And the others have access 

to military base hospitals. And so, it has really created a tremendous burden on these vets, especially as I indicated the oldest and 

the sickest. Because they are the ones who are being sent the farthest. And up until now, the families were not properly reimbursed 

for the travel. And when you look at who generally has to travel, 

it is an extra burden on the family and the community. If an 80- 

year-old man, for example, needs to go to the VA and he has got 

a 5-hour trip, that means his wife is probably about 80 years old 

herself, needs to find help to bring him at least to the first part 

to the Manchester VA, where they can then head off to Boston. 

So the burden is awful and is unfair. And New Hampshire veterans are aware of this. And here is the other problem. We need 

people to enlist in the service. And we have young men and women 

in New Hampshire looking at that and saying, ‘‘You know, that 

just does not seem fair.’’ And so, if we also want to make sure we 

recruit and bring our fine New Hampshire men and women into 

the service, we need to make sure that they know we will keep our 

promise to them and our commitment, and care for them when 

they return. 

Mr. MILLER. So, it is your understanding that veterans in American Samoa and the Virgin Islands have access to military hospitals? 

Ms. SHEA-PORTER. Well, I do not know what they do. I am just 

looking at the 50 States. And as I said, we are looking strictly at 

our 50 States and saying, ‘‘What do they do in every other State?’’ 

Mr. MILLER. Actually, you said the 48 contiguous States. 

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Ms. SHEA-PORTER. Well, that is because the other two have comparable care. And what I am asking for is either or. I am just asking for comparable care. I am not saying it has to be a full-service 

VA hospital as long as they allow contracts locally so that our servicemen and women are not forced to take on an undue burden. 

Mr. MILLER. Thank you. That is all. 

Mr. MICHAUD. Mr. Hare. Questions? Mr. Brown. Ms. Berkley. 

Okay. I just have one. Thank you, Mr. Salazar, for answering the 

question I had for you. I appreciate that. 

Ms. Shea-Porter, you had mentioned that Secretary Peake said 

no hospital. Did Secretary Peake at least acknowledge that there 

is a concern with veterans accessing healthcare? Is he willing to do 

some type of comparable care, whether it is contracting our services in different regions of New Hampshire? 

Ms. SHEA-PORTER. Well, actually I could not get an answer from 

him. I finally said to him, ‘‘Mr. Secretary, are you saying yes or 

no?’’ and he said, ‘‘Neither.’’ And so, you know, I could not get an 

answer. But I do know that shortly thereafter they talked about 

providing radiation care in the community. But this really has been 

a long festering problem. And when we looked at the numbers of 

veterans from other States, and we looked at their ability, there 

cannot be any explanation for it. You know, we have looked at the 

stats and there is just no explanation for New Hampshire being 

without some kind of care there. 

And, again, I am not insisting that they build a full-service VA 

hospital. I want to do whatever is the most economical and practical. But we have to keep our commitments to our veterans and 

that is why I am sitting here today. We owe it to these New Hampshire vets. 

Mr. MICHAUD. Now, you mentioned the time it takes for veterans 

to travel to Boston. My concern is access to healthcare and Maine, 

as you know, is a very rural State and we have to travel long distances. Normally, when we say it is going to take 4 hours to travel 

from one end to Togus, that is at, the speed limit. When you say 

it is going to take 4 hours, how does that traffic affect your veterans traveling? Is it 4 hours because of congestions? Or is it 4 

hours depending on what time they go during the day? 

Ms. SHEA-PORTER. Right. Well, when they start off, and the furthest point from my district could be an hour and a half to 2 hours 

from the tip of the district down. And it is not that heavy. I mean, 

it is New Hampshire. It does not look like Washington traffic for 

sure, but the roads are slower, because if you get in front of a car. 

So you add that time. And then when they get to Manchester and 

they have to take a van, and that is when the traffic really becomes 

very difficult. And so many of our older vets simply must travel in 

a van for a number of reasons. Their unfamiliarity with the roads 

and with urban districts and driving in cities, they are elderly, and 

they are ill. And it is pretty hard to find people in your neighborhood who are happy about driving 4 hours to Boston, you know, 

and going through, and picking their way through that traffic in 

that very heavily congested area in an area that they are not familiar with. 

So that means they have to come to Manchester and be loaded 

on the van. And there are other people who are receiving services 

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as well. And so they come to an urban VA, which is very busy, and 

they have to wait all day. And so these trips are absolutely exhausting them. They can go, you know, for hours and hours and 

hours. From Manchester to the VA can take an hour and a half. 

It does take an hour and a half, it can take 2 hours. Add that in 

addition to the 2 to 3 hours, you know, each way, 5 hours, and then 

the wait. And you get a sense of what we are putting them 

through. And again, they are our oldest and our sickest that are 

being sent down. 

Mr. MICHAUD. Thank you very much. Once again, I would like 

to thank our first panel for your testimony this morning. I look forward to working with you as we work to make sure our veterans 

get the adequate healthcare that they need. Once again, thank you 

very much. 

I would like to welcome the second panel. As they come, it is Joy 

Ilem who works for the Disabled American Veterans (DAV), Joseph 

Wilson from the American Legion, and Dr. Thomas Berger from the 

Vietnam Veterans of America (VVA). I would like to thank our second panel for your willingness to come today and to give your testimony on the bills that we have heard from our first panel. 

I would like to start off with Ms. Ilem. 

STATEMENTS OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; JOSEPH 

L. WILSON, DEPUTY DIRECTOR, VETERANS AFFAIRS AND REHABILITATION COMMISSION, AMERICAN LEGION; AND 

THOMAS J. BERGER, PH.D., SENIOR ANALYST FOR VETERANS’ BENEFITS AND MENTAL HEALTH ISSUES, VIETNAM 

VETERANS OF AMERICA 

STATEMENT OF JOY J. ILEM 

Ms. ILEM. Thank you Mr. Chairman and Members of the Subcommittee. Thank you for inviting the Disabled American Veterans 

to testify at this legislative hearing. We appreciate the opportunity 

to provide our views on the bills under consideration by the Subcommittee today. 

DAV supports the provisions in H.R. 3051, which would establish 

a program for training and certification of family caregivers of 

servicemembers and veterans with traumatic brain injury, and authorize these personal care attendants to receive compensation for 

such services. This program would allow these family members to 

have standardized and consistent training and to receive compensation that recognizes their efforts that will help to ensure the 

stability of the family at an extremely difficult and vulnerable 

time. We note, however, this section of the bill only addresses veterans with traumatic brain injuries but could also benefit other 

catastrophically injured veterans with long-term personal assistance needs, such as veterans with spinal cord injuries or severe 

physical trauma without brain injury. If successful, we would like 

to see this provision related to training and support for caregivers 

expanded to other catastrophically disabled veterans requiring 

caregiver assistance. 

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DAV also supports provisions in the bill requiring outreach to 

educate and make veterans and the public aware of the symptoms 

of PTSD and TBI, and make available best practices for these conditions to non-VA healthcare providers. Often a family member is 

the first to notice cognitive changes in the veterans’ behavior and 

mood. Thus informing the general public is an important element 

of this bill. Likewise, we appreciate the dissemination of best practices on TBI and PTSD to non-VA providers to help ensure that 

veterans who may seek care outside the VA and DoD systems benefit from their expertise. 

Mr. Chairman, DAV also supports but with some concerns Section 4 of this bill to assess the feasibility of using telehealth technology to assess cognitive functioning of military members and veterans who have sustained TBI, with a priority in rural areas. We 

support efforts to assess new web-based diagnostic tools for the 

prevalent cognitive conditions that are emerging among our returning veterans. However, we ask the Subcommittee to ensure that 

any partnership with the private sector to expand telemedicine in 

rural areas include coordination through VA’s Office of Rural 

Health and be supplemented by appropriate resources. 

On a final note, we ask the Subcommittee to also consider expanding this measure to include a standardized and more comprehensive package of support services for caregivers, including financial support, health and homemaker services, respite, education, training, and other necessary relief services. Family members of severely injured veterans often shoulder great and lifelong 

responsibility as home and institutional caregivers, giving up or severely restricting their own employment and educational advancement, and social opportunities. Not surprisingly, family caregivers 

often suffer severe financial and personal hardships as a consequence of providing care to a severely disabled veteran. Yet, in 

their absence, an even greater burden of direct care would fall to 

VA and DoD at significantly higher cost to the Government and reduced quality of life for these veterans who have sacrificed so 

much. 

H.R. 3051 would provide welcome relief to family caregivers of 

severely disabled veterans and is consistent with DAV Resolution 

165 and recommendations of the fiscal year 2009 Independent 

Budget. Therefore, we support this measure and urge the Subcommittee to work toward its enactment. 

The next bill for discussion is H.R. 6153, the ‘‘Veterans Medical 

Personnel Recruitment and Retention Act of 2008.’’ Along with our 

partners in The Independent Budget, DAV has called for improvements in VA policies and procedures used to recruit and retain 

highly qualified VA clinical staff. VA needs new authority to 

achieve and sustain its goal to be competitive with private sector 

providers and become a preferred employer for physicians, nurses, 

dentists, and other medical personnel needed to care for our enrolled veterans. 

This bill aimed at providing meaningful financial and professional incentives to encourage VA medical personnel to pursue full 

careers in the VA healthcare system is timely and appropriate 

given all of the challenges VA faces to maintain delivery of timely, 

high quality, comprehensive healthcare services to our Nation’s 

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veterans. The Independent Budget conveys a series of recommendations that are fully consistent with the intent of this bill. Therefore, 

DAV has no objection to its enactment. 

Mr. Chairman, on the final bill under consideration, since we did 

not have a chance to really review that thoroughly, we will be 

happy to submit in writing our views on that final bill. Thank you. 

[The prepared statement of Ms. Ilem appears on p. 32.] 

Mr. MICHAUD. Thank you. Mr. Wilson. 

STATEMENT OF JOSEPH L. WILSON 

Mr. WILSON. Mr. Chairman and Members of the Subcommittee, 

thank you for this opportunity to present the American Legion’s 

views on these three important pieces of legislation. 

H.R. 3051, the ‘‘Heroes at Home Act of 2007.’’ This bill seeks to 

improve the diagnosis and treatment of traumatic brain injury in 

members and former members of the armed services, to review and 

expand telehealth and telemental health programs of the Department of Defense and Department of Veterans Affairs, and for other 

purposes. Section 2 of H.R. 3051 requests the Secretary of VA to 

establish a program on training and certification of family caregivers of veterans and members of the active-duty armed forces 

with traumatic brain injury as personal care attendants. 

Pursuant to Section 744(a)(2) of Public Law 109–364, the Veterans Traumatic Brain Injury Family Caregiver Panel was established in 2007. The 15-member panel was created by the DoD to 

operate under the Department of Health as a Subcommittee to advise and specifically provide DoD and VA with independent advice 

and recommendations on the development of training curricula to 

be utilized by the above mentioned family members on techniques, 

strategies, and skills for care and assistance for such individuals 

with TBI, or traumatic brain injury. The panel was convened on occasions, to include a recent townhall meeting to discuss matters related to the development of this curriculum and to hear from the 

public about the issue. 

Now, the American Legion asserts that the advice of this subcommittee, incorporated into the provisions of this piece of legislation, is vital and that its absence may deprive such a bill of an effective stance and approach to treatment and care of TBI. The 

American Legion, in its continuing efforts to increase access and 

quality of care to all eligible and potentially eligible veterans, supports this proposal as it would help to accomplish this ongoing 

challenge. 

H.R. 6153, the ‘‘Veterans Medical Personnel Recruitment and Retention Act of 2008.’’ This bill seeks to amend Title 38 of the 

United States Code to enhance the capacity of VA to recruit and 

retain nurses and other critical healthcare professionals in addition 

to addressing other issues. The American Legion applauds this proposal to amend the methods of hiring and retain an additional 

medical personnel of various disciplines to adequately equip VA 

medical facilities to ensure the adequacy and quality of treatment 

and care. The American Legion supports the proposal requested in 

section 2(j), which seeks to amend 7451(c)(2) to allow critical fields 

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such as nurse anesthesiologists to exceed rate limitations on authorized competitive pay. 

Although VA has various anecdotal programs in place to include 

recruitment, relocation, and retention incentives for these hard to 

fill positions, there remains a shortage of such nurses and specialty 

medical physicians. The overall response to the question of shortage indicated that salaries and delays in appointments were key 

causative factors. The American Legion, during its VA Medical 

Center site visits to 49 facilities in 2008, encountered various recruitment issues, including such delays in the appointment of nursing assistants. Management attributed these delays to the 3- to 4- 

month hiring process. By the time management completed the hiring process, applicants had accepted a position in the private sector. 

Also in their site visits, the American Legion representatives 

ascertained other areas with difficulty recruiting. These included 

mental health positions, specifically psychologists and psychiatrists, dermatology, gastroenterology, orthopedics, and anesthesia. 

A study published in the New England Journal of Medicine 

ascertained there were shorter inpatient delays and lower complication rates in hospitals with higher staffing levels while there 

were longer inpatient stays and increased urinary infections, gastrointestinal bleeding, pneumonia, and shock or cardiac arrest in 

hospitals with lower staffing levels. 

We hereby urge Congress to act on this piece of legislation by incorporating it into the VA system to prevent the healthcare system 

from being included in the casualties of the projected shortage of 

medical professionals through the year 2020. 

And I will briefly comment on H.R. 6629, the ‘‘Veterans Health 

Equity Act of 2008.’’ The bill seeks to amend Title 38, United 

States Code, to ensure that veterans in each of the 48 contiguous 

States are able to receive services in at least one full-service hospital of the Veterans Health Administration (VHA) in the State or 

receive comparable services provided by contract in the State. The 

American Legion wholeheartedly concurs with one proposal portion 

of this bill, which urges the Secretary of VA to allow veterans equal 

access to full-service hospitals. However, in Section 2, the terminology, ‘‘certain States,’’ leaves question of an alternative or adverse motive unfavorable to proposals to further enhance access 

and quality of care across the board within the VA healthcare system. In addition, under Section 2 the proposal to insert the language, ‘‘access to full-service hospitals in certain States,’’ once 

again does not warrant unanimous support for this piece of legislation. The term ‘‘certain’’ implies some States as opposed to all. 

The purpose of this piece of legislation, which is also the leading 

opening statement of the bill, seems to be contradicted by Section 

2, which includes such language as stated in the above mentioned 

paragraph. The uncertainty of this legislation leads the American 

Legion to avoid a position on this bill. 

Mr. Chairman and Members of the Subcommittee, the American 

Legion sincerely appreciates the opportunity to submit testimony. 

Thank you. 

[The prepared statement of Mr. Wilson appears on p. 38.] 

Mr. MICHAUD. Thank you very much. Dr. Berger. 

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STATEMENT OF THOMAS J. BERGER, PH.D. 

Mr. BERGER. Mr. Chairman, Ranking Member Miller, and distinguished Members of this Subcommittee and guests, the Vietnam 

Veterans of American, VVA, thanks you for the opportunity to 

present our views on these important pieces of legislation affecting 

the healthcare of America’s troops and veterans. With your permission, I shall try and keep my remarks brief and to the point. 

In general, Vietnam Veterans of American supports the intent of 

H.R. 3051. But remember, medical experts say that traumatic 

brain injuries are the signature wound of the Iraq War in particular and in fact TBIs have become so commonplace that we are 

yet again focused on them today in this hearing. Certain TBI symptoms, such as seizures, can be treated with medications. But the 

most devastating effects, such as depression, agitation, and social 

withdrawal are difficult to treat with medication, especially when 

there is loss of brain tissue. In troops with documented TBIs, the 

loss of brain function is often compounded by other serious medical 

conditions that affect physical coordination and memory functions. 

These patients need a combination of psychological and physical 

treatment that is difficult to coordinate in a traditional medical setting, even when properly diagnosed at an early date. And we must 

remember that both concussive and contusive brain injuries are 

never just isolated injuries. Over time, without proper diagnoses, 

care, and treatment, TBI can affect nearly everything about the 

survivor, including one’s cognitive, motor, auditory, olfactory, and 

visual skills, perhaps ultimately resulting in behavioral modifications and definitely not a mental illness. Families say that they 

struggle with the military and the VA medical systems that were 

unprepared for these wounded. In some cases, new equipment and 

specially trained staff needed for the most catastrophic cases are 

not available, or have not kept pace with the advances in battlefield medicine that kept these servicemembers alive. In addition, 

there are issues about intensity and drain of needed family support 

that will be hard to sustain, as well as the significant issues regarding the complexity of the medical and other specialized needs 

that need to be addressed with TBIs. Of all the War’s medically 

challenging injuries, brain injuries require the most personal involvement, dedication, and cost over time. 

As you are well aware, one of the recommendations of the DoleShalala Commission was to significantly strengthen support for 

families. This will not be an easy task, but VVA believes that H.R. 

3051 can be a key step in achieving this recommendation and providing a mechanism for empowering the families of brain-injured 

servicemembers if, and only if, the VA can develop effective implementation strategies for certification, competency evaluations, and 

meaningful outcome measurements to carry it out. As they say, the 

devil remains in the details. And part of our concern, of course, lies 

with the fact that there is so much variation amongst the States’ 

regulations relative to training, certification, outcome measurements, et cetera, for brain-injured persons. It will be a difficult 

task. But if the VA can pull it off, it certainly holds hope for family 

members. 

Regarding H.R. 6629, we certainly, we did not submit any written testimony but we certainly support equitable pay and hiring 

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processes that will permit our professional staff at the VA facilities 

to at least achieve comparable pay and salaries with those in the 

private sector to provide the care that is needed by our veterans. 

Regarding the, excuse me, that was not H.R. 6629. That was 

H.R. 6153. On H.R. 6629, we just got that on Friday and we have 

not had an opportunity. Now we have heard some background information and we will submit written testimony in 10 days. Thank 

you very much for the opportunity to do this. 

[The prepared statement of Dr. Berger appears on p. 39.] 

Mr. MICHAUD. Thank you very much, doctor. Once again, I would 

like to thank the panel. A couple of questions. Ms. Ilem, you had 

raised concerns with implementing the caregivers’ training program in each of the VA Medical Centers due to the lack of capacity, 

and recommend that the program be limited to polytrauma centers 

and other units within the Defense and Veterans Brain Injury Network to ensure the training is high quality. Do you have any suggestions on how we can address, the challenges you highlighted so 

that the program can be implemented in all VA Medical Centers? 

Ms. ILEM. Well, we did note that so that, you know, initially because we felt that probably that is where the families would be. 

You know, where those patients would be and have the initial opportunity to work with those families. So to keep consistency, you 

know, hopefully to be able to develop some best practices to make 

sure it is consistent, standardized training, to do that, and then to, 

you know, be able to press that out, if necessary, you know, depending on, you know, the need for that. But since so many of 

those veterans are either going to the Veterans Integrated Services 

Network (VISN) area, one of the polytrauma, you know, level one 

polytrauma centers, or then, you know, to their VISN level 

polytrauma center we felt that would be the most appropriate place 

to start just to maintain that high quality and consistency of training. 

Mr. MICHAUD. Mr. Wilson, I did not expect you to comment on 

the Congresswoman’s legislation, but since you did and did not 

take any position on it, would you, having heard her testimony, 

agree that it is important for veterans, regardless of where they 

live, to have access to healthcare? I can understand the concern 

with building a brand new hospital. I want to make sure that veterans get the services they need versus bricks and mortar. But it 

appears that the concern is that there is a large number of veterans who have to travel 4 hours to get the care that they need. 

Would you agree that it is important that, if there is care that is 

needed, whether it is fee-for-service or otherwise, that that be provided? 

Mr. WILSON. Well, in terms of access, and from my experience in 

traveling throughout various VISNs in this Nation, and even to include Puerto Rico, there is an issue with access in addition to New 

Hampshire. The American Legion does not exclude any one particular VA Medical entity within the VA healthcare system. That’s 

where we have concerns regarding the overall piece of legislation 

itself. However, there were portions, in regards to the access of 

care, level of care, and quality of care at New Hampshire. And I 

am sure someone can attest to access as an issue. Let’s use Nevada, because with Nevada has a large catchment area. There is 

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an issue with traveling to various VA medical facilities in Nevada. 

And I can name quite a few, actually, in regards to access. We have 

‘‘A System Worth Saving’’ booklet, our annual publication that we 

disseminate to Congressional Members. You can read it in the 2008 

publication, regarding access issues. So we do support the issue of 

improving access to care. However, regarding that it is not a competition here. We would like to take all VA medical facilities to that 

level of quality access and care. 

Mr. MICHAUD. Thank you. Mr. Miller. Mr. Hare. 

Mr. HARE. Thank you, Mr. Chairman, I just have a couple of 

quick questions here on, for the VVA on H.R. 3051. You highlight 

the need to ensure that VA develop effective implementation strategies for certification, competency, evaluation, and meaningful outcome measurements. I wonder if you could expand on that point? 

And then, is there additional legislative text that you would recommend adding to the bill to ensure that the provisions in the bill 

are implemented effectively? 

Mr. BERGER. Thank you, sir. In regard to the first part of the 

question, I refer to my comment that there is a great deal of variation amongst the States relative to private and not-for-profit institutions or agencies that offer these kinds of services, particularly 

in rural areas across the country. And I am not hinting that they 

are bad in this State or they are better in this State, I am just saying there is no standardization across the country. 

My own personal experience in working both with Easter Seals 

of Illinois and United Cerebral Palsy brings this to the forefront. 

The standards for caregivers for brain-injured persons in these organizations in two parts of the country were extremely different. I 

think that if the VA were to develop a standardized process, for 

lack of a better term, not to run through everything that I said, 

this would help greatly. And then the family members could take 

advantage of this. 

We are going to have a problem down the road, particularly in 

rural areas, with family caregivers taking care of folks if they do 

not receive proper, standardized training. 

Mr. HARE. I just wanted, maybe all three of you could comment 

on this, on H.R. 6153, supporting the legislation. Are there other 

health professionals who are not included in H.R. 6153 who face recruitment and retention challenges and would benefit from flexibilities provided in the bill? For example, I know the Paralyzed 

Veterans of America (PVA) in their statement for the record identified a shortage of spinal cord injury disease nurses and the need 

to apply the specialty pay provisions to the groups. So I guess what 

I am asking you, are there other health professionals that ought to 

be included in the bill, or concerns that you may have with that? 

Mr. WILSON. In regards to specialty medical positions, I do not 

want to, I cannot specify further than what I have recorded on 

paper. However, speaking from our various site visits I can; we will 

soon disseminate the ‘‘System Worth Saving’’ publication in which 

you could actually read for yourself from the horse’s mouth, if I can 

say in retards to the various shortages. The concern, in discussion, 

comes from management within each respective VA medical facility. 

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Mr. BERGER. Mr. Hare, I would certainly add those specialized 

social workers that deal with brain injury and seizure disorders. 

Ms. ILEM. I would agree with PVA’s statement and I am not, any 

other ones have not been brought to our attention, that have been 

missed. But if we are made aware of any of those we will certainly 

forward those on. 

Mr. HARE. Thank you very much. Thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you, Mr. Hare. Mr. Snyder. 

Mr. SNYDER. Thank you, Mr. Chairman. Mr. Wilson, I wanted to 

follow up a little bit on this issue that Mr. Michaud asked about 

with regard to Carol Shea-Porter’s bill. Because I think we are all 

in agreement, you know, we want access for all veterans. It is just, 

I guess it is the reality of the human condition is we tend to nibble 

off things that we can, you know, bite-sized morsels and move on. 

I mean, we have a bill coming out on the floor I think tomorrow, 

or this week, or something, Jerry Moran’s bill. It came out through 

this Committee and it, what do we call it, highly rural areas because we recognize that distances in rural areas are, can make it 

prohibitive. So I, while I understand we are trying to equalize everything, I would also hope we would recognize there may well be 

a peculiar nature of New Hampshire. 

I have traveled in Nevada a fair amount. I have traveled some 

in New Hampshire. It can be hard to get around New Hampshire 

some times of the year. I had trouble walking in New Hampshire 

at certain times of the year. I just want us to appreciate that driving 100 miles in certain parts of the country is probably a whole 

lot different than driving 100 miles in New Hampshire in the wintertime. And so I do not think we should be afraid of doing something that helps one State that for probably historical reasons 

never got themselves a VA hospital for whatever reasons in years 

ago in the past. I do not think we should not be willing to deal with 

that problem hoping that somehow we are going to correct all of 

the problems of access to healthcare before we deal with New 

Hampshire. That does not seem a very good approach. And I use 

as a model as somebody already did the highly rural area we are 

trying to, as a pilot, that Jerry Moran’s bill, which I think you all 

supported. I think the American Legion did support Jerry Moran’s 

bill and it does not deal with nationally. So thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you, Dr. Snyder. Ms. Berkley. 

Ms. BERKLEY. I have no questions of the witnesses but I want 

to thank you for taking time out and coming to testify. 

Mr. MICHAUD. Mr. Salazar. 

Mr. SALAZAR. Thank you, Mr. Chairman. Mr. Berger, do you believe that H.R. 3051 actually begins to implement the provisions of 

the Dole-Shalala recommendations? 

Mr. BERGER. I think that particular recommendation about support for the family is contained in the bill, yes, sir. 

Mr. SALAZAR.. Let me just read you a little bit of the statement 

that was submitted for the record by Anna Frese, who is with the 

Wounded Warrior Project. She talks about her brother, Retired 

Army Sergeant Eric Edmundson, who was seriously injured in Iraq 

in October 2005 and is currently living at home receiving 24/7 care 

from her father, Edgar Edmundson. This is what the father experiwwoods2 on PRODPC68 with HEARING

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enced. ‘‘Upon learning of Eric’s lifelong challenges, our father resigned his position at work in order to provide Eric the full-time 

care that he needed. This decision did leave him and our mother 

with one less income, and in times of need they had to dissolve 

their personal and retirement savings. Just as importantly, now at 

53 years old, my father is no longer covered by health insurance.’’ 

So these are the kinds of issues that families face—— 

Mr. BERGER. Yes, sir. 

Mr. SALAZAR [continuing]. Eespecially in rural communities 

where they do not have facilities close by. It seems to me that soldiers or patients who have gone through some kind of traumatic 

brain disorder can actually recover better and have a better quality 

of life by having family caregivers. Is that correct? 

Mr. BERGER. That is absolutely correct, sir. 

Mr. SALAZAR. Thank you. I would ask for Mr. Wilson and Ms. 

Ilem to comment on that as well? 

Mr. WILSON. I have no comment currently. Please refer to our 

book, ‘‘A System Worth Saving.’’ 

Ms. ILEM. We would agree that the family caregiver issue, just 

as you have noted, in talking with family members you see how 

their lives are impacted and DAV is very supportive of doing everything we can to support the caregiver to make sure veterans have 

the best care possible, and in the best environment for those veterans. 

Mr. SALAZAR.. Well as you know, VA does not support H.R. 3051 

because they say there are current provisions and existing efforts 

that accomplish the goals of the caregivers training program and 

outreach for PTSD and TBI patients. Would you comment on that? 

Mr. BERGER. Again—— 

Mr. SALAZAR. Are the programs that are already in place sufficient? 

Mr. BERGER. I do not believe that they are, sir. 

Mr. WILSON. I also disagree that they are. The Veterans Traumatic Brain Injury Family Caregiver Panel, which is in place, has 

not been fully effective in resolving that issue of that disconnect, 

of that family, or family member, or even an associate being a caregiver to that particular patient. As I stated in the testimony, 

maybe the two in a contiguous effort, or maybe the two actually in 

consortium may be able to decrease the gap there and allow for 

more continuous care. 

Mr. SALAZAR. Ms. Ilem. 

Ms. ILEM. In just briefly looking over VA’s testimony, I think 

they indicated that they are providing their certification and training for these family caregivers through, you know, already an outside third party that is doing that. And I think in just, you know, 

looking at that this morning, you know, the concern would be with 

these very special cases of TBI and the very high-care needs of 

these veterans and the family members, you know, if we are really 

understanding and making sure that they can go the distance to 

provide that care as well, to make sure that they are taking care 

of themselves. We would like to have VA, you know, at the forefront because these are some very specific, you know, service connected injuries that are occurring, for them to be at the forefront 

of providing the training and certification to make sure that they 

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have, you know, the really overview and the quality of that care 

that they hold so high in esteem in VA. 

Mr. SALAZAR.. Would any of you wish to comment on how you 

feel that this would actually save the VA some additional monies 

by being able to take care of these veterans at home? 

Mr. BERGER. Certainly, sir, your testimony threw out some dollar 

figures that I think are absolutely right in line. I do not think you 

can put a dollar value on the care that can be given by family 

members who are properly trained to care for these brain-injured 

troops. And so I will leave it at that. I do not think you can put 

a price tag on it. 

Mr. WILSON. In regards to TBI itself, there are other issues arising from TBI, to include blind eye injury and PTSD. If TBI is left 

untreated, it becomes difficult to distinguish from other disorders. 

For example, a lay person who does not understand the symptoms, 

or in denial, can attribute to the breakdown in his/her family. That 

is also an added issue. And after reading this particular piece of 

legislation, we were in agreement at the American Legion that this 

was something that needed to be implemented. 

Mr. SALAZAR.. Ms. Ilem. 

Ms. ILEM. I think without question the costs would be higher if 

left to the Government to provide, you know, full-time in-house 

care versus at home. But I think that most importantly it is the 

quality of life. And if the family wants to provide that care for their 

loved one, then they should be provided the resources they need 

and the support that they need to provide the best care to that veteran. But I think cost aside, the quality of care issue is probably 

the most important. 

Mr. SALAZAR. Thank you all for your testimony. I yield back, Mr. 

Chairman. 

Mr. MICHAUD. Thank you very much, Mr. Salazar. Once again, 

I would like to thank all three of you for your testimony here this 

morning. 

The last panel is Dr. Cross, who is the Principal Deputy Under 

Secretary of Health, and will be accompanied by Walter Hall and 

Joleen Clark. I want to thank you all, for coming here today to give 

your testimony on the two pieces of legislation we have, and the 

third piece that was added at the last moment. Without any further ado, Dr. Cross. 

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

DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS; ACCOMPANIED BY WALTER A. HALL, ASSISTANT 

GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL, U.S. 

DEPARTMENT OF VETERANS AFFAIRS; AND JOLEEN M. 

CLARK, CHIEF OFFICER, WORKFORCE MANAGEMENT AND 

CONSULTING, VETERANS HEALTH ADMINISTRATION, U.S. 

DEPARTMENT OF VETERANS AFFAIRS 

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

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

the administration’s views on two bills under consideration, H.R. 

3051, the ‘‘Heroes at Home Act of 2007,’’ and H.R. 6153, the ‘‘Veterans Medical Personnel Recruitment and Retention Act of 2008.’’ 

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VA recently received H.R. 6629, the ‘‘Veterans Health Equity Act 

of 2008,’’ and is not prepared to address the bill today but we will 

be happy to submit our views and cost estimates on the bill for the 

record. VA is still preparing cost estimates on the other two bills 

on today’s agenda. As soon as those become available, we will supply them for the record. Also, I want to say I am accompanied 

today by Mr. Walter Hall, Assistant General Counsel, and Mrs. 

Joleen Clark, our Chief Officer for Force Management and Consulting. 

[As of January 12, 2009, the VA failed to provide the Administration views on H.R. 3051, H.R. 6153, and H.R. 6629.] 

I will begin with H.R. 3051. section 2 would require VA to establish a program to train and certify family members of veterans and 

servicemembers with traumatic brain injury, which is also called 

TBI, as personal care attendants. VA supports using family members as caregivers for these veterans, but believes VA’s current 

home healthcare program already accomplishes this in a more efficient and effective manner than would be possible under the bill. 

Implementing section 2, as written, could give rise to potential conflicts concerning the veteran’s care between the family member, the 

caregiver, and the VA, with the veteran. This would place VA in 

an untenable position. We strongly urge the Congress to allow VA 

to continue to obtain caregiver services under the Home Healthcare 

Program, which uses a third party to provide for the training and 

payment of personal care attendants. 

Subsection 3 of H.R. 3051 would require VA to conduct a comprehensive outreach to enhance the awareness of veterans and the 

general public about the symptoms of post traumatic stress disorder and TBI and available VA healthcare services. VA already 

has an extensive and expanding outreach program in place to inform veterans and the general public about PTSD and TBI, as well 

as the services we provide to veterans with these injuries. We, 

therefore, think this statutory mandate is not necessary. 

Section 4 would require DoD and VA to jointly establish a demonstration project to assess the feasibility and advisability of using 

telehealth technology to assist cognitive functioning of Members 

and former Members of the Armed Forces who have sustained head 

trauma in order to improve the diagnosis and treatment of TBI. VA 

supports the goals of this provision, but cannot support this section 

as written because it is too prescriptive. VA and DoD should be allowed more flexibility in executing the demonstration project and 

would be pleased to work with the Subcommittee’s staff to develop 

legislative language that would enhance its value. 

I turn now to H.R. 6153, the ‘‘Veterans Medical Personnel Recruitment and Retention Act of 2008.’’ We support many provisions 

that would contribute to VA’s mission, such as the expansion of 

VA’s education assistance program outlined in section 4. Similarly, 

we endorse several measures that would improve VA’s ability to 

provide comparable pay and benefits to nurses, physicians, and executives. Other sections of the bill need only minor adjustments, 

such as the authority to add nurse assistants to the list of so-called 

hybrid occupations. We believe this authority should apply to 

healthcare delivery occupations in general. 

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However, there are some provisions that would negatively impact 

patient care and VA must oppose. Subsection 2B would change the 

probationary period for full and part-time registered nurses from 2 

years to the equivalency of 4180 hours. Part-time Title 38 employees, including RNs, do not serve probationary periods. These apply 

only to full-time permanent employees. We see no benefit in creating a probationary period for part-time nurses, since it would not 

make them the equivalent of tenured employees for purposes of discipline or discharge. 

VA also opposed section 2C, which would limit temporary parttime employments of hybrid nurses, specifically licensed practical 

nurses, LPNs, and licensed vocational nurses, LVNs, to no more 

than 4180 hours. Currently, the part-time hybrid appointments 

may be for periods exceeding 1 year. Operationally, this change 

could severely limit VHA by preventing us from appointing highly 

qualified LPNs and LVNs who only want to work on a part-time 

basis. 

Finally, we oppose Subsection 2M since it appears to create a 

windfall by extending premium paid benefits for employees performing occasional work. We also note subparagraph 2 would not 

be limited to registered nurses, which we understand is the intent 

of this provision. It would also apply to other employees. We are 

similarly concerned that Subsection 3B, which would amend the 

‘‘Baylor Plan,’’ could provide an unwarranted bonus structure. 

Mr. Chairman, this concludes my prepared statement. I am 

happy to answer any questions that you or the Subcommittee may 

have. 

[The prepared statement of Dr. Cross appears on p. 40.] 

Mr. MICHAUD. Thank you very much, Dr. Cross. You noted that 

VA refers interested family members to home health agencies that 

VA contracts with. How many referrals has VA made and does VA 

pay for the training? 

Dr. CROSS. Under our program right now, VA currently contracts 

with more than 4,000 home health agencies that are approved by 

the Centers for Medicare and Medicaid Services and/or State licensed. And many of these have expertise in training and certifying 

home health aides. Many of them also are found in rural settings 

and we can engage them there. I do not have for you the exact 

number of individuals within that program. 

Mr. MICHAUD. Could you provide that for the Committee? 

Dr. CROSS. Yes, sir. 

Mr. MICHAUD. Of the referrals, how many, have completed the 

certifications as well. 

Dr. CROSS. Yes, sir. 

[The following information from VA was subsequently received:] 

In situations where a veteran will require long-term or lifetime care or assistance in the requirements of daily living, VA provides counseling and 

training to family members and other caregivers who are capable and willing to take on this responsibility. VA is not authorized to pay these individuals and, for practical and legal reasons that were discussed in our testimony and at the hearing, we do not believe VA should be the appropriator 

or payer. 

When it is clinically necessary and appropriate, VA has arrangements 

with local contractors who will provide caregiver training to family members and qualify them to be a State certified caregiver. Following State cerwwoods2 on PRODPC68 with HEARING

21 

tification, the family member caregiver may become a certified, salaried employee of that contractor or another entity that provides caregiver services. 

The decision for referral to a contractor is made on a case-by-case basis. VA 

has no data on the number of individuals who elect to use this process. 

Mr. MICHAUD. Does the VA provide respite care while the family 

caregiver is in training programs so that the family can continue 

to care for the needs of the veteran? 

Dr. CROSS. Yes. Our respite program is more broadly construed. 

It can be for any number of reasons. It would not be limited to just 

that one reason. 

Mr. MICHAUD. In your testimony you identified language on the 

telehealth demonstration as being too prescriptive and detailed. 

Can you expand on that? What type of flexibility do you need? 

Dr. CROSS. We are working with DoD and the Center of Excellence already, and we want to continue doing that, and intend to 

do so. Some of the language in the bill relating to using telehealth 

for educational purposes is kind of a mixed approach, using something that we use for diagnosis and treatment for what appeared 

to be a more broad reaching outreach effort. And we use other modalities for that. We did not think that was a well constructed component within the bill. 

Other portions of the bill relating to the reporting requirements 

would be substantial. We can work with your staff, sir, to try and 

mitigate that. I think clearly on the intent, we have the same intent. 

Mr. MICHAUD. Good. Thank you. On H.R. 6153 you mention that 

it is hard to recruit occupations that this provision would help 

with. Can you give us, some of the top five occupations that you 

are referring to? 

Dr. CROSS. I will ask Ms. Clark to comment. 

Ms. CLARK. Each year we do a, what we call Successions Strategic Plan and we have the networks update their plans. And we 

have what we call our top ten critical occupations. And those this 

year are the traditional ones, nurses, physicians, pharmacists, 

LPNs. We do have an administrative one in there, human resources, occupational therapists, physical therapists, medical technologists. Of the physicians there is several occupations that were 

mentioned, actually, earlier in some of the testimony. Gastroenterologist, anesthesiologist, psychiatrist, there are a few others. 

And then inpatient nursing areas, we do have a few that we target 

and certified registered nurse anesthetists are also one of those occupations. 

Mr. MICHAUD. Thank you. You mentioned in your testimony that 

VA is facing worsening pay compensation issues within the ranks 

of senior pharmacy program managers in VHA, and that special incentive pay provisions for pharmacist executives would not address 

the retention need for the agency in the long run. Could you explain what that need might be, number one? And number two, 

what are you doing to try to address that need? That is, I know 

actually, in VISN 1, they are looking at building a brand new community-based outpatient clinic (CBOC) in the Bangor area, but also 

we have a private college that is interested in working collaboratively with VA for a pharmacy program, which would be a great 

opportunity to work collaboratively with higher ed. If you can, exwwoods2 on PRODPC68 with HEARING

22 

plain what the needs are and what are you doing to help address 

those needs. 

Dr. CROSS. Sir, I will comment briefly on it and ask Ms. Clark 

to add. In consultation with my Chief of Pharmacy for this testimony today, we are holding our own fairly well in most places for 

pharmacists at the staff level. Certainly it remains a concern that 

we have to watch closely, because it is a competitive environment. 

This provision was related to the executive level and we have some 

challenges there in terms of long lag times, absences, and difficulty 

in recruiting. 

To follow on to your other comment, though, and what we are 

doing, we do a great deal of effort in recruiting and reaching out 

to individuals including schools. And I will ask Ms. Clark to comment on some of that. 

Ms. CLARK. We are quite competitive with the pharmacists, the 

staff pharmacists, because we can set special salary rates depending on the area. So that is not as big a concern. We do have to be 

vigilant so that we stay on top of it and keep those salaries competitive. As Dr. Cross mentioned, it is our executive rank, because 

there is not special salary rates for those executive rank. And so 

to try to get people to take those positions is really hard when they 

can get special salary rates and make almost as much as a staff 

pharmacist at those levels. So it is an issue and it is a problem to 

try to get those salaries, something, some kind of other compensation for that level. 

Mr. MICHAUD. Is it more of a problem in rural areas than? 

Ms. CLARK. Well, the rural areas pretty much are just like, with 

setting salaries, are pretty much the same across the country. You 

can set them based on the local market and what the local market 

dictates. And if that dictates paying relocation incentives, retention 

incentives, because you have a hard time keeping people in that 

area, you can pay those things on top of the salaries. So there is 

mechanisms, you know, in place for the staff pharmacists or the 

staff level employee. 

Mr. MICHAUD. Mr. Miller. 

Mr. MILLER. Thank you, Mr. Chairman. PVA expressed concern 

that the development of programs to address the needs for veterans 

with mild or subclinical TBI have not been fully developed or implemented. Could you respond to PVA’s concern? 

Dr. CROSS. We have done a tremendous amount of work in regard to TBI. Let me just highlight a couple of key points. We started this program back in the mid-eighties, creating special centers 

for TBI which we have now modified to call polytrauma centers. 

There were four of them. We are getting ready to open up, we are 

getting ready to build a fifth one in San Antonio. That was not 

enough. We have expanded those to create centers at our Medical 

Centers, and reaching out even into our smallest parts of our program by providing levels of expertise regarding TBI at those sites. 

We have done something that is unique in the United States. We 

are screening for mild TBI and we have developed the screen in 

such a way as to be more sensitive than specific. 

Our intent was to not miss anyone. And so we designed the program with some elements from DoD to create that screening program. We have screened thousands and thousands at this time. 

wwoods2 on PRODPC68 with HEARING

23 

And when they screen positive we put them into a special program. 

And what is more, we are reaching out to the ones that we have 

not seen yet because we are concerned that there are people who 

might need these services that we have not even addressed. We are 

calling every single veteran from Operation Iraqi Freedom and Operation Enduring Freedom who has not been to one of our facilities 

and contacting them by phone and saying, ‘‘Hey, how are you 

doing? Can we help you?’’ 

Mr. MILLER. I think PVA is still saying the milder subclinical 

issue has not been addressed. 

Dr. CROSS. Well, perhaps there is always more to be done. And 

I value my colleagues in PVA’s opinion. I take that very seriously. 

I would be happy to have an engagement to go over what we are 

doing currently because we have been pretty fast moving on this, 

and there is a lot that has been done in the past year or two. 

Mr. MILLER. Thank you, great idea. I think that, just sitting 

down and having a conversation with them may clear up some misconception. Also, on H.R. 6153, their concerns were expressed that 

hiring and promotion processes under Title 38 hybrid is facing extraordinary delays because of boarding the process. My question is, 

are the concerns valid? Are there really problems with the boarding 

process? 

Dr. CROSS. Frankly, there are some concerns that I have about 

how long it takes to bring someone on once we identify an individual that is interested in the job. I should give you just a couple 

of numbers and I will ask Ms. Clark to comment on the process a 

little bit. But we have had some success. We have expanded the 

number of nurse anesthetists. We added in net several thousand 

additional nurses to the VA last year. I have the most recent statistics yesterday. And Ms. Clark, can you comment? 

Ms. CLARK. Yes, I will just add on to that. This year in 2008, we 

are projected in VHA to hire over 40,000 new employees, which is 

approximately a 49 percent increase in hiring over last year, over 

2007. So it is like 13,000 more that are being hired just because 

of the increase in services that we are now adding. So that does 

add an extra burden. With that, we do realize that it takes too 

long. We have added different steps in the process with 

credentialing because we think it is important to have all our staff 

credentialed and make sure they are credentialed properly. So it 

has added some timeframe. 

We went through what we call process redesign to look at all the 

steps and see where things can be cut out, and we are working actively. Last year we started it. This year we are going full force 

with it again. We have even included a performance metric within 

all of our network directors performance plan that after somebody 

is identified they have to be brought on, or not brought on, but be 

offered the position within 30 days. You know, usually they have 

to give a notice to their employer but they can start effectively then 

if they wanted to, actually, after that 30-day timeframe. And it has 

been very successful in some areas. Some areas are still struggling. 

But they all are improving their timeframes. 

Mr. MICHAUD. Thank you. Mr. Hare. 

Mr. HARE. Thank you, Mr. Chairman. Dr. Cross, I just wanted 

to, just a couple things on H.R. 3051. You, in your testimony, you 

wwoods2 on PRODPC68 with HEARING

24 

identified the language of the telehealth demonstration as being too 

prescriptive and detailed. I wonder if you could maybe expand on 

the point and explain what flexibilities that you think are needed? 

Dr. CROSS. I think if you could just leave it up to us to design 

a demonstration project, working with our colleagues in DoD we 

could come to a very workable, practical approach to this. In fact, 

the truth is we are already doing much of this in terms of collaboration. There has never been, in my experience, I have been in the 

military 20, 25 years before coming to the VA, I have never seen 

as much interaction and collaboration between these two organizations as exists now. We are in meetings with them at some level 

virtually every single day. So we can work this through. And I 

think sometimes the people on the ground can put this together 

better than anyone else. 

Mr. HARE. Well let me just say that, you know, last spring we 

heard of internal VA emails identifying 12,000 annual suicide attempts, an estimated suicide rate of 6,570 per year across our veterans population. And these statistics to me show that current efforts are not enough to help with the hundreds of thousands of returning Iraq and Afghanistan veterans. So I would really urge the 

VA to not be complacent with current activities and to implement 

a comprehensive strategy and share best practices with non-VA 

healthcare practitioners. I think this bill goes a long way. And I 

commend my colleague for introducing the bill. And I would I 

would like to see, you know, and I agree with what Mr. Miller said 

earlier, that the working together between the VA and the VSOs 

to come up with something that is actually going to work here. And 

as you know, I am very troubled by the numbers of that as I know 

you are. And whatever we can do that will help, whether it is, you 

know, and again, I think this bill goes a long toward doing just 

that. But I would really like to see a collaborative effort here on 

behalf of the VA and the VSOs to come up with something that A 

will work. And when you design this demonstration project, I was 

just wondering if I could go back to that for a second. When you 

say, how long is that going to take, do you think, to be able to design that project and before we—— 

Dr. CROSS. The demonstration on telehealth? 

Mr. HARE. Yes. 

Dr. CROSS. And the cognitive assessment? I met with my staff on 

this, the experts. I did not actually get a timeframe. I would have 

to get back to you with an answer to be accurate. 

[The following information from VA was subsequently received:] 

Question: What is the projected timeframe for developing the joint DoD 

and VA demonstration project to assess the feasibility and advisability of 

using telehealth technology to assess cognitive functioning of Members and 

former Members of the Armed Forces who have sustained head trauma, in 

order to improve diagnosis and treatment of traumatic brain injury? 

Response: A timeframe has not yet been established. However, the DoD 

and VA have made significant progress in the area of interoperability since 

the National Defense Authorization Act designated DoD as the lead agency 

and VA as the collaborating agency in this initiative. The two departments 

have developed an in-depth interoperability plan for the demonstration 

project that includes verification of an existing evidence-based and validated telehealth application to assess cognitive function. In developing the 

timeframe, DoD and VA will need to allow sufficient time for both departments to develop the project’s clinical scope, arrange technology support, dewwoods2 on PRODPC68 with HEARING

25 

termine location and necessary personnel, and consider legal and regulatory 

issues before the actual demonstration project is underway. 

Mr. HARE. Thank you, Mr. Chairman. 

Mr. MICHAUD. Mr. Salazar. 

Mr. SALAZAR. I do appreciate your having this hearing today, 

first of all. Dr. Cross, you state that whether the caregiver compensation is for caregivers as a VA employee versus the benefit, 

that raises significant legal issues relating to liability, taxation, the 

VA relationship and responsibilities to the veteran, and the caregiver, can you explain that and expand on that a little bit? 

Dr. CROSS. Well, I will do my best but I think my counsel, Mr. 

Hall, will probably do a better job than I can so I will turn it over 

to him. 

Mr. SALAZAR. And before you answer that, can you also address 

the issue of, how this bill adheres to what the Dole-Shalala recommendations were. And, are you saying that they were just spitting in the wind when they made these recommendations because 

you were already doing all of this? Or could you expand on that a 

little bit as well? 

Dr. CROSS. Let me, I wanted to have a chance to respond to that. 

Because we support the intent of this. And in fact, that bill, you 

know, those provisions have been out and under discussion for 

some time now. And so, yes, we have already been acting on many 

of these things. Outreach for PTSD and TBI, we have, I listed just 

in the written testimony several paragraphs of our measures that 

we have instituted. The suicide prevention hotline, Mr. Hare’s comment about suicide, tremendously important issue for us. The clinical guidelines, we are publishing them, working with DoD every 

day to refine them and develop them further. We call in the Institute of Medicine to help us with TBI and PTSD issues. Telehealth, 

we have got tens of thousands of patients now receiving support 

from telehealth. So, yes, we are taking these very seriously. We did 

not wait for today to start on this. And that is why we phrased our 

comments the way we did. But our intent is very much consistent 

with what you have here. And I will ask Mr. Hall to expand on the 

fine points of that distinction. 

Mr. SALAZAR. Let me just follow-up on it. So in other words what 

you are saying is, we do not need the legislation to address the 

issues. We are already doing everything Dole-Shalala recommended, is that correct? 

Dr. CROSS. Well, the training for family members was not one of 

those. We think that there are significant issues that have to be 

addressed there and the way that the bill was phrased to provide 

the support directly was problematic for us. And we wanted to continue using what we have found to be the more effective, efficient 

working well mechanism using these healthcare agencies across 

the United States. 

Mr. SALAZAR. Well, are you currently providing compensation for 

family members, not only the training part of it, but family members when they have to quit their jobs to take care of someone who 

has PTSD or traumatic brain injury? 

Dr. CROSS. I will ask Walt to correct me if I am off base here 

but the home health agencies that we contract with can hire the 

family member and do so. 

wwoods2 on PRODPC68 with HEARING

26 

Mr. SALAZAR. Okay. 

Mr. HALL. Yes, sir. That is what in fact is going on now, is that 

we contract with the home healthcare provider who then hires the 

family member, provides them the training, then supervises the 

care that they give to the veteran. That puts them in the position 

of being responsible for assuring the quality, assuring the liability 

coverage of the caregiver, the family member, in case, and making 

sure that the quality of the care that they are getting meets the 

standards that are required. 

The way the legislation is phrased it says that VA will compensate the caregiver. It does not say exactly what the status of 

the employee, or the caregiver, will be. Will they be VA employees? 

Will they be responsible to VA? Will VA be responsible for them as 

far as things like insurance liability, liability for care, if the care 

that they are not giving somehow, the care that they give somehow 

injures the veteran? What is the liability? If it is a VA employee 

then of course the VA is responsible for that liability regardless of 

the relationship between the caregiver and the veteran. It is just 

a, it raises a number of issues like that. If it is compensation, is 

it compensation to the veteran? Or is it compensation to the caregiver? Do they become a VA beneficiary, for example, like somebody receiving compensation and pension would be receiving? If, 

and then that raises the case of VA’s responsibility for overseeing 

that care. What is the quality of that care? Are they doing the job 

that the veteran needs? If they are not what is VA’s recourse? Do 

we terminate the compensation, and what is the mechanism for 

doing that? It just raises a lot of—— 

Mr. SALAZAR. So then what you are saying, you do not really 

have any oversight over the caregivers that you currently have? I 

mean, that is what I heard you say, is it not? Because of the liability issue? 

Mr. HALL. No. 

Dr. CROSS. First of all, of course, as I pointed out in the written 

testimony I think, we look for those home healthcare agencies that 

are approved by the Centers for Medicare and Medicaid Services 

and State licensed. 

Mr. SALAZAR. Okay. But they assume the liability in case something goes wrong? 

Dr. CROSS. Correct. 

Mr. SALAZAR. And you have oversight over those caregivers? 

Mr. HALL. Yes, sir. They are responsible under the contract that 

we have with them to provide care to a certain standard. 

Mr. SALAZAR. And what is your recourse if they do not? 

Mr. HALL. Then we are able to, under the, we have recourse 

under the contract, either to demand damages or payment from 

them, or to terminate the contract. 

Mr. SALAZAR. Thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you very much, Mr. Salazar. I just have 

one follow up question, Dr. Cross. Actually, the three of us and 

Ranking Member Miller, had the chance to go to Iraq and visit 

with the troops, and talk to the individuals over there about 

healthcare. One of the issues that, I actually asked several of the 

generals we met with is, what they are doing personally to help, 

destigmatize PTSD, or traumatic brain injury. We got, the normal 

wwoods2 on PRODPC68 with HEARING

27 

response that we get. But the interesting thing is, at one facility 

after we went out and did our photo shoot out front, someone with 

lesser command came up to me and very discreetly said, you know, 

‘‘We need more help.’’ They are not getting the help that they need 

to, to the soldiers. 

You mentioned that you are working with the DoD on a daily 

basis. What are you doing to help with that destigmatization? For 

instance, a couple of days ago when I was in Indiana, we had a veteran who called a Congressman, as well as the press, and said he 

was going to kill himself during our meeting at the CBOC. We 

were able to take care of that. But, there is a big problem out 

there. Are you working with other groups? What actually came to 

my attention when you look at a lot of our athletes, which are 

looked at as heroes as well, when you look at the concussion that 

athletes have, which is mild TBI, are you working with the other 

organizations such as, sports, to see what they can do to help 

destignmatize issues such as TBI or PTSD? 

Dr. CROSS. Thank you for that question, sir. The stigma is very 

real. We recognize that. We do not deny that. And we take it very 

seriously. Let me tell you three or four of the things that we are 

doing in conjunction with your experience in Iraq. 

I do not think many people necessarily who are experiencing depression are anxious to go sit in a waiting room that says psychiatry or mental healthcare. We recognize that so we created a nationwide initiative which we have already executed to insert our 

mental healthcare, a portion of it into primary care clinics, where 

the patients have already been and are already usually comfortable. We start the process right there, make the diagnosis, 

make the first contact, break the ice, so to speak, right in that setting. Then we are doing education. If you go out on the metro here 

in Washington, or watch some of the buses going by, you will see 

a sign. It says, it is a 1–800 number, ‘‘Call it for help.’’ It is from 

the VA. If you call that number and press 1 as it tells you, it takes 

you to our facility at Canandaigua, New York. And when you, and 

you can call them anonymously you do not have to give them a 

name, but they will encourage you to do that. And that is our suicide prevention hotline in which we have had like, I think 50,000 

or 60,000 calls since we have opened it. Now, many of those were 

not veterans. Many of them were people just calling for information. But some of them were significantly asking for help and we 

have done many rescues. 

Our Vet Centers are a key tool that we have, where you have 

combat veterans talking to combat veterans. Combat veterans on 

our staff, and they have a totally different record system and create 

a real sense for that individual of privacy and confidentiality, and 

a lack of bureaucracy, perhaps, that would be different from a large 

hospital. So those are several of the things that we are doing. 

We recognize that issue. We think it is very important, and that 

is why we are putting these programs, and have already put those 

programs in place. 

Mr. MICHAUD. I know it is out of your jurisdiction, but actually 

I was reading an article somewhere where they had, I think, the 

Dallas Cowboy Cheerleaders overseas to bring morale to the troops. 

During your discussions, I am just wondering whether it might be 

wwoods2 on PRODPC68 with HEARING

28 

worthwhile with your discussion with DoD whether or not you do 

have these athletes who will admit that they have mental health 

problems and could really help with destigmatization of this issue. 

Dr. CROSS. Sir, even while we are speaking right now there is 

a conference going on, I believe, back at my headquarters and the 

tape, it is not an athlete but it is a movie star. They are doing a 

press release with a videotape of Gary Sinise. I think that was 

Lieutenant Dan. And talking about the issues of, you know, how 

we are encouraging folks to come in and get help. John Elway was 

also involved with us on some public releases that we have done. 

He has been very helpful, and others as well. And I hesitate because I might leave somebody out, but a number of them have been 

very helpful. 

Mr. MICHAUD. Okay. Well, thank you very much. Lastly, I know 

you are going to provide written testimony on Congresswoman 

Shea-Porter’s, legislation. She already made clear—well, the Secretary did—that they are not going to get a hospital, but it appears 

that there is a problem with her veterans getting service. If you are 

opposed to her legislation if there is a way that we can look at addressing her concerns, you know, as well it would be very helpful. 

[As of January 12, 2009, the VA failed to provide the administration views on H.R. 3051, H.R. 6153, and H.R. 6629.] 

Dr. CROSS. Of course, sir, and we will do that. 

Mr. MICHAUD. Okay. Well, once again I want to thank you Dr. 

Cross for your testimony, but also for your ongoing support for taking care of our veterans. You have always been a gentleman and 

I really appreciate working with you and your staff as well. If there 

are no other questions, we will adjourn the hearing. Thank you 

very much. 

[Whereupon, at 11:31 p.m., the Subcommittee was adjourned.] 

wwoods2 on PRODPC68 with HEARING

(29) 

A P P E N D I X 

Prepared Statement of Hon. Michael H. Michaud, Chairman, 

Subcommittee on Health 

I would like to thank everyone for coming today. 

Today’s legislative hearing is an opportunity for Members of Congress, VSOs, the 

VA and other interested parties to provide their views on and discuss legislation 

that have been introduced within the Subcommittee’s jurisdiction in a clear and orderly process. 

I do not necessarily agree or disagree with the bills before us today, but I believe 

that this is an important part of the legislative process that will encourage frank 

discussions and new ideas. 

We have three bills before us today. 

I look forward to hearing the views of our witnesses on these bills before us. I 

also ask that witnesses submit their views for the record on H.R. 6629. 

f 

Prepared Statement of Hon. Jeff Miller, Ranking Republican Member, 

Subcommittee on Health 

Thank you, Mr. Chairman, for holding this legislative hearing. 

Today, we will hear testimony on three legislative proposals— 

H.R. 3051, which would require VA to establish a program to train, certify and 

compensate family members of veterans and servicemembers with Traumatic Brain 

Injury (TBI) as personal care attendants; 

H.R. 6153, the Veterans’ Medical Personnel Recruitment and Retention Act of 

2008; and 

H.R. 6629, which would require that veterans in the 48 contiguous states have 

access to full service medical care through at least one VA hospital in the state, or 

through a contract with other health providers in the state. 

Providing the highest quality of care for our wounded warriors suffering with a 

TBI, the recruitment and retention of the very best VA healthcare providers, and 

access to care for every veteran regardless of where they live are issues that our 

Subcommittee has been focusing on throughout the year. 

VA has recently developed and implemented many new programs and policies to 

address the needs of veterans with TBI, help recruit and retain its corps of 

healthcare professionals and enhance access to care. I want to commend the Department for their ongoing efforts. However, during this critical time, we must continue 

to look at where gaps in services still exist and what more can be done to ensure 

that our veterans receive the highest quality healthcare services. 

I want to thank all of our witnesses for being here today. I look forward to a productive discussion and the opportunity to fully examine the legislative proposals before us. I am hopeful that this debate will help guide our actions on developing legislation that will best serve our Nation’s veterans. 

Thank you Mr. Chairman, I yield back. 

f 

Prepared Statement of Hon. Phil Hare 

First, I would like to thank Chairman Michaud and Ranking Member Miller for 

holding this hearing. The three bills before us today address important issues, all 

of which have huge impacts on the welfare of our Nation’s veterans. 

Second, I would like to thank the sponsors of these bills, the three members that 

are testifying before us today. 

Mr. Salazar is a fellow Committee Member and I know from sitting next to him 

over the past 2 years, that he is a tireless advocate for veterans, especially the many 

wwoods2 on PRODPC68 with HEARING

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rural veterans that live in his large district in Colorado. His bill addresses family 

caregivers for veterans suffering from TBI, and also telehealth services. These are 

crucial matters and are directly in line with Mr. Salazar’s passion for improving the 

lives of veterans and their families. 

Ms. Johnson is also a big supporter of veterans. For 15 years she worked at the 

Dallas VA Medical Center as a medical and psychiatric nurse. Appropriately, her 

bill aims to help VA recruit and retain more nurses and other healthcare professionals. 

Ms. Shea-Porter and I came into Congress at the same time, and I know without 

a doubt, that there is nobody more dedicated to serving our veterans than she is. 

It is a paradox then that her home state, the great State of New Hampshire, does 

not have a VA medical center. Her bill attempts to resolve this injustice. 

Third, I would like to thank all our witnesses for testifying today, including Dr. 

Cross of the VA and each representative of the three VSOs present. I would also 

like to congratulate the Disabled American Veterans for recently electing Raymond 

E. Dempsey, a fellow Illinoisan, as National Commander. Speaking on behalf of the 

great state of Illinois, I take great pride in knowing that such a well-respected organization is under the leadership of Mr. Dempsey. 

Mr. Chairman, thank you again for holding this important hearing. 

f 

Prepared Statement of Hon. Eddie Bernice Johnson, 

a Representative in Congress from the State of Texas 

Thank you, Mr. Chairman, and Members of the Subcommittee, for the opportunity 

to testify today on issues related to veterans. 

Millions of veterans nationwide receive treatment in the VA healthcare system. 

A significant number of these veterans have returned from war—including the wars 

in Afghanistan and Iraq—with serious injuries, including traumatic brain injury. 

Quite understandably, a large number of troops are also suffering from psychiatric 

disorders, such as post-traumatic stress disorder. 

It is our duty to ensure that our veterans, who have so courageously served our 

country, receive the medical support they deserve. The VA system must be able to 

successfully compete for the best healthcare providers in the United States. Today, 

I speak in support of the Veterans’ Medical Personnel Recruitment Act of 2008, because it gives the VA the tools to recruit and retain the very best medical and professional employees. 

This legislation will raise salaries for nurses, physicians, dentists, senior executives and pharmacist executives. It will streamline pay systems, making them easier 

to understand and to implement. It will provide incentives to retired employees to 

return to the VA system by removing annuity and salary offsets, thereby encouraging the qualified workers most familiar with the VA system to return to work. 

The legislation will also increase education benefits for new VA hires and current 

staff. 

I worked as a medical and psychiatric nurse at the Dallas VA Medical Center for 

15 years, and I can attest to the unparalleled role nurses play in all medical facilities. Nurses are often the medical professionals with whom patients have the most 

contact, and they are repeatedly cited by patients as the medical professionals they 

trust the most. There is a nursing shortage in our country, and if we want the VA 

to attract the very best nurses, we must provide the proper incentives. 

Standardizing the definition of ‘‘emergency’’ will facilitate more consistent and equitable use of emergency mandatory overtime. By clarifying VA regulations regarding work schedules, overtime and emergency duty the Veterans’ Medical Personnel 

Recruitment and Retention Act will offer nurses more schedule flexibility and provide for the VA to become a more employee-friendly place to work. The legislation 

will also make it easier for the VA to hire and retain part-time nurses and to allow 

full-time nurses to transition to part-time work schedules. 

The Veterans’ Medical Personnel Recruitment and Retention Act will strengthen 

the VA system, helping to make the VA the healthcare employer of choice. Our veterans, who have so courageously served our country, deserve its passage and implementation. 

Mr. Chairman, this concludes my testimony I will be happy to answer any questions that you may have. 

f 

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Prepared Statement of Hon. John T. Salazar, 

a Representative in Congress from the State of Colorado 

Thank you Mr. Chairman. 

First I would like to thank Dr. Jim Schraa, a Neuropsychologist at Craig Hospital, 

and Anna Frese, with the Wounded Warrior Project, who submitted testimony for 

the record. 

On July 17, 2007 I introduced H.R. 3051 the Heroes at Home Act. 

The purpose of this bill is to improve the diagnosis and treatment of traumatic 

brain injury in current and former Members of the Armed Forces. 

The program will be located in VA healthcare centers across the Nation. 

This is especially important to rural districts like mine where making healthcare 

accessible is a constant challenge. 

H.R. 3051 addresses the need for access to care by expanding both DoD and VA 

telehealth and telemental health programs. 

Ultimately this bill will ease the burden on our veterans suffering from TBI and 

the families who care for them. 

Our Committee has heard testimony from many veterans, Veteran Serving Organizations and the VA on the mounting cases of TBI, PTSD and other invisible 

wounds of war. 

Many agree that veterans are often worse off with these unseen injuries than 

those with visible physical injuries. 

Unlike other injuries that can heal, brain injuries are often permanent and disabling. 

In addition, TBI can sometimes take years to develop and diagnose. 

Even when discovered the road to recovery is long and is borne by the families 

of our brave men and women in uniform. 

We have also heard of the link between TBI and other mental conditions such as 

epilepsy. 

A DoD study after Vietnam found that 15 percent of soldiers with a penetrating 

TBI developed epilepsy soon after their injury. 

H.R. 3051 creates a program to train the family members of TBI patients to become their personal care attendants. 

Participants going through the program would become certified and receive compensation from the VA so that they can focus their energy on caring for their loved 

ones. By taking place at home with family, the healing process is made more comfortable for our veterans. 

The cost to the VA for having someone cared for at home is less than having them 

at a medical facility and allows the VA to allocate the resources they have to serve 

more veterans. 

We have soldiers in Iraq and Afghanistan spending longer periods of time in 

harms way and away from their families. 

With that in mind we need to ensure that there are programs in place to care 

for them when they return home. 

A program that provides quality care for our veterans and a financial benefit for 

their families seems appropriate for the difficult economic times our country is facing. 

Most importantly, this bill will help us all reach our goal of ensuring our veterans 

the best care possible. 

Mr. Chairman, I thank you and the Members of this Subcommittee for the opportunity to introduce legislation that improves the lives of our veterans suffering with 

TBI. 

f 

Prepared Statement of Hon. Carol Shea-Porter, 

a Representative in Congress from the State of New Hampshire 

Mr. Chairman. 

Thank you for the opportunity to speak to your Subcommittee about a critical inequity facing New Hampshire’s veterans—the lack of full service, in state 

healthcare. 

New Hampshire has not had a full service veterans’ hospital since 2001. New 

Hampshire is the only state without a full-service VA hospital or comparable facility. Veterans in Alaska and Hawaii receive care at military hospitals on base. While 

New Hampshire may be a small state, it has a veteran population of over 130,000. 

Unlike many New England states whose veterans populations are declining, New 

Hampshire’s veterans population is projected to grow over the next 10 years. 

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Because New Hampshire does not have a full service veterans’ hospital, our veterans are forced to travel out of state for medical care. Veterans traveling from the 

most northern parts of the state can travel for 3 hours to Manchester and then may 

be forced to travel another hour to Boston, if referred there for care. 

This routinely happens. In 2007, 704 of our veterans were transferred out-of-state 

for Acute Care. Three hundred forty-six of those veterans were sent to Boston. 

I have been calling for the VA to either restore the Manchester facility to fullservice hospital care or allow NH vets to receive care locally since I came to Congress. I have been working with both the VA and my colleagues to realize that goal. 

Chairman Filner visited the Manchester Veterans facility earlier this year and held 

a series of events including a roundtable during which we heard about the serious 

burdens placed on the New Hampshire veterans and their families because we do 

not have a full-service hospital. 

Despite these efforts, the administration refuses to either provide local access to 

care or restore full service VA hospital care to New Hampshire. I met with Secretary Peake at the Manchester Veterans Administration Medical Center in June 

to express my interest in working with him to either restore the facility to a fullservice hospital or provide local access. Unfortunately, after our meeting Secretary 

Peake told the local press that there would be no full-service hospital in Manchester. 

The Administration’s failure to act is unacceptable. New Hampshire’s veterans deserve the best possible care and the current system is not delivering that. This is 

why I introduced H.R. 6629, the Veterans Health Equity Act of 2008. 

This legislation will ensure that veterans have access to at least one full-service 

hospital, or that they can receive care, the same care they would get in a VA hospital, in the state. This would mean that the VA would have to do one of two things, 

either restore the Manchester facility to a full-service hospital, or partner with more 

local health providers to make sure our Veterans can receive the care they need, 

in New Hampshire. 

The men and women in our local VA facility have done a herculean job of caring 

for our vets despite the limits to access imposed on New Hampshire vets. The Administration has very recently shown some willingness to allow radiation therapy 

to be provided locally. But this is not enough. 

Our veterans—regardless of whether they need radiation therapy, mental health 

services, acute care or anything else—need and deserve the care their counterparts 

in every other state receive. It is unconscionable that we deny them this full service 

care and instead offer them ad hoc services. 

Mr. Chairman, I appreciate your leadership in providing the best possible 

healthcare for our Nation’s veterans. I am sure you and the other Members of your 

Subcommittee appreciate the challenges created by the lack of full service hospital 

care in New Hampshire. I look forward to working with you and the Subcommittee 

to address these challenges. 

Thank you again for giving me the opportunity to testify on this important issue. 

I look forward to answering any questions you may have. 

f 

Prepared Statement of Joy J. Ilem, 

Assistant National Legislative Director, Disabled American Veterans 

Mr. Chairman and Members of the Subcommittee: 

Thank you for inviting the Disabled American Veterans (DAV) to testify at this 

legislative hearing of the Committee on Veterans’ Affairs Subcommittee on Health. 

DAV is an organization of 1.3 million service-disabled veterans, and devotes its energies to rebuilding the lives of disabled veterans and their families. 

You have requested testimony today on two bills primarily focused on healthcare 

services for injured military servicemembers and veterans, and personnel issues affecting healthcare employees of the Veterans Health Administration (VHA) of the 

Department of Veterans Affairs (VA). We appreciate the opportunity to provide our 

views on these measures to the Subcommittee. 

H.R. 3051—the Heroes at Home Act of 2007 

In general, this bill seeks to improve the diagnosis and treatment of traumatic 

brain injury (TBI) and raise awareness about post-traumatic stress disorder (PTSD) 

among current military servicemembers and veterans; provide support to families 

of severely injured veterans; and, expand telehealth and telemental health programs 

of the Department of Defense (DoD) and VA. 

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[1]The President’s Commission on Care for America’s Returning Wounded Warriors. Final Report: Serve, Support, Simplify. July 2007: 9. [2] Ibid. 

Section 2 of the bill would require VA, in collaboration with the Secretary of Defense, to develop a program of training and certification of family caregivers and 

other personal care attendants of veterans and still-active members of the Armed 

Forces with TBI, at every VA medical center. The curricula developed would incorporate the standards and protocols of national brain injury care specialist organizations and, to the degree possible, would require use of, and would expand the curricula developed under, the John Warner National Defense Authorization Act for 

Fiscal Year 2007 (Public Law 109–364). Certification received by family caregivers 

or others would qualify them to be compensated for personal care services rendered 

to the injured veteran or servicemember. Training would be provided at no cost to 

the veteran or caregiver, but would be borne by VA or reimbursed through 

TRICARE. 

Section 3 of the bill would require VA to conduct comprehensive outreach to enhance awareness among veterans and the general public about the symptoms of 

PTSD and TBI and the services provided by the VA. It would further require VA 

to make information available to non-VA practitioners on best practices in treatment of TBI and PTSD. 

Section 4 of the bill addresses telehealth and telemental health services of DoD 

and VA, and would require the Secretaries to jointly establish a demonstration program to assess the feasibility of using telehealth technologies to evaluate cognitive 

functioning among servicemembers who have sustained head trauma. In addition, 

the bill would require an assessment of telehealth tools to obtain information regarding the nature and symptoms of brain injury, the use of technology to rehabilitate those with TBI, and the usefulness of applying such technology to dissemination of educational material to veterans and servicemembers. The funds for the demonstration would be drawn from the DoD–VA healthcare Sharing Incentive Fund 

and the results of the demonstration would be reported in the administration’s joint 

report to Congress on sharing initiatives between the two Departments. Another 

study the bill would require is an ongoing review of telehealth and telemental 

health services, to include the number of servicemembers and veterans who have 

used such services and the extent to which the National Guard and Reserve components of the armed forces use them, in addition to identifying improvements for 

such programs. The report would also require best practices of civilian mental 

health providers assisting veterans and former servicemembers and demonstrate 

the feasibility and advisability of partnering with civilian mental health facilities to 

provide telehealth and telemental health programs. 

While modern protective gear and battlefield medicine have greatly improved 

from previous conflicts, the intensity of polytrauma injuries, including TBI, presents 

great challenges to DoD and VA in meeting servicemembers and veterans acute, rehabilitative and long-term care health needs. As you well understand, Mr. Chairman, the most severe of these injuries may require a lifetime of care. The family 

members of military polytrauma casualties typically appear at the bedside of their 

loved one and remain with them throughout their acute treatment and extensive rehabilitative periods. A survey conducted on behalf of the President’s Commission on 

Care for America’s Returning Wounded Warriors (Commission) found that ‘‘. . . 33 

percent of active duty, 22 percent of reserve component, and 37 percent of retired/ 

separated servicemembers [who were injured] report that a family member or close 

friend relocated for extended periods of time to be with them while they were in 

the hospital.’’ [1]

Family members of severely injured veterans often shoulder a great and lifelong 

burden as home and institutional caregivers, giving up or severely restricting their 

own employment and educational advancement and negatively impacting social 

interactions that are taken for granted in the normal course of life. The Commission’s survey also found that ‘‘21 percent of active duty, 15 percent of reserve component, and 24 percent of retired/separated servicemembers [who were injured] say 

friends or family gave up a job to be with them or act as their caregiver.’’ [2] Not 

surprisingly, family caregivers often suffer severe financial and personal hardships 

as a consequence of providing care to a severely disabled veteran. Yet, in their absence, an even greater burden of direct care would fall on DoD and VA, at significantly higher financial cost to the Government and a reduced quality of life for severely wounded war veterans. 

DAV testified before the Senate Committee on Veterans’ Affairs earlier this year 

in support of S. 2921, a bill that would require VA to develop a pilot program to 

train and certify family caregivers of traumatically brain injured veterans. We are 

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[3] Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and 

Services to Assist Recovery. Ed’s: Tanielian, T; Jaycox, L. RAND Center for Military Health Policy Research: 2008 

very enthusiastic about bolstering the financial support for these vulnerable families 

and believe that this is also an idea that will improve the quality of care our veterans receive. We agree with the intent of H.R. 3051 that this common-sense program could be started without being a pilot—since family caregivers of severely injured veterans are already shouldering a great deal of the care these veterans receive. This program would allow these family members to have up-to-date and consistent training and to receive compensation that recognizes their services and will 

better ensure the stability of the family at an extremely difficult and vulnerable 

time. The needs of these veterans and their families are urgent. However, we believe that initially, the training and certification process may need to be limited to 

sites that have these capabilities in place—most likely in the polytrauma centers 

and other units within the Defense and Veterans Brain Injury Network. We ask the 

Subcommittee to consider this aspect of the bill and modify it accordingly to ensure 

the training provided is of high quality and focused on the particular needs of these 

families. 

Similar to the provision for a training and certification program in S. 2921, section 2 of the Heroes at Home Act would address veterans with traumatic brain injuries but would also be beneficial for other catastrophically injured veterans with 

long-term personal assistance needs, such as veterans with spinal cord injuries or 

severe physical trauma without brain injury. Indeed, an educational proposal to assist family caregivers of all veterans with catastrophic injuries who would be taking 

on personal assistance duties was originally recommended by the Commission on 

Care for America’s Returning Wounded Warriors. If successful, we would like to see 

this provision related to training caregivers expanded to other catastrophically disabled veterans requiring caregiver assistance. 

Section 3 of H.R. 3051 would require that VA conduct outreach activities targeted 

at increasing recognition of symptoms and public awareness that resources are 

available within VA to treat traumatic brain injury and PTSD. Veterans may not 

be the first to recognize the changes in their own behavior consequent to their exposure to concussive and traumatic events. Indeed, even with the high rates of prevalence expected for both TBI and PTSD, some veterans will not recognize their own 

symptoms until weeks or months after repatriation, if ever. [3] Often, a family member notices changes in a veteran’s behavior and mood; thus, informing the general 

public is also an important element of this bill. DAV believes that there must be 

a systematic means of educating veterans and their families about these problems 

and how to find support. We acknowledge that some veterans are receiving care for 

war-related disabilities outside of the VA and military systems, so we appreciate the 

requirement in the bill that VA would disseminate best practices on both mild-tomoderate TBI and PTSD to non-VA providers. 

Mr. Chairman, DAV also supports, but with some concern, section 4 of this bill 

to improve and expand telehealth and telemental health in VA and DoD. DAV certainly agrees that it is a challenge for VA and DoD to place resources everywhere 

veterans want and need to receive care. Tele-medicine has played a vital role in filling gaps in care in a number of communities—particularly in rural and frontier 

communities that lack access to a full continuum of care, and in some cases even 

basic healthcare services. We support efforts to assess new web-based diagnostic 

tools for the prevalent cognitive conditions that are emerging among our returning 

veterans. However, this section also contains a provision that would require VA and 

DoD to study ways that civilian providers might be used to enhance telehealth services offered to injured veterans and servicemembers. DAV has long held the position 

that contracting for healthcare outside VA should be attempted judiciously so as not 

to undermine VA’s high-quality and specialized health and rehabilitative programs, 

and only when community-based care is coordinated and of high quality. Thus, we 

ask the Subcommittee to carefully consider the results of the required study in this 

bill before advancing any legislative mandate for VA or DoD to significantly expand 

tele-medicine into the private sector. Any such expansion should include coordination through the VA Office of Rural Health and would also need to be attended by 

new resources outside VA’s Medical Care appropriation to garner full DAV support. 

While we support this bill, we would ask the Subcommittee to also consider the 

needs of veterans with less severe traumatic brain injuries. Mild-to-moderate brain 

injuries are prevalent among the Iraq and Afghanistan deployments—possibly as 

many as 320,000 veterans may be affected, yet of those reporting a probable TBI, 

57 percent had not been evaluated by a clinician for that injury according to the 

recent RAND report. Key findings of the study also noted that about half of those 

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[4] Ibid. 

who need treatment for PTSD, depression or probable TBI seek care for those conditions, and only slightly more than half who receive treatment get minimally adequate care. [4] The DoD and VA must be at the forefront of efforts to improve the 

diagnosis, treatment, management and surveillance of all brain injuries to ensure 

high-quality and consistent care is obtained for all servicemembers and veterans 

who suffer from concussive blasts in Iraq and Afghanistan. This bill would acknowledge the enormous debt the Nation owes, not only to injured veterans, but to their 

family caregivers, whose lives may be forever altered. However, we ask the Subcommittee to also consider expanding this measure to include the broader slate of 

initiatives DAV supports for family caregivers. DAV supports legislation to provide 

comprehensive supportive services, including financial support, health and homemaker services, respite, education and training and other necessary relief to immediate family member caregivers of veterans severely injured, wounded or ill from 

military service. 

With these cautionary notes, DAV believes the ideas in the bill are worthy and 

if implemented carefully, could provide relief and support for sick and disabled veterans, particularly those with invisible wounds of war, including TBI and PTSD, 

and would provide welcome relief to family caregivers of the severely disabled. With 

exceptions noted, most of the proposals are consistent with recommendations of the 

Fiscal Year 2009 Independent Budget. Thus, DAV supports this bill and urges the 

Subcommittee to work toward its enactment. 

H.R. 6153—Veterans’ Medical Personnel Recruitment and Retention Act of 

2008 

Along with our partners in the Independent Budget, DAV has called for improvements in VA policies and procedures used to recruit and retain highly qualified VA 

clinical staff. Also for the past several years our organizations have expressed concerns that VA needs new authority to achieve and sustain this goal, to be competitive with private sector providers and become a preferred employer of physicians, 

nurses, dentists and other personnel needed to care for enrolled veterans. With increasing numbers of veterans turning to VA for their healthcare and—particularly 

at a time of ongoing military engagements in Iraq and Afghanistan—VA needs the 

best and the brightest to meet the increasingly complex medical needs of an aging 

veteran population, veterans severely disabled during wartime service, and enrollees 

suffering from chronic disease. This bill, aimed at providing meaningful financial 

and professional incentives to encourage VA clinicians to pursue full careers in the 

VA healthcare system appears to be timely and appropriate given all of the challenges VA faces to maintain its effectiveness as a provider of comprehensive 

healthcare services. 

Section 2 of the bill would provide authority to the Secretary of Veterans Affairs 

to establish additional ‘‘hybrid title 38-title 5’’ occupations (32 such occupations have 

been established by previous Acts of Congress in section 7401, title 38, United 

States Code, including psychologist, physician assistant, licensed vocational or practical nurse, social worker, and numerous technical health fields). Under this section, 

the Secretary would be required to report any such reclassification of VA occupations to the Office of Management and Budget (OMB) and to both House and Senate 

Committees on Veterans’ Affairs. This section would also add ‘‘nurse assistant’’ as 

a specific new occupational class in this hybrid category. Section 2 would clarify probationary periods and appointment policies for full-time and part-time registered 

nurses. The section also would authorize VA on a case-by-case basis to reemploy 

Federal annuitants with temporary appointments in selective healthcare occupational fields under sections 7401 and 7403, title 38, United State Code, without offsetting their retirement annuities for which they would remain eligible under title 

5, United States Code. This section would provide VA additional authority to raise 

compensation of personnel employed in the immediate Office of the Under Secretary 

for Health; provide VA pharmacist executives eligibility for special incentive pay; 

and provide clarification on compensation policy for VA physicians, including comparability pay adjustments and market pay provisions in chapter 74, title 38, United 

States Code. Finally, it would provide additional policy clarifications on nurse compensation caps, special compensation for nurse executives; locality salary systems 

for VA nurses; part-time nurse compensation rules; weekend premium rules, as well 

as clarified direction on the use and disclosures of wage surveys in nurse locality 

compensation determinations. 

Section 3 of the bill would add a new section 7459, title 38, United States Code, 

to specify VA policy on VA’s use of overtime by VA nurses, in effect reversing VA’s 

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practice of requiring ‘‘mandatory overtime,’’ and extending specific protections to VA 

registered nurses, licensed practical or vocational nurses, nursing assistants (and 

other nursing positions designated by the Secretary for purposes of these protections), under the Civil Rights Act 1964, from discrimination or any adverse action 

based on their refusal to work required overtime. Under this section, the VA Secretary would be provided an emergency exigency power in certain circumstances to 

require a nurse to work overtime, but the section defines the term ‘‘emergency’’ 

within narrow grounds. Section 3 also clarifies language on weekend duty and other 

alternative work schedules for VA nurses, and would provide a number of associated 

technical and conforming amendments. 

Section 4 of the bill would reinstate the former Health Professionals Educational 

Assistance Scholarship Program, an authority that expired in 1998, and would extend its coverage to employees appointed under paragraphs (1) and (3) of section 

7401, title 38, United States Code. It would add ‘‘retention’’ as an additional purpose 

of VA’s Education Debt Reduction Program, and would increase the amounts of assistance to eligible VA employees. The section also would establish a loan repayment 

program targeted to VA clinical research personnel who come from disadvantaged 

backgrounds. 

Mr. Chairman, while DAV has no national resolution adopted by our membership 

that addresses these specific matters, The Independent Budget for Fiscal Year 2009, 

sponsored by DAV, Veterans of Foreign Wars of the United States (VFW), American 

Veterans (AMVETS) and Paralyzed Veterans of America (PVA), conveys a series of 

recommendations that are fully consistent with this bill. Therefore, DAV would have 

no objection to its enactment. 

Mr. Chairman and Members of the Subcommittee, as you may know, our DAV advocacy campaign, Stand Up For Veterans, is well underway. Its purpose is to generate greater public awareness and support for strengthening Federal policies to 

provide greater healthcare assistance to veterans disabled in the ongoing wars in 

Iraq and Afghanistan, as well as to sick and disabled veterans from prior eras and 

conflicts. In this effort, our campaign has focused on TBI, post-deployment mental 

health challenges (including PTSD), women veterans’ health, family caregiver support, and reforms in budgeting that will bring sufficient, timely and predictable 

funding to VA healthcare. DAV has been pleased by Congressional responsiveness 

to many of the proposals emanating from our campaign that we have shared and 

discussed with Members of this Subcommittee and others in Congress. We appreciate that responsiveness and encourage the Congress to complete a significant 

package of veterans’ health legislation before adjournment. 

Mr. Chairman, this concludes my statement on these two bills, and I would be 

happy to answer questions on these issues from you or other Members of the Subcommittee. 

SUPPLEMENTAL STATEMENT 

H.R. 6629, the Veterans Health Equity Act of 2008 

This measure would seek to ensure availability of at least one full-service hospital 

of the Department of Veterans Affairs (VA) Veterans Health Administration (VHA), 

or comparable services through contract, in each of the 48 contiguous States. 

Congresswoman Shea-Porter provided an opening statement for the Subcommittee 

at the September 9th hearing explaining the reasons for the introduction of this 

measure (H.R. 6629). Ms. Shea-Porter noted that New Hampshire was the only 

State that did not have access to a VA full-service medical center and that the most 

ill veterans in her state routinely had to drive or be transported to Boston for more 

comprehensive healthcare services. She stated that she was particularly concerned 

that the sickest and generally very elderly veterans with complex and chronic 

health problems were subjected to having to first report to the VA’s Manchester facility—which could be up to a 3 hour drive—and then having to continue on for another hour to get to the Boston VA Medical Center (VAMC) or other VA provider 

sites. Finally, the Congresswoman noted that it may not be fiscally responsible, 

given the veterans’ population in her state, to have VA provide a full continuum of 

hospital services and that contracting for such services may be the best option. Her 

main concern was that sick and disabled veterans in New Hampshire are having 

to make unnecessarily long trips to Boston area VAMCs to get the care they need 

for complex health conditions. 

Convenient access to comprehensive VA healthcare services remains a problem for 

many of our Nation’s sick and disabled veterans. While VA must contract or use 

fee basis to provide care to some veterans, it maintains high quality care and cost 

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effectiveness by providing health services within the system. According to VA, the 

Manchester VAMC of New Hampshire provides urgent care, mental health and primary care services, ambulatory surgery, a variety of specialized clinical services, 

hospital based home care and inpatient long-term care. In addition, communitybased outpatient clinics (CBOCs) are located in Somersworth, Tilton, Portsmouth 

and Conway. 

In light of the escalating costs of healthcare in the private sector, to its credit, 

VA has done a remarkable job of providing high quality care and holding down costs 

by effectively managing in-house health programs and services for veterans. However, outside care coordination is poorly managed by VA. When it must send veterans outside the system for care, those veterans lose the many safeguards built 

into the VA system through its patient safety program, evidence-based medicine, 

electronic health records, and bar code medication administration program (BCMA). 

The proposal in H.R. 6629 to use broad-based contracting for necessary hospital 

services in the New Hampshire area concerns us because these unique internal VA 

features noted above culminate in the highest quality care available, public or private. Loss of these safeguards, which are generally not available in private sector 

systems, equate to diminished oversight and coordination of care, and, ultimately, 

may result in lower quality of care for those who deserve it most. However, we agree 

that VA must ensure that the distance veterans travel, as well as other hardships 

they face, be considered in VA’s policies in determining the appropriate locations 

and settings for providing VA healthcare services. 

In general, current law places limits on VA’s ability to contract for private 

healthcare services in instances in which VA facilities are incapable of providing 

necessary care to a veteran; when VA facilities are geographically inaccessible to a 

veteran for necessary care; when medical emergency prevents a veteran from receiving care in a VA facility; to complete an episode of VA care; and for certain specialty 

examinations to assist VA in adjudicating disability claims. VA also has authority 

to contract to obtain the services of scarce medical specialists in VA facilities. Beyond these limits, there is no general authority in the law to support broad-based 

contracting for the care of populations of veterans, whether rural or urban. 

DAV believes that VA contract care for eligible veterans should be used judiciously and only in these authorized circumstances so as not to endanger VA facilities’ ability to maintain a full range of specialized inpatient and outpatient services 

for all enrolled veterans. VA must maintain a ‘‘critical mass’’ of capital, human, and 

technical resources to promote effective, high-quality care for veterans, especially 

those with complex health problems, such as blindness, amputations, spinal cord injury, or chronic mental health problems. Putting additional budget pressures on this 

specialized system of services without making specific appropriations available for 

new VA healthcare programs only exacerbates the problems currently encountered. 

Nevertheless, after considerable deliberation, and in good faith to be responsive 

to those who have come forward with legislative proposals such as H.R. 6629, to 

offer alternatives to VA healthcare, we have asked VA to consider developing a series of tailored demonstration projects and pilot programs to provide VA-coordinated 

care (or VA-coordinated care through local, state, or other Federal agencies) in a selected group of communities that are experiencing access challenges, and to provide 

to the Committees on Veterans’ Affairs reports of the results of those programs, including relative costs, quality, satisfaction, degree of access improvements, and 

other appropriate variables, compared to similar measurements of a like group of 

veterans in VA healthcare. To the greatest extent practicable, VA should coordinate 

these demonstration pilots with interested health professions’ academic affiliates. 

We suggest the principles of our recommendations from the ‘‘Contract Care Coordination’’ section of the FY 2009 Independent Budget be used to guide VA’s approaches in this effort. Also, any such demonstration pilot projects should be funded 

outside the Veterans Equitable Resource Allocation (VERA) system, and their expenditures should be monitored in comparison with VA’s historic costs for care. 

Veterans service organization representatives from the local areas involved, and 

other experts need a seat at the table to help VA consider important program and 

policy decisions, such as those described here, that would have positive effects on 

veterans who live in these areas. VA must work to improve access for veterans that 

are challenged by long commutes and other obstacles in getting reasonable access 

to a full continuum of healthcare services at VA facilities and explore practical solutions when developing policies in determining the appropriate location and setting 

for providing VA healthcare services. 

As a final note, we believe VA must fully support the right of all enrolled veterans 

to have reasonable access to healthcare and we insist that funding for alternative 

care approaches and outreach be specifically appropriated for this purpose, and not 

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be the cause of reductions in highly specialized VA medical programs within the 

healthcare system. 

f 

Prepared Statement of Joseph L. Wilson, Deputy Director, Veterans Affairs 

and Rehabilitation Commission, American Legion 

Mr. Chairman and Members of the Subcommittee: 

Thank you for this opportunity to present The American Legion’s views on these 

two important pieces of legislation. 

H.R. 3051, Heroes at Home Act of 2007 

This bill seeks to improve the diagnosis and treatment of traumatic brain injury 

in members and former members of the Armed Forces; to review and expand telehealth and telemental health programs of the Department of Defense (DoD) and the 

Department of Veterans Affairs (VA), and for other purposes. 

Section 2 of HR 3051 requests the Secretary of VA establish a program on training and certification of family caregivers of veterans and members of the active duty 

Armed Forces with Traumatic Brain Injury (TBI), as personal care attendant. Pursuant to section 744(a)(2) of Public Law 109–364, a Veterans’ Traumatic Brain Injury Family Caregiver Panel was established in 2007. 

The 15 member panel was created by the DoD to operate under the Department 

of Health as a Subcommittee to advise and specifically provide DoD and VA with 

independent advice and recommendations on the development of training curricula 

to be utilized by the above mentioned family members on techniques, strategies, and 

skills for care and assistance for such individuals with TBI. The panel has convened 

on occasions, to include a recent townhall meeting, to discuss matters related to the 

development of a this curriculum and to hear from the public about the issue. 

The American Legion asserts that the advice of this Subcommittee into the provisions of this piece of legislation is vital, and that its absence may deprive such a 

bill of an effective stance and approach to treatment and care of TBI. The American 

Legion, in its continued efforts to increase access and quality of care to all eligible 

and potentially eligible veterans, supports this proposal, as it would help to accomplish this ongoing challenge. 

H.R. 6153, Veterans’ Medical Personnel Recruitment and Retention Act of 

2008 

This bill seeks to amend Title 38 of the United States Code to enhance the capacity of VA to recruit and retain nurses and other critical health-care professionals, 

in addition to addressing other issues. The American Legion applauds this proposal 

to amend the methods of hiring and retaining additional medical personnel of various disciplines to adequately equip VA Medical facilities to ensure the adequacy 

and quality of treatment and care. 

The American Legion supports the proposal request in section 2(j), which seeks 

to amend 7451(c)(2), to allow critical fields such as nurse anesthesiologists, to exceed rate limitations on authorized competitive pay. Although VA has various antidotal programs in place, to include recruitment, relocation, and retention incentives 

for these hard-to-fill positions, there remains a shortage of such nurses and specialty medical physicians. 

The overall response to the question of shortage indicated that salaries and delays 

in appointments were key causative factors. The American Legion, during its VA 

Medical Center site visits to 49 facilities in 2008 encountered various recruitment 

issues, including such delays in the appointment of nursing assistants. Management 

attributed these delays to a three to 4 month hiring process. By the time management completed the hiring process, applicants have accepted a position in the private sector. 

In their site visits the American Legion representatives ascertained other areas 

with difficulty recruiting; these included mental health positions, specifically psychologists and psychiatrists; Dermatology; Gastroenterology; Orthopedics; and, Anesthesia. A study published in the New England Journal of Medicine ascertained 

there were shorter inpatient stays and lower complication rates in hospitals with 

higher staffing levels, while there were longer inpatient stays and increased urinary 

infections, gastrointestinal bleeding, pneumonia and shock or cardiac arrest in hospitals with lower staffing levels. Thus planning and adequate staffing up front can 

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help curtail long term care costs and unnecessary complications to the veteran patients down the road. 

We hereby urge Congress to act on this piece of legislation by incorporating it into 

the VA system to prevent the Healthcare system from being included in the casualties of the projected shortage of medical professionals through the year 2020. 

Mr. Chairman and Members of the Subcommittee, The American Legion sincerely 

appreciates the opportunity to submit testimony and looks forward to working with 

you and your colleagues on the abovementioned matters and issues of similarity. 

Thank you. 

f 

Prepared Statement of Thomas J. Berger, Ph.D., Senior Analyst for 

Veterans’ Benefits and Mental Health Issues, Vietnam Veterans of America 

Mr. Chairman, Ranking Member Miller, Distinguished Members of this Subcommittee, and guests, Vietnam Veterans of America (VVA) thanks you for the opportunity to present our views on H.R. 3051, the ‘‘Heroes at Home Act of 2007,’’ that 

is designed to improve the diagnosis and treatment of TBI (traumatic brain injury) 

for servicemembers and veterans, and to review and expand the telehealth and telemental health programs DoD and VA. With your permission, I shall keep my remarks brief and to the point. 

First, VVA thanks you, Mr. Chairman and Mr. Miller as well as distinguished 

Members of this Subcommittee for your active concern in regard to Traumatic Brain 

Injury (TBI) and related mental health problems of our troops and veterans, and 

for your leadership in holding this hearing today. 

In general, Vietnam Veterans of America supports the intent of H.R. 3051. However, medical experts say that traumatic brain injuries are the ‘‘signature wound’’ 

of the Iraq war in particular, a by-product of the explosions caused by I.E.D. roadside blasts and suicide bombers. TBIs have become so commonplace that they, in 

fact, form the basis for today’s hearing. 

Although TBI may share some symptoms with post traumatic stress disorder, it 

is markedly different than PTSD, which is triggered by extreme anxiety, and permanently resets the brain’s fight-or-flight mechanism. Battlefield medics and corpsmen 

can often miss traumatic brain injuries, and many troops don’t know the symptoms 

or won’t discuss their problems for fear of being sent home stigmatized with mental 

illness. The same is true for those who return to the U.S. for garrison duty or exit 

their term of military service and become veterans. 

Certain TBI symptoms, such as seizures, can be treated with medications, but the 

most devastating effects—depression, agitation and social withdrawal—are difficult 

to treat with medication, especially when there is loss of brain tissue. In troops with 

documented TBI, the loss of brain functions is often compounded by other serious 

medical conditions that affect physical coordination and memory functions. These 

patients need a combination of psychological and physical treatment that is difficult 

to coordinate in a traditional medical setting, even when properly diagnosed at an 

early date. And we must remember that both concussive and contusive brain injuries are never just isolated injures. Over time without proper diagnoses, care and 

treatment, TBI can affect nearly everything about the survivor including one’s cognitive, motor, auditory, olfactory and visual skills, perhaps ultimately resulting in 

behavioral modifications, not a mental illness. 

As more and more troops return home damaged from the war, their families must 

contend with not only the physical desolation of their loved ones, but come to grips 

with the new emotional reality of their lives which have changed drastically and not 

necessarily for the better. Take for example, a 35-year old soldier or Marine who 

returns home with what is diagnosed with traumatic brain injury (TBI). His/her impairment affects the future of the entire family. His or her spouse and children have 

to deal with his/her ability to concentrate, the mood swings, the depression, the anxiety, even the loss of employment. As you can well imagine, the economic and emotional instability of a family can be as terrifying and as real as focusing or simply 

waking in the middle of the night and crying because of nightmares. In cases of severely brain-damaged casualties, spouses, parents and siblings may be forced to give 

up careers, forsake wages, and reconstruct homes to care for their wounded relatives, rather than to consign them to the anonymous care of a nursing home or 

assisted living facility. 

Families say that they also struggle with military and VA medical systems that 

were unprepared for these wounded. In some cases new equipment and specially 

trained staff needed for the most catastrophic cases are not available or have not 

kept pace with the advances in battlefield medicine that kept these servicemembers 

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live and brought them home safely. In addition, there are issues about the intensity 

and drain of needed family support that will be hard to sustain, as well as significant issues regarding the complexity of the medical and other specialized needs that 

need to be addressed. Of all the war’s medically challenging injuries, brain injuries 

require the most personal involvement and cost over time. 

TBI also presents a most puzzling challenge, especially in mild to moderate cases. 

Symptoms can be hidden or delayed, diagnosis is difficult, and evidence-based treatments are as of yet largely undetermined. Very few medical facilities are capable 

of providing even the most basic level of care for brain-injured patients, forcing most 

to seek treatment miles from home, if they can find it at all, and we must remember 

that over forty percent of our troops deployed in Iraq and Afghanistan come from 

rural America. 

As you are well aware, one of the recommendations of the Dole-Shalala Commission was to ‘‘significantly strengthen support for families.’’ This will not be an easy 

task, but VVA believes H.R. 3051 to be a key step in achieving this recommendation 

and providing a mechanism for empowering the families of brain-injured 

servicemembers IF the VA can develop effective implementation strategies for certification, competency evaluations, and meaningful outcome measurements to carry 

it out. As they say, ‘‘the devil remains in the details’’. 

I thank you again for the opportunity to offer VVA’s views on this proposed legislation, and I shall be glad to answer any questions you might have. 

f 

Prepared Statement of Gerald M. Cross, M.D., FAAFP, 

Principal Deputy Under Secretary for Health, 

Veterans Health Administration, U.S. Department of Veterans Affairs 

Good morning Mr. Chairman and Members of the Subcommittee. Thank you for 

inviting me here today to present the administration’s views on two bills, H.R. 3051, 

the ‘‘Heroes at Home Act of 2007,’’ and H.R. 6153, the ‘‘Veterans’ Medical Personnel 

Recruitment and Retention Act of 2008.’’ I am accompanied by Mr. Walter A. Hall, 

Assistant General Counsel, and Ms. Joleen Clark, Chief Officer, Workforce Management and Consulting, Veterans Health Administration. 

H.R. 3051. ‘‘Heroes at Home Act of 2007’’ 

H.R. 3051 includes several provisions intended to enhance care and services to 

veterans and particularly new OEF/OIF veterans suffering from traumatic brain injury. section 2 of H.R. 3051 would require VA to establish a program to train and 

certify family members of veterans and servicemembers with traumatic brain injury 

(TBI) as personal care attendants. VA would be responsible for developing curricula 

for training family caregiver personal care attendants and for determining the eligibility of family members to participate in the program. A family caregiver who is 

certified as a personal care attendant would be eligible for compensation from VA 

for care provided to a veteran or servicemember. 

Mr. Chairman, VA does not support section 2 because VA already has a program 

in place that accomplishes the goals of that section in a far more efficient and effective manner. To keep VA from being in the position of having to directly oversee 

the quality of care provided by individual caregivers, including family members, VA 

uses a third-party to obtain needed caregiver services. Implementing the bill, as 

written, would not only be impractical but also inadvisable. The resulting arrangement could well give rise to potential conflicts concerning the veteran’s care between 

the family member-caregiver and the veteran, placing VA in an untenable position. 

We strongly urge the Congress to let us continue to obtain caregiver services as we 

currently do under our Home healthcare Program. 

This bill provides that certified family caregivers shall be eligible for compensation but it does not state the nature of such compensation – is it payment for services provided so that the caregivers are VA employees or is it a benefit and, if so, 

is it to the veteran/servicemember or to the caregiver? Whether the compensation 

is for employment or is a benefit raises significant legal issues relating to liability, 

taxation and VA’s relationship and responsibilities to both the patient and the caregiver. We also note the bill would make VA responsible for compensating caregivers 

of both veterans and active duty members of the Armed Forces. That responsibility 

to pay compensation may be that only relationship VA has with active duty members. 

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Under our program, VA currently contracts with more than 4,000 home health 

agencies that are approved by the Centers for Medicare and Medicaid Services 

(CMS) and/or are state licensed. Many of these agencies have expertise in training 

and certifying home health aides, including family members. Many operate in rural 

communities. VA refers interested family members to these agencies and, after their 

training, these family caregivers become paid employees of the agencies. VA provides remuneration pursuant to agreements with the home health agencies, thus 

compensating family caregivers indirectly. Importantly, VA also ensures that these 

home health agencies meet and maintain training and certification requirements 

specific to caregivers of TBI patients. For the reasons we have discussed, this model 

is preferable to that which would be required by section 2. 

Subsection 3(a) of H. R. 3051 would require VA to conduct comprehensive outreach to enhance the awareness of veterans and the general public about the symptoms of post traumatic stress disorder (PTSD) and TBI and available VA health and 

other services. Mr. Chairman given the extensive and expanding outreach program 

that we already have in place to inform veterans and the general public about PTSD 

and TBI and the services we provide to veterans with these symptoms and injuries, 

this statutory mandate is not necessary. Let me take a moment to describe just 

some of the exciting new efforts underway to reach out to returning veterans. 

VA is making intensive outreach efforts to veterans as they leave active duty. 

Upon return from deployment, every eligible veteran receives a letter from the Secretary of Veterans Affairs informing him or her of the availability of VA services 

near his or her home. VA is currently sending out follow-up letters to all of those 

returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans who have not come to VA for care, to reinforce the point that care is available 

through the Department. As of January 2008, more than 796,000 letters had been 

mailed. On April 24 of this year, the Secretary announced the creation of a ‘‘Combat 

Veteran Call Center’’ to begin contacting the nearly 570,000 recent combat veterans 

who have not used VA healthcare services to ensure they know about VA’s medical 

services and other benefits. 

In addition, the Vet Center program reaches out to returning veterans in their 

communities. Informing combat veterans and family members about the availability 

of readjustment counseling services is one of the primary missions of the Vet Center 

program. In response to the growing numbers of veterans returning from combat in 

OEF/OIF, the Vet Centers initiated an aggressive outreach campaign to welcome 

home and educate returning servicemembers at military demobilization and National Guard and Reserve sites. The Vet Center program also provides access to 

other VHA and Veterans Benefits Administration (VBA) programs. To augment this 

effort, the Vet Center program recruited and hired 100 OEF/OIF veterans to provide 

the bulk of this outreach to their fellow veterans. Outreach provided by fellow combat veterans promotes a peer relationship that helps veterans with PTSD and other 

readjustment problems overcome any perceived stigma that may be associated with 

asking for professional assistance. Vet Center staff also participate with VAMC representatives in all onsite and call center Post-Deployment Health Reassessment 

events across the country, and provide outreach throughout the local community at 

events that feature veterans and family members. This is essential for making effective contact with veterans who have already returned to their home communities 

and are resuming normal family and work life. 

VA is preparing a series of public service announcements to inform veterans about 

various VA services. As a first action, VA has released a series of posters and other 

public service announcements on VA’s Suicide Prevention Hotline. Additionally, VA 

is using non-traditional approaches to disseminate outreach information, including 

presentations about mental health issues that are played on the Music Television 

Channel (MTV) and targeted at young OEF/OIF veterans and their families. VA is 

also developing a comprehensive nation-wide TBI awareness educational campaign 

that targets active duty servicemembers and veterans, media and the general public, Congress, Veterans Service Organizations, State VA Offices, and a variety of 

other key stakeholder groups. Some primary messages included in this campaign 

are identification of the symptoms of mild/moderate TBI, how to access VA 

screenings and treatment, and the benefits and advantages of receiving care from 

VA versus that of the private sector. Lastly, VA’s National Center for PTSD website, 

www.ncptsd.va.gov, posts regularly updated Fact Sheets and other information on 

PTSD available for the general public. 

Mr. Chairman, VA also believes that Subsection 3(b), which would require VA to 

share best practices developed for the treatment of PTSD and TBI with non-VA 

health practitioners, is redundant of activities already in place and therefore unnecessary. VA’s reports and other documentation on best practices are generally a matter of public record. Moreover, VA participates in healthcare conferences where best 

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practices are exchanged and works continually with national organizations to share 

medical information. The following are a few examples of VA’s sharing of best practices: 

• VA’s Clinical Practice Guidelines, including topics such as PTSD, depression, and substance use disorder treatment are publically available on the 

Internet. 

• Local VA medical centers and Mental Illness Research Education and 

Care Centers (MIRECCs) are collaborating with the States in educating 

practitioners on issues of military culture and best practices for treatment of returning veterans. 

• VA is involved in national meetings, such as the August 2008 ‘‘Conference and Policy Academy on Returning Veterans and their Families’’, 

which was a collaboration among the Substance Abuse and Mental 

Health Services Administration (SAMHSA), the Department of Defense, 

and VA. The meeting was designed to help the states and communities 

develop effective plans and best practices for helping returning veterans 

and their families. VA staff made presentations on VA care during the 

Conference phase and provided consultative support to State teams during the Policy Academy. 

• VA’s National Center for PTSD has a web based curriculum ‘‘PTSD 101’’ 

providing education on best practices in PTSD assessment and treatment 

available to non-VA practitioners on VA’s National Center for PTSD 

website (www.ncpted.va.gov.) 

• The clinical experience and advances in rehabilitation methodologies at 

the Polytrauma Rehabilitation Centers (PRC) have been shared with the 

DoD/VA Senior Oversight Committee (SOC), which functions as the main 

conduit by which lessons learned are distributed within DoD and VA. 

• VA and the Defense Center of Excellence for Psychological Health and 

TBI are collaboratively developing Clinical Practice Guidelines for mild 

TBI, which will be published and available to the public in late 2008. 

• In June of this year, VA’s Office of Rehabilitation Research and Development, in collaboration with DoD, sponsored a State-of-the-Art Conference 

on Approaches to TBI: Screening, Treatment, Management, and Rehabilitation. 

Section 4 would require DoD and VA to jointly establish a demonstration project 

to assess the feasibility and advisability of using telehealth technology to assess cognitive functioning of members and former members of the Armed Forces who have 

sustained head trauma, in order to improve the diagnosis and treatment of TBI. In 

selecting sites, priority would be given to locations providing services in rural areas. 

This section would require, among other things, that the demonstration project address the use of telehealth technology to assess the feasibility of obtaining information regarding the nature of any brain injury incurred by a servicemember or veteran and any symptom of TBI in such individuals. Mr. Chairman, VA supports the 

goals of this provision but cannot support the section as written. 

Section 4, as written, is too prescriptive and detailed. VA and DoD should be allowed more flexibility in executing the demonstration project. The technology is 

evolving and new ideas for utilizing the telehealth networks are emerging. DoD and 

VA should be given every opportunity to discover the possibilities of maximizing the 

technology rather than focusing on the enumerated requirements currently specified 

in section 4. We would be pleased to work with Subcommittee staff to develop legislative language that would make the project more tenable and productive. 

VA is continuing to develop cost estimates for H.R. 3051 and will have the results 

for the Subcommittee as soon as possible. 

H.R. 6153. ‘‘Veterans’ Medical Personnel Recruitment and Retention Act of 

2008’’ 

H.R. 6153 contains several provisions intended to enhance VA’s ability to recruit 

and retain nurses and other health-care professionals. Many of these provisions 

would be helpful, and we can support them. However, several of the provisions 

would not be helpful or are otherwise flawed. 

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Authority to Extend Hybrid Status to Additional Occupations 

Subsection 2(a) of the bill would amend section 7401(3) to add ‘‘nurse assistants’’ 

to the list of so called hybrid occupations for which the Secretary is authorized to 

appoint and to determine qualifications and rates of pay under title 38. In addition, 

it would authorize the Secretary to extend hybrid status to ‘‘such other classes of 

healthcare occupations as the Secretary considers necessary for the recruitment and 

retention needs of the Department’’ subject to a requirement to provide 45 days’ advance notice to the Veterans’ Affairs Committees and OMB. Before providing such 

notice, VA would be required to solicit comments from labor organizations representing employees in such occupations. 

VA favors such a provision. Nursing Assistants are critical to the Veterans Health 

Administration’s (VHA) ability to provide care for a growing population of older veterans, who are high-acuity patients and/or frail elderly requiring 24-hour nursing 

care. 

Turnover data, 10.5 percent for 2006 and 11.1 percent for 2007, illustrate the 

great difficulty VA experiences in retaining this occupation. It is increasingly critical 

for VHA to be able to quickly and easily employ these nurse extenders. The same 

holds true for other hard-to-recruit healthcare occupations. This bill would give the 

Secretary the ability to react quickly when it is determined that these authorities 

would be useful in helping in recruiting and retaining a critical occupation without 

seeking additional legislative authority. However, the bill language should be modified to specifically apply to occupations that clearly involve the delivery of 

healthcare. In addition, because this authority involves the conversion of title 5 occupations to title 38 hybrid, the 45-day notice requirement should be modified to 

add OPM. Thus, we recommend modifying subsection 2(a) of the bill to read: 

(a) SECRETARIAL AUTHORITY TO EXTEND TITLE 38 STATUS TO 

ADDITIONAL POSITIONS. 

(1) IN GENERAL.-Paragraph (3) of section 7401 of title 38, United States 

Code, is amended by striking ‘‘and blind rehabilitation outpatient specialists.’’ and inserting in its place the following: ‘‘blind rehabilitation outpatient specialists, and such other classes of healthcare occupations as the 

Secretary considers necessary for the recruitment and retention needs of 

the Department who: 

(A) are employed in the administration (other than administrative, clerical, and physical plant maintenance and protective services employees); 

(B) are paid under the General Schedule pursuant to section 5332 of title 

5; 

(C) are determined by the Secretary to be providing either direct patient 

care services or services incident to direct patient care services; and 

(D) would not otherwise be available to provide medical care and treatment for veterans. 

(2) The Secretary’s authority provided in paragraph (1) is subject to the 

following requirements: 

‘‘(A) Not later than 45 days before the Secretary appoints any personnel 

for a class of healthcare occupations that is not specifically listed in this 

paragraph, the Secretary shall submit to the Committee on Veterans’ Affairs of the Senate, the Committee on Veterans’ Affairs of the House of 

Representatives, the Office of Management and Budget and the Office of 

Personnel Management notice of such appointment. 

‘‘(B) Before submitting notice under subparagraph (A), the Secretary shall 

solicit comments from any labor organization representing employees in 

such class and include such comments in such notice.’’ 

Probationary Periods for Part-Time Nurses 

Subsection 2(b) provides for probationary periods for part-time (PT) Registered 

Nurses (RN) and revises the probationary period for RNs, both fulltime (FT) and 

PT, from 2 years to its equivalency in hours, 4180. It also provides that a PT appointment of a person who previously served on a FT basis in a ‘‘pure’’ title 38 position (7401(1)), and completed a probationary period in the FT position would not 

have to serve a probationary period in the PT ‘‘pure’’ title 38 position. VA opposes 

this provision because it is technically flawed and would not be helpful. 

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Part-time title 38 employees, including RNs, do not serve probationary periods. 

Probationary periods apply to full-time, permanent employees. We see no benefit to 

creating a probationary period for part-time nurses. Moreover, a probationary period 

for PT RNs would not make them the equivalent of tenured employees, for example 

for purposes of discipline or discharge. 

Prohibition on Temporary Part-Time Nurse Appointments In Excess of 

4,180 Hours 

Subsection 2(c) would amend section 7405(f)(2) to limit temporary part-time appointments of hybrid (Licensed Practical Nurse (LPN) and Licensed Vocational 

Nurse (LVN)) nurses to no more than 4180 hours. VA opposes this provision. Currently, all part-time hybrid appointments may be for periods exceeding 1 year. The 

purpose of this restriction on LPNs and LVNs is not apparent. Operationally, it 

could hamstring VHA when it determines using that part-time LPNs and LVNs best 

serve patient care needs. The result could be to deprive VA of highly qualified LPNs 

and LVNs wishing to work only on a part-time basis, for example, for personal and 

family reasons. 

Reemployed Annuitant Offset Waiver 

Subsection 2(d) generally provides that annuitants may be temporarily reemployed in a title 38 position without being subject to having their salary offset by 

the amount of their annuity. 

VA instead favors a Government-wide policy on waivers of this offset. Under current law, VA must obtain a waiver for individuals on a case-by-case basis, or obtain 

delegated waiver authority from the Office of Personnel Management (OPM). VA 

has done this for some critical occupations. The Administration has submitted a bill, 

which VA favors, to provide agencies with the authority to grant offset waivers to 

facilitate the temporary part-time reemployment of annuitants, which has been introduced as H.R. 3579/S. 2003. With many VA employees at or near retirement eligibility the potential for significant losses of mission-critical leaders and technical 

experts is a significant threat to VA’s capability to deliver high quality healthcare 

to our Nation’s veterans. VA access to retired title 38 healthcare providers, without 

financial penalty, would enhance our ability to meet these challenges and maintain 

the continuity of quality patient care, including support in times of disaster. As explained by OPM, 3579/S. 2003 ‘‘would allow Federal agencies to rehire recently retired employees to assist with short-term projects, fill critical skill gaps and train 

the next generation of Federal employees.’’ 

Minimum Rate of Basic Pay for section 7306 Appointees Set to Lowest Rate 

of Basic Pay for SES 

Subsection 2(e) would amend section 7404(a) to add a provision setting the basic 

pay of non-physician/dentist section 7306 employees at not less than the lowest rate 

of basic pay for the Senior Executive Service (SES). This amendment would be effective the first pay period that is 180 days after enactment. 

VA supports the principle of pay equity with SES rates for its section 7306 nonphysician/dentist executives as a tool needed to meet the challenge of recruitment 

and retention. However, we recommend some modifications in the bill’s language. 

Equity in pay for executive level managers and consultants is essential to attracting and retaining candidates for key positions. The pay schedule for 38 USC § 7306 

appointees is now capped at the pay rate for Level V of the Executive Schedule (currently $139,600). Locality pay is paid up to the rate for Level III (currently 

$158,500). Individuals appointed under 38 USC § 7306 serve in executive level positions that are equivalent in scope and responsibility to positions in the SES. By 

comparison, employees in the SES receive a significantly higher rate of basic pay. 

The maximum SES pay limitation is the rate for Level II (currently $172,200) when 

OPM has certified that an agency meets all regulatory criteria for certified performance appraisal systems, including the employing agency makes meaningful distinctions based on performance. 

We estimate the costs of this provision to be $225,290 in FY 2009 and $2,466,862 

over a 10-year period. 

We recommend modifying this proposal to state that the basic pay of non-physician/dentist section 7306 employees be set at the rates of pay for SES employees 

under section 5382 of title 5. This modification would allow VA executive pay to 

track the full range of SES pay. The SES pay system conditions pay up to EL II 

on OPM certification that an agency’s SES rating system meets all regulatory criteria for certified performance appraisal systems. In this regard we note that VHA 

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uses the same rating system for its section 7306 executives as it uses for its SES 

members. OPM has certified VA’s SES performance appraisal system in the past, 

and it is currently certified by OPM through calendar year 2009. For consistency, 

we also recommend that the bill be modified to require that the Secretary make the 

same certification for the rating system covering section 7306 employees. Thus, we 

suggest that subsection 2(e)(3) be modified to read as follows: 

‘‘(3) Positions to which an Executive order applies under paragraph 

(1) and are not described by paragraph (2) shall be paid basic rates of pay 

in accordance with section 5382 of title 5 for Senior Executive Service positions and not greater than the rate of basic pay payable for level III of 

the Executive Schedule; or if the Secretary certifies that the employees are 

covered by a performance appraisal system meeting the certification criteria established by regulation under section 5307(d), level II of the Executive Schedule.’’ 

Comparability Pay Program for section 7306 Appointees 

Subsection 2(f) would amend section 7410 to add a new subsection to establish 

‘‘comparability pay’’ for non-physician/dentist section 7306 employees of not more 

than $100,000 per employee in order to achieve annual pay levels comparable to the 

private sector. Similar to provisions for RN Executive Pay in section 7452(g), it 

would provide that ‘‘comparability pay’’ would be in addition to other pay, awards 

and bonuses; would be considered base pay for retirement purposes; would not be 

base pay for adverse action purposes; and could not result in aggregate pay exceeding the annual pay of the President. 

VA supports the concept of comparability pay for its non-physician/dentist executives. However, at this time we cannot support this proposal because it is a potentially precedent-setting departure from the unitary approach to government-wide 

SES pay. The Department is evaluating alternative proposals that may be more appropriate in addressing the comparability pay issues of these executives. 

We estimate the cost of this provision to be $1,165,500 for FY 2009 and 

$12,761,900 over a 10-year period. 

Special Incentive Pay for Department Pharmacist Executives 

Subsection 2(g) would further amend section 7410 to authorize recruitment and 

retention special incentive pay for pharmacist executives of up to $40,000. VA’s determination of whether to provide and the amount of such incentive pay would be 

based on: grade and step, scope and complexity of the position, personal qualifications, characteristics of the labor market concerned, and such other factors as the 

Secretary considers appropriate. As with RN Executive Pay and comparability pay 

added by subsection (l), it would provide that ‘‘comparability pay’’ would be in addition to other pay, awards and bonuses; would be considered base pay for retirement 

purposes; would not be base pay for adverse action purposes; and could not result 

in aggregate pay exceeding the annual pay of the President. 

This provision would provide a retention incentive to about 40 positions: pharmacy benefit managers (PBM), consolidated mail outpatient pharmacy (CMOP) directors and VISN formulary leaders (VFL). Although VA is facing worsening pay 

compression issues within the ranks of senior pharmacy program managers in the 

VHA, we cannot support this provision because it will not address the Department’s 

retention needs in the long-term. The Department is evaluating alternative proposals that will be more appropriate in addressing the recruitment and retention 

needs of our pharmacy executives. 

We estimate the cost of this provision to be $1,391,500 for FY 2009 and 

$16,324,220 over a 10-year period. 

Physician/Dentist Pay 

Section 2(h) concerns physician/dentist pay. VA supports this provision. 

Paragraph (1) would provide that the title 5 non-foreign cost of living adjustment 

allowance for physicians and dentists would be determined as a percentage of base 

pay only. This would clarify the application of the title 5 non-foreign cost of living 

adjustment allowance to VHA physicians and dentists. The VA physician/dentist pay 

statute, 38 U.S.C. § 7431, does not address how the allowance is determined for physicians and dentists. We recommend that this provision be amended to clarify that 

it is applicable only to these physicians and dentists employed at Department facilities in Alaska, Hawaii, and Puerto Rico. These are the only Department facilities 

to which the title 5 non-foreign cost of living adjustment allowance is applicable. 

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Paragraph (2) would amend section 7431 (c)(4)(B)(i) to exempt physicians and 

dentists in executive leadership provisions from the panel process in determining 

the amount of market pay and tiers for such physicians and dentists. In situations 

where physicians or dentists occupy executive leadership positions such as chief officers, network directors, and medical center directors, the consultation of a panel has 

some limitations. The small number of physicians and dentists who would qualify 

as peers for the executive leaders results in their serving on each other’s compensation panels and, in some cases, on their supervisor’s panel. Providing the Secretary 

with discretion to identify executive physician/dentists positions that do not require 

that panel process would resolve these issues. 

Paragraph (3) would provide an exception to the prohibition on the reduction of 

market pay for changes in board certification or reduction of privileges, correcting 

an oversight in the recent revision of the physician/dentist pay statute. This modification would allow VA to address situations where there is a loss of board certification or an adverse reduction in clinical privileges. No costs are associated with 

this provision. 

RN and CRNA Pay 

Subsections 2(i) and 2(j), relate to RN and Certified Registered Nurse Anesthetist 

(CRNA) Pay. 

Section 2(i) would amend the cap for registered nurse to maximum rate of EL V 

or GS–15, whichever is greater. The current cap is the rate for EL V. Subsection 

(j) would amend section 7451 (c)(2) to exempt CRNAs from the current cap of EL 

V. 

It is important for pay caps to be both fiscally responsible and sufficient to promote employee recruitment and retention. These proposals are not consistent with 

these principles. We note the alternative GS–15 cap would be meaningless inasmuch as it already is lower than the existing cap that is set at EL V, with a difference of about $15,000. Moreover, it is unclear whether this alternative cap would 

be at the GS–15 rate before locality pay or after locality pay. The CRNA cap would 

leave CRNA pay rates completely uncapped, which would allow rates to potentially 

exceed those of physicians and dentists, the title Executive Schedule (Levels I–V), 

or the VA 7306 Schedule. 

We would support this provision if the bill were amended to modify section 

7451(c)(2) to read: ‘‘The maximum rate of basic pay for any grade for a covered position may not exceed the rate of basic pay established for positions in level IV of the 

Executive Schedule under section 5315 of title 5.’’ This would increase the cap from 

level V to level IV for both RNs and CRNAs, consistent with the pay cap that applies to the GS locality pay system. We estimate the cost of this provision to be 

$4,803,964 for FY 2009 and $56,357,188 over a 10-year period. 

Subsection 2(k) would make amendments to the RN locality pay system (LPS). 

These provisions are not helpful and unnecessary. No costs are associated with this 

provision. 

Paragraph (1) would require the Under Secretary for Health to provide education, 

training, and support to VAMC directors in the ‘‘conduct and use’’ of LPS surveys. 

We are concerned that this provision’s focus on facility-conducted surveys is at odds 

with Public Law Number 106–419, which enabled VAMCs to use third-party salary 

surveys whenever possible rather than VA-conducted surveys. The use of third-party 

surveys is in fact the preference of the Department. We recommend modifying this 

provision to read: ‘‘The Under Secretary for Health shall ensure appropriate education and training are available with regard to the conduct and use of surveys, including third party surveys, under this paragraph’’. This would cover both types of 

surveys. Paragraph (2) would require the annual report VAMCs must provide to VA 

Central Office to include the methodology for every schedule adjustment. These reports form the basis for the annual VA report to Congress. We are concerned that 

this provision, especially in conjunction with proposed paragraph 3, could result in 

the inappropriate disclosure of confidential salary survey data, contrary to current 

section 7451 (d)(5). It also would impose an onerous burden inasmuch as VHA has 

nearly 800 nurse locality pay schedules. We do note that VA policy does provide for 

how these surveys are to be obtained or conducted. 

Paragraph (3) would require the most recent VAMC report on nurse staffing to 

be provided to any covered employee or employee’s union representative upon request. This provision should be modified to specify at what point the report must 

be provided. It would not be appropriate to provide an individual a copy of the 

VAMC report before Congress receives the VA report. 

Subsection 2(I) would increase the maximum payable for nurse executive special 

pay to $100,000. This provision would make the amount of nurse executive pay conwwoods2 on PRODPC68 with HEARING

47 

sistent with the Executive Comparability Pay in subsection 2(f). For the same reason we oppose subsection 2(f), we do not support this proposal. We estimate the cost 

of this provision to be $316,250 for FY 2009 and $3,710,053 over a 10-year period. 

The caption for subsection 2(m) suggests it provides for eligibility of part-time 

nurses for certain nurse premium pay. However, many of the substantive amendments are not limited to part-time nurses, or to all registered nurses. 

VA opposes subsection 2(m) as seriously flawed, unnecessary, and costly. 

Subparagraph (1)(A) would amend section 7453 (a) to make part-time nurses eligible for premium pay under that section. However, part-time nurses already are eligible for section 7453 premium pay where they meet the criteria for such pay. 

Subparagraphs (1)(B) and (1)(C) would require evening tour differential to be paid 

to all nurses performing any service between 6 pm and 6 am, and any service on 

a weekend, instead of just those performing service on a tour of duty established 

for those times to meet on-going patient care needs. Under current law, these differentials are limited to the RN’s normal tour of duty and any additional time 

worked on an established tour. 

The ‘‘tour of duty’’ in the current law reflects the requirement of ensuring adequate professional care and treatment to patients during off and undesirable tours. 

The limitation of tour differential and weekend pay only for service on a ‘‘tour of 

duty’’ rewards those employees who are subject to regular and recurring night and 

weekend work requirements. If that is changed to ‘‘period of service’’, any employees 

performing night or weekend work on an occasional or ad-hoc basis would also be 

entitled to this premium pay in addition to overtime pay, providing an inappropriate 

windfall for performing occasional work. 

Subparagraph (2) would authorize title 5 VHA employees to receive 25 percent 

premium pay for performing weekend work on Saturday and Sunday. We understand the purpose of this provision is to limit the expansion of weekend premium 

pay to non-tour hours to registered nurses. However, it does not fully achieve that 

purpose. Pursuant to section 7454(a) and (b)(2), physician assistants, expanded-function dental auxiliaries, and hybrids are also entitled to weekend pay under section 

7453. The expansion of weekend pay would apply to them as well. In addition, because physician assistants and expanded-function dental auxiliaries are entitled to 

all forms of registered nurse premium pay under section 7453, the expansion of the 

night differential premium pay would also apply to them. Furthermore, where VA 

has authorized section 7453 night differential for hybrids, the expansion of the night 

differential premium pay would apply to them as well. 

Subsection 2(n) would add additional occupations to those exempt from the 28th 

step cap on title 38 special salary rates: LPNs, LVNs, and unspecified ‘‘other nursing positions otherwise covered by title 5’’. Notwithstanding the exemption, under 

current statute, title 38 special salary rates cannot exceed the rate for EL V. The 

language ‘‘nursing positions otherwise covered by title 5’’ is unclear as to what positions it would include. RNs are appointed under title 38, LPNs/LVNs are hybrids, 

and section 2(a)(2) of the bill would convert nursing assistants to hybrid. Moreover, 

it is not apparent why only these positions and not all positions authorized title 38 

special rates would be exempted. Using the same formula for the cap on title 5 special rates would afford VA the most flexibility in establishing maximum rates for 

title 38 special rates. Adopting the title 5 fixed percentage formula would render the 

section 7455(c)(2) report for exceeding 94 percent of the grade maximum unnecessary, so we propose deleting it. Thus we recommend amending section 7455 to read 

as follows: 

(a)(1) Subject to subsections (b), (c), and (d), when the Secretary determines it to be necessary in order to obtain or retain the services of persons 

described in paragraph (2), the Secretary may increase the minimum rates 

of basic pay authorized under applicable statutes and regulations, and 

may make corresponding increases in all rates of the pay range for each 

grade. Any increase in such rates of basic pay— 

* * * * 

(c) An increased minimum rate established under subsection (a) may not 

exceed the maximum rate of basic pay (excluding any locality-based comparability payment under section 5304 of title 5 or similar provision of 

law) for the grade or level by more than 30 percent, and no rate may be 

established under this section in excess of the rate of basic pay payable 

for level IV of the Executive Schedule. 

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Subsection 3(a)(1) would add new section 7459, imposing restrictions on nurse 

overtime. section 7459 generally would prohibit mandatory overtime for nurses 

(RNs, LPNs, LVNs, nursing assistants, and any other nurse position designated by 

the Secretary). It would permit mandatory overtime by nurses under certain conditions: an emergency that could not have been reasonably anticipated; the emergency 

is non-recurring and not due to inattention or lack of reasonable contingency planning; VA exhausted all good faith, reasonable attempts to obtain voluntary workers; 

the affected nurses have critical skills and expertise; and the patient work requires 

continuity of care through completion of a case, treatment, or procedure. VA could 

not penalize nurses for refusing to work prohibited mandatory overtime. Section 

7459 provides that nurses may work overtime hours on a voluntary basis. 

VA favors this mandatory overtime restriction with the caveat that first and foremost, VA needs to be able to mandate overtime where issues of patient safety are 

identified by facility leadership. We note VAMCs currently have policies preventing 

RNs from working more than 12 consecutive hours and 60 hours in a 7 day period 

pursuant to section 4(b) of PL 108–445. 

Subsection 3(b) would amend 38 U.S.C. 7456 (the ‘‘Baylor Plan’’), which authorizes VA to allow nurses who perform two 12-hour regularly scheduled tours of duty 

on a weekend to be paid for 40 hours. This work-scheduling practice typically would 

be used when facilities encounter significant staffing difficulties caused by similar 

work scheduling practices in the local community. Currently, VA has no nurses 

working on the Baylor Plan. The proposed revision would substitute scheduled ‘‘periods of service’’ for ‘‘regularly scheduled 12-hour tour of duty.’’ The purpose and effect 

of this amendment are unclear. VA would oppose a revision of this authority if it 

were to mandate that all work on 12 hour regular weekend tours of duty automatically be considered Baylor Plan tours such that it would mandate that any nurse 

who works two 12-hour shifts on a weekend in addition to their regular tour of duty 

to get paid for 40 hours, in addition to premium pay for the extra work, such as 

overtime; and to mandate that nurses are not on the Baylor Plan but who routinely 

work 12-hour shifts under compressed work schedules that fall on weekends are entitled to 40 hours of pay for the 24 hours worked on the weekend in addition to pay 

for the remaining 16 hours. 

Subsection 3(b)(2)(A), in eliminating the requirement that service be on a ‘‘tour 

of duty’’ appears to make the Baylor 1,248 hourly rate divisor apply to all service 

on the weekend instead of just non-overtime hours. It is not appropriate for nonBaylor weekend work hours, and VA opposes this provision. 

Subsection 3(b)(3) would delete section 7456(c), the current Baylor Plan requirement, which provides for a 5-hour leave charge for each 3 hours of absence that reflects the relative value of the truncated Baylor tour, in effect increasing the value 

of leave for affected employees. VA opposes this provision as providing an unwarranted windfall. 

Subsection 3(c) would amend section 7456A to change the 36/40 alternate work 

schedule to a 72/80 alternate work schedule, so that under the schedule six 12-hour 

‘‘periods of service’’ anytime in a pay period would substitute for three ‘‘12-hour 

tours of duty’’ in each week of the pay period. Similar changes would be made to 

section 7456A’s overtime, premium pay and leave provisions. 

VA is experiencing planning problems with the use of the current 36/40 schedule. 

That problem stems from the 36/40 language requiring three 12-hour tours in a 

work week and because VA defines ‘‘work week’’ as Sunday-Saturday. Changing 

’’work week’’ to ‘‘pay period’’ only makes the problem occur every 2 weeks instead 

of every week, so we do not view that as helpful. We do support changing the 36/ 

40 alternate work schedule to a 72/80 alternate work schedule, so that the six 12- 

hour tours can occur anytime in a pay period, providing more work scheduling/planning flexibility. VA will soon undertake a pilot in which all hours worked on tours 

of duty that begin in a work week (even if they end in the following work week) 

will be considered part of the work week for the purpose of the 36/40 alternate work 

schedule. We think this may help resolve the problem. 

Section 4 would make amendments to VA’s Education Assistance Programs. VA 

supports these proposals. 

Subsection 4(a) would amend section 7618 to reinstate the Health Professionals 

Educational Assistance Scholarship Program through the end of 2013. This program 

expired in 1998. The Health Professional Scholarship Program would help reduce 

the nursing shortage in VA by obligating scholarship recipients to work for 2 years 

at a VA healthcare facility after graduation and licensure. 

This proposal would also expand eligibility for the scholarship program to all hybrid occupations. This would be helpful in recruiting and retaining employees in the 

several hard-to-fill hybrid occupations. We estimate the cost of this provision to be 

$725,000 in FY 2010 with a 5-year total of $21,380,000. 

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Subsection 4(b) would make certain amendments to the Education Debt Reduction 

Program. It would amend section 7681(a)(2) to add retention as a purpose of the 

program and amend section 7682(a)(1) to make it available to ‘‘an’’ employee, in lieu 

of ‘‘recently appointed.’’ It would also increase the authorized statutory amounts in 

section 7683 to $60,000 and $12,000, respectively. 

The ‘‘recently appointed’’ requirement limits eligibility to employees who have 

been appointed within 6 months. VA’s experience has been that this is not a sufficient period. In several instances, employees applying just missed the 6 month deadline. In many cases it takes more than 6 months for employees to become aware 

of this very helpful recruitment and retention program. VA also supports the increased amounts in light of increased education costs since the program was enacted. We estimate the cost of this provision to be $5,400,000 for FY 2010 and 

$77,352,000 over a 10-year period. 

Subsection 4(c) would authorize VA researchers from ‘‘disadvantaged backgrounds’’ to use authorities in the Public Health Service Loan Repayment Program. 

This program presently is not available to Federal employees other than those working for the National Institutes of Health (NIH). Clinicians with medical specialization and research interests who might otherwise consider career clinical care or clinical research opportunities with VHA are therefore less likely to do so because VA 

employees are not eligible for the LRP program. These same research-focused, 

entry-level professionals have historically been the highest caliber and most soughtafter candidates. VA researchers should be able to participate in this much soughtafter program. VHA’s Education Debt Reduction Program (EDRP) is only available 

for employees hired for permanent title 38 positions. Those in time-limited clinical 

research training positions such as the Research Career Development Awards 

(which historically have served as entryways to VA careers in clinical care and research) are not eligible. There are no costs associated with this proposal; it would 

not increase the funding of this program, but simply authorize VA researchers to 

participate in it. 

Mr. Chairman, this concludes my prepared statement. I will be happy to answer 

any questions that you and the Members of the Subcommittee might have. 

f 

Statement of Raymond C. Kelly, National Legislative Director, American 

Veterans (AMVETS) 

Chairman Michaud, Ranking Member Miller, thank you for holding this important hearing today. AMVETS is pleased to provide our views on H.R. 3051, the Heroes at Home Act of 2007, and H.R. 6153, the Veterans Medical Personnel Recruitment and Retention Act of 2008. 

H.R. 3051 will establish two separate programs. First it will provide training and 

certification of family caregivers for veterans and members of the Armed Forces 

with Traumatic Brain Injury (TBI). Once a family member has been deemed eligible 

for the certification they also become eligible for compensation for the care they provide. H.R. 3051 will also establish a DoD–VA demonstration project to test the feasibility of using telehealthcare to care for servicemembers and veterans who have or 

could have TBI. 

TBI is the signature wound of the current conflicts in Iraq and Afghanistan. Identifying, treating, and caring for servicemembers who have TBI ranks at the top of 

AMVETS’ priorities; therefore, AMVETS fully supports H.R. 3051, which will provide training and certification for family members of servicemembers who are affected by the unique nature of TBI. Family members are a natural choice for caring 

for patients who need daily in-home care. Because of the desire to help, family members will become caregivers. Providing them with the proper training and certification will give them the confidence they need to fully care for their loved one and 

reduce VA’s need to provide additional home healthcare. 

H.R. 3051 will also broaden the use of telehealth and telemental health services. 

VA is a national leader in the development and use of telehealth programs. Nearly 

200,000 veterans have been seen this year by specialists from the convenience of 

their local CBOC. Evaluating, diagnosing and treating mental health conditions related to TBI through telehealth will improve the lives of our servicemembers who 

have sustained head injuries. AMVETS supports the provision that will establish 

the telehealth and telemental health demonstration project. It is critical that VA 

and DoD make every effort to make receiving treatment for our servicemembers and 

veterans as convenient and as effective as possible, and the use of telehealth will 

ensure that veterans in remote locations or veterans who may have trouble traveling any distance will receive the attention and care they need and deserve. 

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i Chwalisz, Kathleen. ‘‘Perceived Stress and Caregiver Burden after Brain Injury: A Theoretical Integration.’’ Rehabilitation Psychology, Vol. 37, No. 3, 1992. pp 189–203. ii Hall KM, Karzmark P, Stevens M, Englander J, O’Hare P, Wright J. Arch Phys Med 

Rehabil. 1994 Aug;75 (8): 876–84. 

H.R. 6153, the ‘‘Veterans’ Medical Personnel Recruitment and Retention Act of 

2008’’ would give the Department of Veterans Affairs an enhanced ability to recruit 

and retain nurses and other critical healthcare professionals at VA facilities. The 

Veterans Health Administration (VHA) is the largest direct provider of healthcare 

services in the Nation and adequate staffing is necessary to provide the care our 

veterans deserve. It is for this reason that AMVETS wholly supports H.R. 6153. 

Critical shortages of healthcare professionals, such as registered nurses (RN), registered nurse anesthetists, physical and occupational therapists, speech pathologists, 

pharmacists, and physicians make it difficult to fill positions in the best of circumstances. Add to this the difference between VA compensation and private sector 

salaries and it becomes evident why the VA is understaffed. 

One recruitment and retention tool in H.R. 6153 would be to increase pay for critical jobs. Currently VA medical professionals’ salaries are not in line with what 

other facilities can pay. This has resulted in understaffed hospitals. By increasing 

the limitation on special pay for nurse executives from $25,000 to $100,000, for example, the VA has a tool to recruit new professionals as well as provide retention 

incentives for those already employed by VA facilities. 

Another recruitment tool provided for in H.R. 6153 is limits on mandatory overtime and more flexible work schedules. It also improved education assistance programs and loan repayment plans. Combined with increased pay for certain positions, these tools would expand VA’s ability to recruit and retain employees which 

would translate into improved care for our Nations’ veterans. AMVETS wholly supports H.R. 6153. 

Mr. Chairman, this concludes my testimony. I will be happy to answer any questions regarding our opinion on these matters. 

f 

Statement of Susan H. Conners, President/Chief Executive Officer, 

Brain Injury Association of America 

The Brain Injury Association of America (BIAA) and its nationwide network of 

state affiliates representing survivors of traumatic brain injury (TBI), their families, 

researchers, clinicians and other professionals, strongly supports The Heroes at 

Home Act of 2007 (H.R. 3051) and urges the United States House Committee on 

Veterans’ Affairs to approve this important legislation in a timely manner. 

The Heroes at Home Act of 2007 (H.R. 3051) would significantly improve support 

for family caregivers of returning servicemembers with traumatic brain injury (TBI). 

This important bill proactively acknowledges the reality that a brain injury impacts 

the entire family, not just the individual. 

Importantly, this legislation acknowledges the critical role played by family caregivers in facilitating recovery from brain injury and addresses the pressing need to 

increase support for these caregivers through programs providing access to training, 

certification and financial compensation for their work as personal care attendants. 

Family care is the most important source of assistance for people with chronic or 

disabling conditions, including people with brain injury. Yet, research has found 

that all too often, the traumatic brain injury of a spouse or close relative places extreme stress on family caregivers, frequently resulting in adverse physical and emotional outcomes for the caregivers themselves. Unfortunately, despite these documented physical hardships and psychological stress, family caregivers receive little 

support. 

Specifically, stress reaction is known to occur in situations where the demands of 

the environment exceed an individual’s resources. One critical component that has 

been found to be related to caregiver burden is whether or not the caregiver perceives the effects of the injury to exceed the caregiver’s resources to manage the situation. In other words, perceived stress has consistently predicted negative outcomes for the caregiver.i A lack of financial resources and social supports are some 

of the common perceived stresses impacting family caregivers of loved ones with 

TBI. 

One longitudinal study found that 47 percent of family caregivers of individuals 

with TBI had altered or given up their jobs at 1 year postinjury, and 33 percent 

at 2 years postinjury, decreases in both employment and financial status were reported over a 2-year time period postinjury ii. Particularly in light of the fact that 

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caregivers often report severe financial strain and frequently must give up their jobs 

in order to take care of their loved one with TBI, increased financial support and 

access to respite care for family caregivers of returning servicemembers with TBI 

is vital and long overdue. 

Again, the Brain Injury Association of America enthusiastically endorses The Heroes at Home Act of 2007 (H.R. 3051) and strongly encourages the Committee to 

approve this legislation. 

Sincerely, 

Susan H. Connors 

f 

President/Chief Executive Officer 

Statement of Hon. Paul W. Hodes, 

a Representative in Congress from the State of New Hampshire 

I strongly support my colleague Carol Shea-Porter’s bill, H.R. 6629, the Veterans 

Health Equity Act. Her bill would ensure that New Hampshire’s veterans have access to the healthcare they have earned. I thank Chairman Michaud for holding this 

important hearing that highlights the lack of adequate access to healthcare for New 

Hampshire’s veterans. 

New Hampshire is the only state in the continental United States that does not 

have a full service Veterans Affairs Medical Center (VAMC). In my district alone, 

there are over 66,000 veterans, making up 13 percent of the population. New Hampshire’s many veterans deserve the same access to healthcare services as veterans 

in other states across the country. 

Seven years ago, the Manchester VAMC suspended various inpatient and outpatient services and was downgraded from a full-service VAMC. Now, veterans in 

New Hampshire must travel to surrounding states like Maine, Vermont or Massachusetts to receive VA healthcare services. 

This travel causes both physical and financial hardships for our wounded veterans. Without a full service VAMC in state, New Hampshire’s veterans are forced 

to drive across state lines, traveling farther and paying more at the pump with 

record gas prices to access the healthcare they earned. 

Recently, the Secretary of Veterans Affairs James Peake visited New Hampshire 

and announced that the VAMC in Manchester will not return to a full service 

VAMC. I was extremely disappointed in Secretary Peake’s shortsighted remarks. 

More wounded warriors are returning home from the Wars in Iraq and Afghanistan 

as veterans with physical and mental wounds, with Post Traumatic Stress Disorder 

and Traumatic Brain Injury, stretching our veteran’s healthcare system. 

With so many soldiers fighting abroad, we should not be turning our backs on veterans at home when they need it most. New Hampshire is the only state in the continental U.S. without a full service VA. With record high gas prices, we shouldn’t 

ask Granite State veterans to drive long distances just to get the care they have 

earned. I strongly support H.R. 6629, the Veterans Health Equity Act, which would 

ensure that veterans across the country will receive the same access to healthcare 

that they deserve, no matter which state they live in. 

f 

Statement of Barbara Cohoon, Deputy Director, Government Relations, 

National Military Family Association, Inc. 

Chairman Michaud and Distinguished Members of this Subcommittee, the National Military Family Association (NMFA) would like to thank you for the opportunity to present written testimony for the record on ‘Heroes at Home Act of 2007.’ 

We thank you for your focus on the many elements necessary to ensure quality 

healthcare and mental healthcare for our wounded/ill/injured servicemembers, veterans, and the families who care for them; and, recognizing the important role caregivers play in the care of their loved one. 

NMFA will discuss several issues of importance to wounded/ill/injured 

servicemembers, veterans, and their families in the following subject areas: 

I. Wounded Servicemembers Have Wounded Families 

II. Who Are the Families of Wounded Servicemembers? 

III. Caregivers 

IV. Mental Health 

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Wounded Servicemembers Have Wounded Families 

NMFA asserts that behind every wounded servicemember and veteran is a 

wounded family. Spouses, children, parents, and siblings of servicemembers injured 

defending our country experience many uncertainties. Fear of the unknown and 

what lies ahead in future weeks, months, and even years, weighs heavily on their 

minds. 

Transitions can be especially problematic for wounded/ill/injured servicemembers, 

veterans, and their families. The Department of Defense (DoD) and the Department 

of Veterans Affairs (VA) healthcare systems, along with State agency involvement, 

should alleviate, not heighten these concerns. It is NMFA’s belief the government 

must take a more inclusive view of military and veterans’ families. Those who have 

the responsibility to care for the wounded servicemember must also consider the 

needs of the spouse, children, parents of single servicemembers, siblings, and especially the caregivers. According to the VA, ‘informal’ caregivers are people such as 

a spouse or significant other or partner, family member, neighbor or friend who generously gives their time and energy to provide whatever assistance is needed to the 

veteran.’’ 

Who are the families of Wounded Servicemembers 

In the past, the VA and the DoD have generally focused their benefit packages 

for a servicemember’s family on his/her spouse and children. Now, however, it is not 

unusual to see the parents and siblings of a single servicemember presented as part 

of the servicemember’s family unit. In the active duty, National Guard, and Reserves almost 50 percent are single. Having a wounded servicemember is new territory for family units. Whether the servicemember is married or single, their families 

will be affected in some way by the injury. As more single servicemembers are 

wounded, more parents and siblings must take on the role of helping their son, 

daughter, sibling through the recovery process. Family members are an integral 

part of the healthcare team. Their presence has been shown to improve their quality 

of life and aid in a speedy recovery. 

NMFA recently gathered information about issues affecting our wounded 

servicemembers, veterans, and their families through our Healing Adventure Operation Purple Camp in August and a focus group held this March at Camp Lejeune. 

They said following the injury, families find themselves having to redefine their 

roles. They must learn how to parent and become a spouse/lover with an injury. 

Spouses talked about the stress their new role as caregiver has placed on them and 

their families. Often overwhelmed and feeling as if they have no place to turn to 

for help. 

Caregivers 

Caregivers need to be recognized for the important role they play in the care of 

their loved one. Without them, the quality of life of the wounded servicemembers 

and veterans, such as physical, psycho-social, and mental health, would be significantly compromised. They are viewed as an invaluable resource to DoD and VA 

healthcare providers because they tend to the needs of the servicemembers and the 

veterans on a regular basis. And, their daily involvement saves DoD, VA, and State 

agency healthcare dollars in the long run. 

Caregivers of the severely wounded, ill, and injured servicemembers who are now 

veterans have a long road ahead of them. In order to perform their job well, they 

must be given the skills to be successful. This will require the VA to train them 

through a standardized, certified program, and appropriately compensate them for 

the care they provide. NMFA is pleased with the ‘Heroes at Home Act of 2007’ legislation that will provide for the training, certification, and compensation for injured 

servicemembers or veterans with TBI. TBI has become the signature wound of this 

current conflict; however, the legislation should be flexible and allow for the expansion of training, certification, and compensation to encompass other injuries. Often, 

our wounded servicemembers and veterans present with more than one type of injury. This legislation places VA in an active role in recognizing caregivers’ important 

contributions and enabling them to become better caregivers to their loved ones. It 

is a win-win for everyone involved. 

The VA currently has eight caregiver assistance pilot programs to expand and improve healthcare education and provide needed training and resources for caregivers 

who assist disabled and aging veterans in their homes. These pilot programs are 

important, but there is a strong need for 24-hour in-home respite care, 24-hour supervision, emotional support for caregivers living in rural areas, and coping skills 

to manage both the veteran’s and caregiver’s stress. These pilot programs, if found 

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successful, should be implemented by the VA as soon as possible and fully funded 

by Congress. However, one program missing is the need for adequate child care. 

Veterans can be single parents or the caregiver may have non-school aged children 

of their own. Each needs the availability of child care in order to attend their medical appointments, especially mental health appointments. NMFA encourages the 

VA to create a drop-in child care for medical appointments on their premises or 

partner with other organizations to provide this valuable service. 

Mental Health 

Families’ needs for a full spectrum of mental health services—from preventative 

care and stress reduction techniques, to individual or family counseling, to medical 

mental health services—will continue to grow. It is important to note if DoD has 

not been effective in the prevention and treatment of mental health issues, the residual will spill over into the VA healthcare system. The need for mental health 

services will remain high for some time even after military operations scale down 

and servicemembers and their families transition to veteran status. The VA must 

be ready. They must partner with DoD and State agencies in order to address mental health issues early on in the process and provide transitional mental health programs. They must maintain robust rehabilitation and reintegration programs for 

veterans and their families that will require VA’s attention over the long-term. 

NMFA is especially concerned with the scarcity of services available to the families as they leave the military following the end of their activation or enlistment. 

They may be eligible for a variety of health insurance programs, such as TRICARE 

Reserve Select, TRICARE, or VA. Many will choose to locate in rural areas where 

there may be no mental health providers available. We ask you to address the distance issues families face in linking with mental health resources and obtaining appropriate care. Isolated veterans and their families do not have the benefit of the 

safety net of services and programs provided by MTFs, VA facilities, CBOCs, and 

Vet Centers. NMFA recommends the use of alternative treatment methods, such as 

telemental health. The ‘Heroes at Home Act of 2007’ provision for telemental health 

will provide an additional benefit to this population. Another solution is modifying 

licensing requirements in order to remove geographical practice barriers that prevent mental health providers from participating in telemental health services outside of a VA facility. 

NMFA appreciates the ‘Heroes at Home Act of 2007’ inclusion of an outreach and 

public awareness provision. The VA must educate their healthcare and mental 

health professionals, along with veterans’ families of the effects of mild Traumatic 

Brain Injury (TBI) in order to help accurately diagnose and treat the veteran’s condition. Veterans’ families are on the ‘‘sharp end of the spear’’ and are more likely 

to pick up on changes contributed to either condition and relay this information to 

VA providers. VA mental and healthcare providers must be able to deal with 

polytrauma—Post-Traumatic Stress Disorder (PTSD) in combination with multiple 

physical injuries. NMFA appreciates Congress establishing the National Center of 

Excellence and the Defense Center of Excellence. Now, it is very important for DoD 

and VA to partner in researching TBI and PTSD. We believe the VA needs to educate their civilian healthcare providers on how to identify signs and symptoms of 

mild TBI and PTSD. And, as the VA incorporates Project Hero, they must educate 

civilian network mental health providers about our military culture. 

NMFA strongly suggests standardized training, certification, and compensation for caregivers of injured servicemembers or veterans with TBI. 

NMFA recommends the use of alternative treatment methods, such as 

telemental health; and, the modification of licensing requirements to remove geographical practice barriers that prevent mental health providers 

from participating in telemental health services outside of a VA facility. 

The VA must educate their healthcare and mental health professionals, 

along with veterans’ families of the effects of mild Traumatic Brain Injury 

(TBI) and Post-traumatic Stress Disorder (PTSD) to help accurately diagnose and treat the servicemember’s condition. The VA needs to encourage 

more education for civilian healthcare providers on how to identify signs 

and symptoms of mild TBI and PTSD. NMFA recommends spouses and parents of returning servicemembers and veterans need programs providing 

education on identifying mental health, substance abuse, suicide, and traumatic brain injury. 

NMFA recommends Congress require Vet Centers and the VA to develop 

a holistic approach to veteran care by including their families in providing 

mental health counseling and programs. 

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NMFA would like to thank you again for the opportunity to present testimony for 

the record on the ‘Heroes at Home Act of 2007’ for servicemembers, veterans, and 

their families. Military families support the Nation’s military missions. The least 

their country can do is make sure servicemembers, veterans, and their families have 

consistent access to high quality mental healthcare in the DoD, VA, and within network civilian healthcare systems utilizing alternative treatment methods, such as 

telemental health. Wounded servicemembers and veterans have wounded families. 

The caregiver must be supported by the VA by providing training, certification, and 

compensation for the care of their loved one. The system should provide coordination 

of care DoD, VA, and State agencies working together to create a seamless transition. We ask Congress to assist in meeting that responsibility. 

f 

Statement of Paralyzed Veterans of America 

Chairman Michaud, Ranking Member Miller, and Members of the Subcommittee, 

Paralyzed Veterans of America (PVA) is pleased to present our views concerning 

H.R. 6153, the ‘‘Veterans Medical Personnel Recruitment and Retention Act of 

2008,’’ and H.R. 3051, the ‘‘Heroes at Home Act of 2007,’’ which will improve the 

diagnosis and treatment of Traumatic Brain Injury (TBI) for members and former 

members of the Armed Forces. 

H.R. 6153, THE ‘‘VETERANS MEDICAL PERSONNEL RECRUITMENT AND 

RETENTION ACT OF 2008’’ 

PVA’s primary concern, and the basic reason for our existence, is the health and 

welfare of our members and our fellow veterans. The thousands of Department of 

Veterans Affairs (VA) healthcare professionals and all of those individuals necessary 

to support their efforts are at the core of VA’s primary mission. These individuals 

serve on the frontline every day, caring for America’s wounded veterans from Iraq 

and Afghanistan and seeing to the complex medical needs of our countries older veterans from previous wars. PVA believes that VA’s most important asset is the people it employs to care for those who have served our Nation. 

Mr. Chairman, when PVA testified on May 22, 2008 concerning the human resources challenges facing the Department of Veterans Affairs’, we applauded the 

Subcommittee for its timely and well placed interest in the issues concerning VA 

healthcare personnel. PVA continues to believe that Congress must assist VA efforts 

to recruit and retain its corps of healthcare professionals as the demand for 

healthcare increases both because of the ongoing Global War on Terrorism and the 

aging of the veteran population from previous wars. The current serious national 

short fall in the supply of physicians, nurses, pharmacists, therapists and psychologists threatens VA staffing as competition for experienced medical personnel and 

newly licensed professionals continues to increase. H.R. 6153 is a step in the right 

direction. 

The United States is currently in the tenth year of a critical nursing shortage 

which is expected to continue through 2020. The shortage of registered bed-side 

nurses and registered nurse specialists is having an impact on all aspects of acute 

and long-term care. America’s nursing shortage has created nurse recruitment and 

retention challenges for medical-care employers nationwide and is making access to 

quality care difficult for consumers. 

The gap between the supply of and the demand for nurses may adversely affect 

the VA’s ability to meet the healthcare needs of those who have served our Nation. 

According to VA, it employs more than 64,000 nursing professionals, and has one 

of the largest nursing staffs of any healthcare system in the world. Of that 64,000, 

VA has 43,000 registered nurses, 12,000 licensed practical nurses, and 9,000 nursing assistants. VA also says that approximately 4,300 nurses retire or leave each 

year. VA must be able to recruit the best nurses, and retain a cadre of experienced, 

competent nurses. Providing high quality nursing care to the Nation’s veterans is 

integral to the healthcare mission of VA. 

During PVA’s previous testimony, we asked for the Subcommittee’s consideration 

of specially pay for nurses providing care in VA’s specialized service programs such 

as: spinal cord injury/disease (SCI/D), blind rehabilitation, mental health and brain 

injury. PVA is disappointed that the Subcommittee chose not to include such specific 

language in H.R. 6153. 

Mr. Chairman, veterans who suffer spinal cord injury and disease require a cadre 

of specialty trained registered nurses to meet their complex initial rehabilitation 

and life-long sustaining medical care needs. PVA’s data reveals a critical shortage 

of registered nurses who are providing care in VA’s SCI/D center system of care. 

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tremely difficult and demanding. These difficult care conditions become barriers to 

quality registered nurse recruitment and retention. Many of VA’s SCI/D nurses are 

often placed on light duty status because of injuries they sustain in their daily 

tasks. When this happens it becomes a significant problem because it places additional patient care responsibility on those SCI/D nurses not on light duty. PVA believes SCI/D specialty pay is absolutely necessary if nurse shortages are to be overcome in this VA critical care area. We strongly encourage your committee to include 

a Title 38 specialty pay provision that will assist VA’s efforts to recruit and retain 

nurses in these specialized areas. 

PVA is concerned about the VA’s current ability to maintain appropriate and adequate levels of physician staffing at a time when the Nation faces a pending shortage of physicians. Recent analysis by the Association of American Medical Colleges 

(AAMC) indicates the United States will face a serious doctor shortage in the next 

few decades. The AAMC goes on to say that currently, ‘‘744,000 doctors practice 

medicine in the United States, but 250,000—one in three—are over the age of 55 

and are likely to retire during the next 20 years.’’ The subsequent increasing demand for doctors, as many enter retirement, will increase challenges to VA’s recruitment and retention efforts. PVA believes H.R. 6153 will allow VA to be more competitive in recruiting doctors for the VA system. 

Mr. Chairman, the Veterans Health Administration has made great strides over 

the last decade to improve the quality of care it provides to our Nation’s veterans. 

Despite these gains, VA now finds itself in a precarious situation if it expects to retain its position as a vastly improved healthcare system. As stated earlier, H.R. 

6153 is only a first step in meeting the challenges associated with maintaining a 

highly qualified medical care workforce for VA. Competition to hire medical care 

professionals, during a national period of low supply, is making it more-and-more 

difficult for VA to successfully recruit and retain qualified personnel. This Subcommittee and VA must be vigilant in developing programs that will provide professional healthcare workers to care for our veterans. 

H.R. 3051, ‘‘THE HEROES AT HOME ACT OF 2007’’ 

Traumatic Brain Injuries (TBI) have become an important topic as a result of the 

wars in Afghanistan and Iraq. In fact, The Independent Budget, co-authored by 

PVA, AMVETS, Disabled American Veterans (DAV) and the Veterans of Foreign 

Wars (VFW), identified treatment for veterans with TBI as a critical issue for 2008 

and beyond. PVA welcomes the Subcommittee’s action on H.R. 3051. 

TBI, Spinal Cord Injury, and other serious injuries account for almost 20 percent 

of the combat casualties sustained by U.S. soldiers, airman and Marines in OEF/ 

OIF. Explosive blast pressure waves from improvised explosive devices (IEDs) violently shake or compress the brain within the closed skull and cause devastating 

and often permanent damage to brain tissues. There has been universal recognition 

that veterans with severe TBI will need a lifetime of intensive services to care for 

their injuries. However, PVA is concerned that, at all levels, development of programs to address the needs of veterans with mild, subclinical TBI have not been 

fully developed or implemented. 

DoD and VA experts note that TBI can also be caused without any apparent physical injuries if a person is in the vicinity of these IED detonations. Veterans suffering from this milder form of TBI may not be readily detected; however, symptoms 

can include chronic headaches, irritability, disinhibition, sleep disorders, confusion, 

executive functioning and memory problems, and depression, among other symptoms. With tens of thousands of IED detonations now recorded in Iraq alone, it is 

believed that many OEF/OIF servicemembers have suffered mild, but pathologically 

significant, brain injuries (including multiple concussions) that have gone 

undiagnosed and largely untreated thus far. TBI and its associated symptoms may 

be detected later only if proper screening is conducted. 

PVA is concerned about emerging literature that strongly suggests that even 

mildly injured TBI patients may have long-term mental and physical health consequences. According to DoD and VA mental health experts, mild TBI can produce 

behavioral manifestations that mimic Post Traumatic Stress Disorder (PTSD) or 

other conditions. And TBI and PTSD can be coexisting conditions. Much is still unknown about the long-term impact of these injuries and the best treatment models 

to address mild-to-moderate TBI. We believe VA should conduct more research into 

the long-term consequences of brain injury and development of best practices in its 

treatment; however, we suggest that any studies undertaken include older veterans 

of past military conflicts who may have suffered similar injuries that thus far have 

gone undetected, undiagnosed or misdiagnosed, and untreated. Their medical and 

social histories could be of enormous value to VA researchers interested in the likely 

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long-term progression of these new injuries. Likewise, such knowledge of historic experience could help both the DoD and VA better understand the policies needed to 

improve screening, diagnosis, and treatment of mild TBI in combat veterans of the 

future. This is where PVA sees great potential for the demonstration project of Telehealth and Telemental programs proposed in H.R. 3051. We would caution the Subcommittee, however, to ensure that this program is a supplement to regular VA programs and not used as one more way for VA to move veterans’ healthcare further 

away from VA facilities. 

Individuals suffering from mild brain injury often present complex, difficult-to-assess complaints and conditions that can masquerade as other diagnoses. This complexity requires an integrated, personalized recovery plan coordinated by a cadre of 

specialists with expertise in TBI to diagnose and manage their medical, psychological, and psychosocial needs. 

Although VA has initiated new programs and services to address the needs of severe TBI patients, gaps in services still exist. The VA’s Office of the Inspector General (OIG) issued a report in July of 2006, titled ‘‘Health Status of and Services for 

Operation Enduring Freedom/ Operation Iraqi Freedom Veterans after Traumatic 

Brain Injury Rehabilitation.’’ The report assessed healthcare and other services provided for veterans and active duty patients with TBI, and then examined their status approximately 1 year following completion of rehabilitation. 

The report found that better coordination of care between DoD and VA healthcare services was needed to enable veterans to make a smooth transition. According 

to the report, the goal of achieving optimal function of each individual requires further interagency agreements and coordination between the DoD and VA. PVA believes the true measure of success will be the extent to which those most severely 

injured veterans are eventually able to recover, reenter their communities, or at 

minimum, achieve stability of function at home or in the least restrictive, age-appropriate continuing care facilities provided by VA to meet their needs and preferences. 

PVA strongly supports the provisions of H.R. 3051 which provide training and certification for family caregiver personal attendants at no cost to the family. Providing 

the ability for family members to care for their loved ones injured in conflict will 

assist in keeping the families strong while properly caring for the veteran. Though 

PVA remains concerned about whether VA has addressed the long-term emotional 

and behavioral problems that are often associated with TBI, and the devastating impact on both the veteran and his or her family, we believe this program may help 

address these concerns. As noted in the July 2006 OIG report, ‘‘these problems exact 

a huge toll on patients, family members, and healthcare providers.’’ The following 

excerpt from the report is especially telling: 

In the case of mild TBI, the [veteran’s] denial of problems which can accompany damage to certain areas of the brain often leads to difficulties receiving services. With more severe injuries, the extreme family burden can lead 

to family disintegration and loss of this major resource for patients. 

The OIG recommendations included improving case management for TBI patients 

to ensure lifelong coordination of care; improving collaborative policies between the 

DoD and VA; starting new initiatives to support families caring for TBI patients, 

including providing access to VA or contract caregivers; and recommending that rehabilitation for TBI patients be initiated by the DoD when clinically indicated. We 

fully concur with the OIG’s recommendations and recognize that supporting these 

patients for a lifetime of care and service will be a continuing challenge for VA. 

VA now requires a case manager be assigned to each OEF/OIF veteran enrolled 

in VA healthcare. The case manager’s duty is to communicate and coordinate all VA 

benefits and services. Also, VA has created liaison and social work positions in DoD 

facilities to assist injured servicemembers with their transitions to veteran status 

and to provide advice and assistance to them and their families in accessing VA 

services. PVA commends VA for its efforts to improve the knowledge and skills of 

VA clinicians through educational initiatives defining the unique experience and 

needs of this newest generation of combat veterans. We also acknowledge VA’s dedication and commitment to meeting the needs of veterans with TBI through high 

quality services at its polytrauma-TBI lead centers, for ongoing research into this 

debilitating injury, and for establishing effective services with academic and military affiliates to fill gaps in service when and where they are found. However, we 

are concerned about media reports from veteran patients with TBI and their family 

members who claim that VA TBI care is not up to par in certain locations, prompting them to seek rehabilitation services from private facilities. VA must ensure that 

its TBI network provides excellent care to all veterans irrespective of their degree 

of impairment. VHA’s current continuing education programs should be enhanced 

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to ensure that all VA providers are knowledgeable about the spectrum of clinical 

presentation and treatment of veterans with combat-related TBI. 

We encourage VA and Congress to ensure that severely wounded TBI veterans 

are receiving the best treatment and rehabilitation care available and that the 

needs of their family caregivers be met with innovative and effective programs. 

Mr. Chairman, this concludes our remarks. PVA will be happy to respond to any 

questions you or Members of the Subcommittee may have. 

f 

Statement of James C. Schraa, Psy.D., Neuropsychologist, Licensed 

Psychologist, State of Colorado, Craig Hospital, Englewood, CO 

Severe traumatic brain injury is a family injury in the sense that it converts the 

loved ones of the brain injured servicemembers into caregivers and personal care attendants. After acute rehabilitation, the family members must substitute their judgment, planning and memory functions for the cognitive abilities and emotional control that their loved one has lost. Positive outcomes following severe traumatic brain 

injury are strongly associated with ongoing family support and involvement. Unfortunately, providing care giving and a safe structure for the severely brain injured 

is associated with the experience of high levels of stress and very high divorce rates. 

The civilian literature also establishes that brain injury substantially increases the 

frequency of bankruptcy. 

The vast majority of Americans would agree that supporting our troops includes 

helping families to successfully cope with the behavioral and adjustment challenges 

that persist following severe traumatic brain injury. Americans want their military 

servicemembers with severe brain injuries to have as much quality of life as possible. This is clearly associated with keeping them with their families and in their 

own communities. The Medicare cost literature amply documents that maintaining 

patients in the community is also cost effective. The most expensive cases in terms 

of long-term medical costs are the chronically institutionalized disabled. Thus, Representative Salazar’s Bill, H.R. 3051 not only reflects the loyalty we feel to our fellow citizen soldiers, but also represents a cost-effective approach to reduce 

healthcare costs (references available on request). It should also be noted that divorce involving patients with severe brain injuries results in increased long-term 

costs to government agencies for establishing and managing guardianships and 

conservatorships. 

The literature on urban versus rural health-related quality of life establishes that 

the rural veteran population experiences lower physical and mental quality of life. 

Numerous studies have established that members of the National Guard and Reserve experience higher rates of emotionally based symptoms and problems related 

to alcoholism. Fewer supports in rural communities contribute to poorer coping in 

all at-risk groups including soldiers with traumatic brain injury. Rural VA clinics 

and Veteran Centers in rural communities constitute tremendous improvements for 

veterans but they usually do not include specialty care. Therefore, in all states with 

dispersed rural populations, initiatives to improve telemedicine are needed. Rural 

veterans with moderate to severe traumatic brain injuries will clearly be in need 

of ongoing consultation for the foreseeable future. Given the difficulties that this 

group of brain injured veterans has with driving and transportation, telemedicine 

outreach projects to increase their access to services should be supported. 

I have had the experience of working with patients with severe traumatic brain 

injuries and spinal cord injuries for 26 years at Craig Hospital. Our experience is 

that supporting and maintaining families in the community is the most cost effective approach to long-term care, and the approach that affords the highest quality 

of life. There is literature from the Workers’ Compensation Reinsurance industry 

which establishes that maintaining brain injured patients with their families in the 

community is the most cost effective treatment approach. Therefore, I strongly recommend that you consider passing H.R. 3051. H.R. 3051 is superior to S. 2921 because it will help keep more families with a brain injured servicemember intact, and 

prevent the institutionalization of more soldiers with severe brain injury than the 

provisions of S. 2921 

Respectfully submitted, 

James C. Schraa, Psy.D. 

Neuropsychologist 

Licensed Psychologist, State of Colorado 

f 

Craig Hospital, Englewood, CO 

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Statement of Christopher Needham, Senior Legislative Associate, National 

Legislative Service, Veterans of Foreign Wars of the United States 

Mr. Chairman and Members of the Subcommittee: 

Thank you for the opportunity to provide testimony for this legislative hearing. 

The 2.3 million men and women of the Veterans of Foreign Wars of the U.S. appreciate the voice you give them at these important hearings. 

H.R. 3051, the Heroes at Home Act 

The VFW strongly supports the Heroes at Home Act. This legislation would dramatically improve the delivery of healthcare for those veterans suffering from traumatic brain injury. We thank Representative Salazar and the original cosponsors of 

this legislation for its introduction, and we urge its passage. 

We especially appreciate section 2 of the legislation. It would create a family caregiver program to train families or friends of veterans suffering from the effects of 

severe traumatic brain injuries. 

The newest generation of war veterans is presenting VA with many new 

healthcare challenges. Advances in technology and battlefield medicine are allowing 

many hundreds of men and women to survive injuries that previously would have 

been fatal. This, however, is coming at a price; many of them are grievously wounded and suffering from complex and intertwined ailments that are stretching VA’s 

ability to adapt. Once the worst of their ailments are addressed, a great number 

of these men and women are returning home to their immediate families. In some 

cases, this is a spouse and in other cases—especially given the relatively young age 

of many of these men and women—to their parents. 

The impact on these families is daunting. Their loved ones have complex physical 

and emotional difficulties and they must battle the bureaucracy of VA and DoD to 

ensure that everything the veteran is due comes to him or her. These families often 

have to put their lives on hold, delaying work, their education, relationships and 

other aspects of their life because of their veteran’s illnesses and conditions, and the 

demands their intensive care require. With the complexity of the overlapping bureaucracies, some veterans fall through the cracks and do not receive the pays or 

compensation they need to cover their care. Further, in cases where parents—as opposed to spouses—are providing care, they may not be eligible for the full range of 

services and benefits the two departments provide. 

Section 2 would go a long way toward fixing these problems, training and certifying family and friends to serve as caregivers, which would make them eligible for 

compensation for their time and service. 

Section 3 would require the Secretary to conduct outreach to educate veterans and 

the public about PTSD and TBI, as well as to provide information about the range 

of services VA can provide for their treatment. Additionally, it would require VA to 

release information about the best practices it develops so that healthcare practitioners can learn from VA’s experiences when dealing with these conditions for all 

Americans in the civilian world. Both are worthy provisions. 

Section 4 of the bill would expand telehealth and telemental health options 

through a pilot program that primarily focuses on rural areas. It would determine 

the feasibility of using these technologies to assess the cognitive function of service 

men and women and veterans, as well as to help with rehabilitation. This is a good 

goal and a creative approach to solving the difficulties some veterans experience 

when trying to access their care. Should the program work, it would be of great benefit to many thousands of veterans suffering from these conditions. 

H.R. 6153, the Veterans’ Medical Personnel Recruitment and Retention Act 

The VFW is happy to offer our support to this legislation, which would improve 

VA’s ability to recruit and retain nurses and other healthcare practitioners. This is 

a continuing challenge for VA and one that is shared by all healthcare facilities. 

With the nursing shortage around the country, it is critical that VA have the tools 

and flexibilities it needs to adapt and be competitive in the marketplace as the 

workplace of choice for high quality healthcare providers. 

This bill would improve pays for various healthcare specialties, including specific 

targeting for nurse executives and part-time nurses. It also revises rules relating 

to overtime and weekend duty and work schedules, which could help ease the burden many nurses face. Additionally, it reinstates the health professional educational 

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assistance scholarship program, which is an excellent recruitment benefit that 

would make VA more attractive to various healthcare providers. 

We believe that its passage would improve VA’s abilities to recruit and retain 

high-quality healthcare providers. This can only serve to better the care VA provides 

to this Nation’s veterans. For this reason, we support this bill. 

H.R. 6629 

We understand that this bill was introduced to address a specific problem in New 

Hampshire. New Hampshire is the only one of the contiguous 48 states that lacks 

a full-service veterans hospital. As a result, veterans seeking certain types of basic 

care are forced to travel to hospitals in other states, whether in White River Junction, Vermont or near Boston, Mass. 

This bill would require VA to either run a full-service hospital in each of the 48 

contiguous states or it would require VA to fully contract out for all healthcare services. It is the latter part that causes us to have some qualms with the bill. 

First, we believe that New Hampshire veterans deserve better. Many face long 

drives for basic care. In 2007, for example, over 700 veterans were transferred outof-state for acute care. If they live in the northern part of the state, this could mean 

a travel time of 4 hours one-way just for basic services that the Manchester VA 

should otherwise be able to provide. Only recently has the Secretary announced that 

Manchester will begin offering radiation therapy, meaning that veterans who needed this for the treatment of cancer had to travel hours for care. Clearly, this is unacceptable. 

We believe, however, that the mechanism of this bill could create some further 

inequities. Should the contracting provisions be in force, a veteran living across the 

border from the White River Junction VA Medical Center in Lebanon, NH would 

be entitled to contract care for any service they would need. Presumably, they could 

call up their private physician and have an appointment in a matter of hours or 

days. The same veteran, should they live five miles to the west in Vermont, would 

be required to wait in line for their turn at the White River Junction Medical Center. That is not fair. 

We have supported contracted care in limited cases, namely where VA is otherwise unable to provide care—particularly in the case of specialized services. This 

legislation, though, could lead to wide-spread contracting, which we oppose. 

VA already has the authority to provide fee-basis care, and it uses it with great 

success in many areas, especially in some remote parts of the west. We would urge 

the Committee to use its oversight authority to ensure that VA is doing the right 

thing for New Hampshire’s veterans. If VA does not believe that the Manchester 

Medical Center requires full services, then we need the Committee to ensure that 

veterans who need these specific services receive contracted care when they would 

otherwise have to travel these long distances. We need to adapt the lessons VA has 

learned from other areas to New Hampshire, even if most people have not previously considered New Hampshire to be a large state or one that would require significant travel. 

This concludes my statement. I would be happy to answer any questions you may 

have. 

f 

Statement of Anna Frese, Family Outreach Coordinator for Brain Injury, 

Wounded Warrior Project 

The men and women of the Armed Forces have been providing an example of 

service, to their country, for over 200 years. Many families have watched and supported their loved one as they head off to fulfill the missions assigned to them. Unfortunately, in the process of fulfilling those missions, not all loved ones return 

home as they left. The need has presented itself, to assist in supporting the service 

of the family member, whose chosen mission is to care for and provide a quality of 

life to their loved one that has been seriously injured while in service to their country. 

I thank the Committee for allowing me the opportunity to respectfully submit this 

testimony for the record and I strongly support this direly needed legislation. My 

name is Anna Frese and I currently am working with the Wounded Warrior Project 

(WWP) as a Family Outreach Coordinator for Brain Injury. My understanding for 

the urgent need of H.R. 3051 does not just come from working with the Wounded 

Warrior Project, but also what I witness daily as sister of Retired Army Sergeant 

Eric Edmundson, who was seriously injured in Iraq in October of 2005, and is currently living at home receiving 24/7 total care from our father, Edgar Edmundson. 

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Our family made the decision to bring Eric home and care for him. This decision 

was made knowing that it was what Eric would want. As our father says, ‘‘My son 

went to war, he honored himself, he honored his family, and he honored his Nation. 

He went to war, did his duty and got injured. As a parent, Eric, in my eyes is not 

a handicapped person, he is not a 100 percent disabled Veteran; Eric in my eyes 

is a 28 year old husband, a father and a young man with a whole life ahead of him. 

I as a parent need to honor him, and see to it that his needs are met.’’ 

It is important for Eric’s young family that Eric be home, and be an active part 

in daily life. Eric is not only dealing with medical or rehab issues, he needs to be 

home to help deal with everyday issues so that he is meeting his responsibilities 

and being included, involved and helping to keep his small family intact. Anyone 

can be trained to take care of medical needs, but when you are 28 years old, a husband and father with responsibilities and a desire to get your life back—it goes a 

lot deeper than pills and therapy. You need to be around people that know you, understand you, and are willing and able to be there for you. 

Our father sees it as his duty to ensure not only that Eric’s short term goals are 

met but that a focus remains on his long term goals as well. He focuses on helping 

Eric in maintaining a high morale and self-esteem which is paramount in the 

achievement of reaching his goals. Some long term goals to getting his life back include his hobbies of hunting and fishing—and our family sees that there is no reason that he can’t have those as a regular part of his life. 

The decision to bring Eric home came with sacrifice and changes on many levels. 

Ours is just one of many families that have adapted to the ‘‘new normal’’ with 

changes in family infrastructure, in relationships with friends and extended family, 

in finances, in hopes, plans and goals for the future. Upon learning of Eric’s lifelong 

challenges, our father resigned his position at work, in order to provide Eric the fulltime care that was needed. This decision did leave him and our mother with one 

less income, and in times of need they had to dissolve their personal and retirement 

savings. Just as importantly, now at 53 years old my father is no longer is covered 

by health insurance. 

The financial and emotional stress of not having the ability to maintain ones 

physical health is not only reflected in our family, but again in many of the families 

caring for their severely injured Veteran. By the Committee supporting H.R. 3051, 

family caregivers will have the option of receiving training by the VA, certifying 

them to receive compensation for the care they are providing their Veteran. This 

compensation will possibly allow some to better manage their own lives and health, 

so that they will be there for their loved one in the future. 

One constant statement that I hear not only from my father, but other family 

caregivers who have made the same decision as ours, is that they are grateful. They 

are grateful to have the opportunity to spend time and enjoy the life of their loved 

one. So many Servicemember and Veterans have persevered through immeasurable 

odds, and families see it as their time to persevere and provide as much joy and 

quality of life as possible. 

The family caregivers of these returning wounded warriors appreciate the concern, and acknowledge the recommendations that are trying to provide for the many 

others caring for their loved one. These warriors need someone at their side who 

knows them, understands them, and someone who is willing to be there for them 

and speak for them, in order for him to fully recover—or recover as much as possible. Families just wish it to be known they are committed to being by their Veterans side no matter what; the need is just too urgent. This legislation will allow 

family caregivers to follow through on that commitment. 

Æ 

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